There are many forms of abuse but are usually classified under five main headings, physical, sexual, psychological, financial and institutional. Signs of possible abuse can come in physical forms, such as bruises, cuts, burn marks, etc; emotional signs like flinching, crying and any other changes in the normal behaviour of the client. Although these are signs of abuse it is in no way conclusive evidence of such.
Warning signs are NOT evidence of abuse but possible indicators of such.
Physical abuse can take many forms but is usually where some form of bodily harm is committed. For example: hitting, slapping, scalding, burning, pinching, force feeding, refusing access to toilet facilities, misuse of medication or restraint, leaving someone in soiled clothes or bedding, etc.
The warning signs for possible physical abuse can be things like withdrawal or mood changes, finger marks or multiple bruises, black eyes or bruised ears, scratches or cuts, burn marks, welt marks, a history of unexplained falls or injuries, pressure sores or rashes from wet/soiled bedding or clothes, fractures especially if accompanied by multiple bruises or finger marks, explanations that don’t match the injuries, reluctance to be left with the alleged abuser, etc.
Sexual abuse is when a sexual activity is performed without informed consent being freely given, such as rape or sexual assault, indecent exposure, sexual harassment, masturbation, involving a vulnerable adult in pornography, enforced witnessing of sexual acts or sexual media, attempted or penetration of intimate areas without informed consent, etc. It can also involve abuse of a position of power. Children are unable to give informed consent to any sexual activity of any description. Some adults are also unable to do this due to diminished capacity or a lack of understanding of the meaning.
The physical warning signs for possible sexual abuse can be things like scratches, abrasions or persistent infections in the anal or genital area (including urine infections), pregnancy, bruises, bite or scratch marks on the body, burns, blood on underwear, abdominal pain with no diagnosable cause, etc.
The emotional warning signs for possible sexual abuse can be refusal to undress for activities such as swimming or bathing, flinching when carrying out normal duties such as washing, self injury, self destructive behaviour including alcohol or drug abuse, suicide attempts, depression, aggression, anxiety, crying, sexual abuse of others, provocative sexual behaviour or promiscuity, reluctance to be left with the alleged abuser, etc.
The key point to remember when determining possible sexual abuse is the mental capacity to give informed consent to any sexual activity.
Psychological abuse – an element of psychological abuse exists in all forms of abuse. Emotional distress will be caused when a person becomes a victim of abuse at the hands of someone they trusted such as a family member, friend or carer. There is some abuse that is purely psychological such as bullying, shouting, ignoring, swearing, humiliation, blaming, intimidation, verbal abuse, threats of harm or abandonment, harassment, coercion, deprivation of privacy or dignity, etc.
Indicators for possible psychological abuse can be the carer (either professional, family or friend) seeming to ignore the vulnerable persons presence and needs, cared for person fearful of raised voices or distressed if they feel they are in trouble, reports from neighbours about shouting, screaming or swearing, the client not wanting to be alone with alleged abuser, no value of basic human rights (such as opinion, choice and dignity), being treated like a child, etc.
Financial abuse can be committed by family, friends, care workers or other outside influences and includes fraud, theft, exploitation, pressure regarding things such a wills, property, inheritance or financial transactions, etc.
Indicators are people not being able to manage their own financial affairs when they have the mental capacity to do so, family unwilling to pay from clients funds for services even though the client has enough funds, mismanagement or misappropriation of clients finances, denying client access to their own account, loss of trust, insecurity, client is overly conforming or submissive and Power of Attorney obtained when individual is unable to comprehend.
Example: A client is bed ridden and gives a family friend her bank card in order for that care giver to do shopping, pay bills, etc. The family friend then abuses this position by stealing the money from the client’s bank or transferring it directly into their account (fraud).
Institutional abuse can be committed by organisations, groups or even individuals and includes abuse of power or authority, not maintaining professional boundaries, misuse or misappropriate dispensing of medication, physical restraint, using information of client to embarrass or bully and not maintaining dignity.
Indicators can be loss of control, low self-esteem or confidence, crying, a severe lack of staff, aggressive or submissive behaviour.
Self Neglect/Neglect by others can be done either by the client themselves or by their carer, professional or otherwise, not meeting the support needs of the vulnerable person and can include neglectful or self harming behaviours, refusing to eat or drink, neglecting personal hygiene, refusing the toilet when able to use, actual bodily harm e.g. cutting and hitting. Neglect by others can include not maintaining an expectable level of hygiene e.g. leaving client in wet/soiled pads, not covering the basic needs of the client e.g. not washing them properly, toileting, feeding or personal care.
Indicators are weight loss, lack of personal hygiene e.g. not bathing or washing regularly, dehydration, signs of self harm, depression, withdrawn or submissive behaviour.
Discriminatory abuse can include racist or sexist abuse, abuse based on disability, age, gender, sexual orientation or religion; harassment or slander.
Again: Warning signs are NOT evidence of abuse but possible indicators of such.
Factors contributing to risk of abuse are age e.g. elderly or young children; poor communication between care giver and service user (this could be because of a medical problem or social/relationship issue); care giver having an addiction such as alcohol or drugs; challenging behaviour by the service user; care giver believing service user is being deliberately difficult, care role forced not taken on willingly, major changes to lifestyle because of giving care, multiple care responsibilities, carer or service user having lack of sleep, being socially isolated, care giver or service user being young or immature, financial or housing issues, illness or injury, culture or religion discrimination or prejudice, refugee or asylum-seekers, environmental/economic factors such as financial situation, mental health difficulties, physical disabilities such as sensory impairment, cognitive ability, level of education, intellectual understanding, learning difficulties and many more.
Abuse by professionals risk factors are bullying of staff members by manager, a culture of not treating the service users with dignity or respect, poor-quality training, lack of investment into further staff training, poor staffing issues, lack of opportunity for care giver to form a rapport with the service user, low staff morale and not enough support for the staff via appraisals or supervisions.
If you suspect someone is being abused then use your skills such as observation and communication with other professionals. You must inform your line manager of your suspicions and monitor the situation closely.
If a services user makes an allegation of abuse first you must inform them that you cannot promise to keep it confidential, you will have to inform the office. This can be difficult because often abuse sufferers will start off by saying something like “If I tell you something, will you promise not to tell anyone else?” Never promise this. Explain to the service user that you can’t promise that you won’t tell anyone but the people you do inform will be able to help the service user or it will only be shared on a ‘need to know’ basis.
However, if the service user (vulnerable adult) refuses to allow you to share the information then, other than the necessity to tell your manager, it will be difficult for you to do anything about the abuse. All effort should then go into trying to encourage the service user to agree to the sharing of information and pursuing an investigation. If the client has full mental capacity, and absolutely refuses, then you will have to accept that you can only monitor the situation carefully.
Secondly, reassure the service user that you believe what you’ve been told, offer comfort if required and also confirm that it is not their fault that this has happened to them.
Try to not get into a situation where you are given a lot of detailed information, although this might be difficult because the service user might want to tell you everything once they have started to talk or the location/environment might not allow it. If you do get stuck in a situation where you are given a lot of information try not to ask leading questions such as “and then did he punch you?” Say instead “and then what happened?” Listen carefully and try to remember everything you are told so that you can record the details later.
Any written information pertaining to alleged or potential abuse must be kept in a locked cabinet. If the information is held electronically then it should be password protected. Only essential information should be kept and only used for the abused benefit or best interests.
In response to alleged abuse you should Protect, Report, Preserve, Record and Refer.
Protect -Make sure the abused person is safe and protected against any further abuse. Ensure medical treatment is provided when necessary. Offer comfort and support to the abused so they know that they are safe. Concerns, suspicions or conclusive evidence of abuse require an immediate response. You may be even required to remove the alleged offender, take the service user to a safe place or offer to contact a trusted family member to provide support.
Report – All concerns about an abusive situation should be reported immediately to your line manager, or if that is not possible the on-call person so you can hand over the responsibility to them. It will be necessary to also write up a full written report as soon as possible after the admission or occurrence.
Preserve – You must ensure any evidence of the alleged abuse is not compromised.
Sexual or Physical abuse can leave traces of forensic evidence so every effort should go into preserving it, such as don’t clear up, don’t clean any part of the area where the abuse took place, don’t remove bedding or any clothes the abused might be wearing, keep other people away from the crime scene and try to persuade the abused not to take a shower, bathe, wash, brush their hair or teeth.
If you suspect or are told about financial abuse then you must ensure that any documentation pertaining to that fact is kept in a safe place so it can be used as evidence.
Record and refer – Any form of abuse, suspected or otherwise must be recorded either by writing it down as soon as possible after being told or on audio tape so it can be written down later. This can then be used as part of the evidence process. Make sure you take note of everything you observed, anything you have been told (hearsay) and by whom, any previous concerns and what has specifically has raised your concern this time. When making a formal statement or preparing a document that will be used in court, you don’t include anything that can be classed as hearsay.
A referral is where you provide the authorities with the information they require in order to resolve the matter for the service user such as the police, social services, the health trust, etc.
The national policies and local systems that relate to safeguarding and protection from abuse are:
National: Care Quality Commission, Criminal Record Bureau (CRB checks), Independent Safeguarding Authority (ISA), Common Assessment Framework (CAF), Vetting and Barring Scheme (VBS), No Secrets national framework and codes of practice for health and social care (2000), Safeguarding Adults review (2009), Working Together to Safeguard Children (2006) and Every Child Matters (2003).
Local: Local Area Agreements (LAAs), Local Safeguarding Adults Board (LSABs) and Local Safeguarding Children’s Board (LSCBs).
The role of these different agencies include multi-agency and inter-agency working collaborations such as health services, e.g. GP’s, nurses, health visitors, occupational therapists; voluntary services, e.g. NSPCC, Age UK, MIND, RNIB, RNID; social services, e.g. residential children’s home workers, social worker, care assistants; the police; consulting the police regarding all safeguarding incidents; responsibilities for overseeing the Safeguarding Assessment and its outcome; allocating a named person usually from statutory agencies in health or social care; convening or chairing strategy meetings, including the agreement of responsibilities, Lead Professional; actions and time-scales; providing information about activities and outcomes to the Safeguarding Coordinator; overseeing the convening of Safeguarding Case Conferences; coordinating and monitoring investigations.
There are numerous sources of information and advice about the role of a home care assistant with regards to the safeguarding and protecting individuals from abuse such as policies, procedures and expected ways of working within the workplace environment; information from the Independent Safeguarding Authority (ISA); relevant and up to date information from websites, leaflets, organisations, local and voluntary groups including government sources e.g. DfE and DoH; voluntary organisations e.g. NSPCC, Benardos; Social Care Institute for Excellence and publications, e.g. Health and Social Care 3rd Edition; What to Do If You Suspect A Child Is Being Abused (2003); National Council for Voluntary Youth Services ‘Keeping it Safe: a young person-centred approach to safety and child protection; Working Together to Safeguard Children (2006).
You can reduce the risk of abuse by giving knowledge and empowerment to the service provider this includes:
Person-centred values – Dignity, independence, rights, fulfilment, privacy and choice. Reducing vulnerability by boosting confidence; autonomy; positive communication; listening and promoting independent decision making. Awareness that everyone has the right to live without fear, violence and abuse; protected from harm or exploitation.
It is important that you build self esteem and confidence by encouraging active participation in a variety of activities such as personal care, walks, cooking, etc.
Promoting choices and rights by encouraging independent thinking, choices and decisions; empowerment, independence and the importance of informed consent.
It is vital to have an accessible complaints procedure in place that is easily read and understood. This will give the service user the confidence to know how to report a complaint and what action the company will take once the complaint is issued. This will reduce the likelihood of abuse. The complaints procedure should have transparent policies; accountability; procedures and outlines of working practices; clear guidelines on reporting and recording the complaint; robust guidelines for following up the complaint and accessibility (wide distribution, high visibility, etc).
The company provides a care plan folder which is left in the service users home. This includes personal information of the service user such as name, telephone, address, doctors surgery, etc; observation sheets; medication records including authorisation to administer medication on behalf of the service user and the medication policy; Financial Record including procedures and expenses sheets; client guide giving an overview of the aims and objectives of the company, services offered, service overview, terms and conditions, quality assurance process, key policies and contacts, complaints on compliments procedures and hours of operation. At the back is a copy of the contract between the company and service user.
Unsafe practices which might affect the well-being of service users are:
Neglect of personal care duty such as not giving a wash or bath when required, withholding toilet facilities, force feeding and inappropriate dressing.
Not following the medication procedures such as failing to check dosage or not properly recording the administration of medication on the given documentation.
Failing to record financial transactions correctly.
Misuse of authority – physical restraint, not respecting professional boundaries.
Failure to carry out supervisions or risk assessments.
Bad communication and sharing of private confidential information such as not giving the client the respect they deserve or talking to them in a derogatory manner and breech of confidentiality.
Failing to keep staff updated on current legislation and safeguarding practices such as insufficient training or unsafe recruitment, not carrying out CRB or reference checks.
If unsafe practices have been identified then you must immediately report your concerns verbally to your direct line manager and then follow it up in writing. Find out what the policies are on ‘whistle blowing’ and follow them.
You can be dismissed or suspended if you fail to report your suspicions or allegations of abuse, unsafe practices or not following procedures. If nothing is forthcoming after you have made your report then you have the right to contact the police or social services directly. It is then their responsibility to ensure your report is investigated and followed up.