Select Committee on Health Second Report

4  The settings of elder abuse

Who abuses and why?

32. In many ways it is misleading to talk of elder abuse as a single phenomenon. Abuse takes place in a range of settings, and its prevalence varies, as an audit of calls to the AEA helpline demonstrates:[28]
Figure 2: Settings of elder abuse

33. In the light of such findings we examined characteristics of abuse in different settings.

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
Types of complaint
% of total
Poor care practice 3,583 28
Inadequate staffing 2,896 23
Other 1,771 14
Abuse 1,278 10
Unsatisfactory premises 991 8
Quality of food 880 7
Poor management 798 6
No leisure activity 488 4
Total 12,685 100

Data source: Ev 107

43. Many memoranda highlighted the current lack of training of care staff in the issue of identification and management of elder abuse. This evidence was corroborated during the oral evidence when the lack of training for care staff in all environments was raised on numerous occasions.

44. We recommend that the training of care assistants working in domiciliary environments and of those employed in care homes is expanded to include elements that will help them to identify abuse and to ensure they are informed of how to report abuse when it is encountered. We make further recommendations on training below at paragraphs 113 and 127.

NHS care


45. During the inquiry our attention was drawn to a number of investigations relating to allegations of abuse. One of these was undertaken by CHI in August 2002 following allegations of physical and emotional abuse of patients by care staff on Rowan ward at Manchester Mental Health & Social Care Trust. CHI investigated the systems and processes within the trust rather than the actual allegations of abuse as these were the subject of a police investigation. The CHI investigation concluded: "The Rowan ward service had many of the known risk factors for abuse: a poor and institutionalised environment, low staffing levels, high use of bank and agency staff, little staff development, poor supervision, a lack of knowledge of incident reporting, a closed inward looking culture and weak management at ward and locality level."[39]

46. The CHI report found evidence that the concerns raised by ward staff were not appropriately dealt with and that systems that should have alerted the trust to potential problems did not function or were under-developed. It highlighted the fact that in the older age services there was very little awareness of the policy to protect vulnerable adults. It further criticised the dissemination and implementation of policies as being weak or non-existent. We note that Dr Ladyman requested urgent reassurance that such events would not happen elsewhere and that the Department subsequently agreed that strategic health authorities would review services in their respective areas to address potentially similar high-risk situations. We note that the Chair of the Trust has now resigned and the Chief Executive has left the Trust. We hope that CHAI will review the Strategic Health Authority inquiry conclusions in respect of Rowan Ward.


47. We were also reminded that in November 2000 CHI published the report of its investigation into the North Lakeland NHS Trust. In May 1996 five student nurses had voiced their concerns about physical abuse of patients at Garlands Hospital. An investigation by the trust concluded that there had been "departures from accepted practice" but these had been with "good intent." The ward at the centre of the allegation was merged with two other wards in 1997, bringing together patients with severe physical disabilities and patients with behavioural problems. In December 1998 two nurses complained about the physical abuse of two patients. The subsequent inquiry only investigated the specific complaints and did not consider the previous incidents. The investigation concluded that there was sufficient evidence for disciplinary action, which resulted in three staff receiving disciplinary warnings, one being dismissed and one resigning.

48. The Trust Chairman established an external review panel to scrutinise the 1998 investigation and related matters. The review panel found that a range of "degrading - even cruel - practices" had been used by some staff and condoned by others. The report listed allegations that had been substantiated, including: a patient being restrained by being tied to a commode; patients being denied ordinary food; patients being fed while sitting on commodes; and patients being deliberately deprived of clothing and blankets. We are concerned that the report found that the allegations investigated in 1998 were similar to those made by the students in 1996. CHI's report noted that the 1996 report had "confirmed and even condoned unacceptable practice." Of further concern to us was one of the main findings which stated: "Some staff CHI interviewed still failed to recognise the abuse which had taken place as unacceptable practice. CHI could not be confident, at the time of their visit, that abuse or malpractice would be reported, or that the Trust would respond effectively to such reports."[40] The CHI report concluded that: "that a culture had developed within the Trust that allowed 'unprofessional, counter-therapeutic and degrading - even cruel - practices' to take place. These practices went unchecked and were even condoned or excused when brought to the attention of the Trust."[41]

49. We recommend that the Department reviews the frequency and effectiveness of the inspection of NHS establishments providing care for older people. We also recognize the importance of lay personnel having an input into the inspection process and urge that further measures are taken to increase user engagement. We believe that lay visitors, by talking to residents informally and alone, are more likely to obtain information about abuse from embarrassed or frightened victims. Further measures may need to be introduced to make staff aware of their responsibility to report abuse and to allow them to do this in a confidential manner.

28   Ev 67 Back

29   Q 28  Back

30   Ev 145 Back

31   Ev 45 Back

32   Ev 150 Back

33   Ev 177 Back

34   Ev 177 Back

35   Royal College of Psychiatrists, Institutional Abuse of Older Adults, June 2000, p 6 Back

36   Ev 158  Back

37   Institutional Abuse of Older Adults, p 6 Back

38   Ev 107 Back

39   Commission for Health Improvement, Investigation into matters arising from care on Rowan ward, Manchester Mental Health & Social Care Trust, Executive Summary (September 2003), p 2 Back

40   CHI, The North Lakeland NHS Trust Executive Summary (November 2000) pp 1 - 6 Back

41   Ibid, p 1  Back

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