Domiciliary care
34. A number of submissions drew particular attention
to the potential for abuse to occur 'behind closed doors,' in
situations where services were provided in a 'one-to-one situation',
and where an older person was entirely dependent on the district
nurse, or care worker, who came into their home. Gary Fitzgerald
for AEA told us that it was almost impossible to quantify the
level of 'unknown abuse' that occurred in such settings, but in
terms of calls to his organisation's helpline it was clear that
a great deal of reported abuse took place in people's own homes.
"[29] Such concerns
were also recently highlighted by the BBC Panorama programme broadcast
in November 2003 which used an under cover reporter to investigate
the vulnerability of older people cared for in their own homes.
35. Evidence from Surrey Multi-Agency Protection
Committee highlighted the national trend of supporting frail,
older people at home wherever possible, and the simultaneous raising
of the social services eligibility thresholds that people must
satisfy in order to qualify for any assistance at home. This was
widely believed to put greater stress on informal carers.
36. If the carer and the person being cared for are
rarely seen by service providers, the opportunistic identification
of any abuse being perpetrated by the carer is unlikely. When
help is arranged it is often provided by a variety of sources,
such as health, social services and private agencies. Any indications
that abuse is occurring can easily be missed if these sources
of care do not communicate with one another.[30]
We accept the risks associated with these trends. However, we
are also aware that in practice carers rarely seem to abuse the
person they support as a result of such stress. Help the Aged
noted the emphasis often placed on carer stress in cases of abuse,
but argued that in practice this was rare and that "few incidents
of abuse are committed by loving, supportive people who have lashed
out as a consequence of the burden of their caring responsibilities."[31]
The Institute of Gerontology also supported the view that there
was no sound research evidence to underpin the theory that elder
abuse frequently resulted from carer stress.[32]
37. The British Geriatric Society identified a number
of potential risk factors that "are associated with physical
and psychological abuse in a domestic setting."[33]
These were:
· social
isolation - those who are abused usually have fewer social contacts
than those who are not abused;
· a history
of a poor quality long-term relationship between the abused and
the abuser;
· a pattern
of family violence (the abuser may have been abused as a child);
· dependence
of the person who abuses on the person they abuse (for example
for accommodation, financial and emotional support); and
· a history
of mental health problems or a personality disorder, drug or alcohol
problem in the person who abuses.[34]
38. Abuse in domiciliary settings is the commonest
type of abuse, but the most difficult to combat. Contact between
victims of abuse and statutory services may be limited, and those
abused will often feel under threat, or obligation, to those abusing
them. The only measures likely to have much impact here would
be ones which increased the climate of awareness of the problem,
making health and social care professionals more aware of the
issue, and those which empowered older people to report abuse
more easily, recognising the reasons for their reluctance to do
so. Our recommendations below relating to training and advocacy
issues may go some way to tackle this difficult problem, but we
readily acknowledge that there are no simple solutions.
39. We are concerned about inadequacies in current
regulation. The National Care Standards Commission highlighted
the failure of domiciliary care regulations to provide for the
notification of 'adverse events' (such as a sudden death or serious
accident), which is a requirement of the regulations governing
care homes. We agree with the NCSC that the failure of the National
Minimum Standards for domiciliary care to require reporting of
adverse incidents is an anomaly that should be removed.
Care homes
40. A number of submissions highlighted the imbalance
in power that typically characterises the relationship between
the perpetrator and the person subject to abuse. Some, such as
Coventry City Council Social Services Department, argued that
it was therefore particularly important to empower vulnerable
adults and the care staff who worked with them.
41. Elder abuse has until recently been regarded
primarily as a domestic phenomenon, as illustrated by the 1993
Department of Health guidelines, No Longer Afraid: The Safeguard
of Older People in Domestic Settings. By contrast, a report
published in 2000 by the Royal College of Psychiatrists stated
that: "Abuse does not only occur in rare, dramatic and well-publicised
incidents; it is a common part of institutional life."[35]
BUPA suggested that residents of care homes who were physically
frail and intellectually impaired might be at particular risk
of sexual abuse, while "those with challenging behaviour
can lead to staff retaliating abusively."[36]
The UK Central Council for Nursing, Midwifery and Health Visiting,
now replaced by the Nursing and Midwifery Council, receives on
average about 1,000 allegations of abuse per annum. Some 50% of
these relate to physical, verbal or sexual assault. In 1998, 84
nurses (mostly employed in nursing homes) were struck off the
register for abuse.[37]
42. The National Care Standards Commission is an
independent, non-departmental public body established by the Care
Standards Act 2000, to regulate a wide range of social care and
private and voluntary health care services in England. The NCSC
registers and inspects approximately 29,000 care homes for older
people, which provide just under half a million places. The NCSC
stated in their written evidence that only 50% of care homes for
older people are meeting or exceeding the relevant standards for
complaints or protection.[38]
The Commission received 12,685 complaints in 2002-03. Of these,
1,278 (10%) made specific allegations of abuse, but the majority
of complaints alleged poor practice or neglect, which could also
be classified as forms of abuse.Table
1 - NCSC complaints 2002-2003