Select Committee on Health Second Report

7  Tackling elder abuse

Training and good practice

85. The experience of the AEA helpline is that poor practice forms the largest proportion of reported abuse by paid staff, and the implications of this for adequate training are clear. The UK Home Care Association (UKHCA) similarly acknowledged the historically low standards of training for home care workers, which, coupled with inadequate supervision, had allowed bad practice to "continue unidentified and unchallenged."[70] The introduction of regulation brings new standards for care services that address training, supervision, reviews of care packages, and complaints systems. UKHCA concluded that many of the right building blocks of policy and monitoring were therefore either in place, or scheduled to be so, but noted their concern "that the implementation of some elements has stalled or is threatened by a lack of resources and that consequently the rate of risk reduction is significantly slower than we believe is needed." [71]

86. Representatives of the regulatory bodies all emphasised to us their optimism that improvements would be made over time, notably as a consequence of the introduction of the Codes of Conduct and Practice issued by the General Social Care Council. These will be applicable to all social care employers and employees (not merely those who are currently registered). Lynne Berry, Chief Executive of the GSCC told us:

    I have to say that people have embraced the codes with enormous enthusiasm. We have sent out well over a million so far, in a very short time. I think the fact that the sector is actively looking to these and wanting to use them as a basis for training and so on is very encouraging.[72]

87. Ms Berry outlined the range of activity the GSCC was undertaking in order to achieve this. This included the training of NCSC staff in the relevance of the codes to their inspections. The GSCC would also be issuing guidance on good practice in embedding the codes, following consultation.

88. While we welcome the publication of the codes of practice, and believe that they have considerable potential to raise standards, we recognise that the distribution of copies of the codes is just the first step. Embedding the codes in day-to-day practice will be a challenging task, not least because of the implications for trainers, and their capacity to deliver the volume and quality of training that will be required.

89. We were keen to identify the extent to which training was playing its part in achieving a culture in which abuse is reduced. Submissions to our inquiry illustrated the importance of training in creating and sustaining such a culture. We learned that the CDNA survey of its members in 2002 indicated that although 88% of the respondents had encountered elder abuse at work, only 35% felt equipped to deal with the problem. However, 99% considered training would be beneficial and 98% indicated they were willing to undertake training. Specific training on elder abuse is not a mandatory part of the nurses' training curriculum.

90. Jonathan Coe, for POPAN, told us that there were two aspects to training.

    One is about ensuring that health and social care workers have the skills to detect abuse and then to deal with it, and to know what systems to use. The second part is to train people to take collective responsibility for responding to abuse by other health and social care professionals.[73]

91. A number of training initiatives have been undertaken. The CDNA has produced a publication, Response to Elder Abuse - A Guide for Nurses. In Surrey, strategies have included multi-agency awareness-raising training, where specialist police officers have jointly trained with social services colleagues to interview vulnerable victims.[74] The NCSC told us that the codes and national minimum standards were creating much "extra leverage" in promoting training, and this is something we welcome.[75]

92. Jenny Potter, National Officer for the CDNA, told us that her members were "seeing elder abuse in the community and they have no mandatory training to help them deal with this problem when they meet it."[76] She continued "I think if we could have training in the recognition of abuse, you would get an awful lot more figures and a lot more reporting, but certainly most health professionals do not know about abuse and how to recognise it."[77] When we asked Mrs Potter about the triggers for elder abuse and the order of importance she stated that lack of training was at the head of the list and continued:

    A lot of unqualified people in residential care homes and nursing homes are doing tasks that they should not be doing and in the community, social services are doing an awful lot of personal care for people which at one time was undertaken by health services. It was branched off a few years ago and social services now undertake more of the personal care in the community.[78]

93. We are concerned that the area of elder abuse does not currently form a mandatory part of the training for nurses and care workers. Given the scale of the problem, and the fact that care of older people will increasingly feature in nurses' work given the ageing of the population, we recommend that this omission is corrected as soon as possible and that the identification of abuse of older people and other vulnerable adults and the actions to take upon detection are instituted into the nursing curriculum.

Dealing with complaints

94. POPAN identified some of the issues that might impede victims of abuse raising their concerns and reporting abuse. People who have been abused will often be too traumatised to talk about it. The vulnerability of clients, and their dependence on the abuser, could also make it extremely difficult for an older person to make a complaint. Many people had no experience of being heard or taken seriously if they have been mistreated. Even if someone did feel able to complain, they might be unaware of the procedures they needed to follow or be unable to access them.[79] POPAN suggested that changes could be introduced to encourage people to report abuse that they had experienced or witnessed. For example, changing the language that was used might alter people's perceptions. Rather than making a 'complaint', people might be more willing to express 'concerns about professional behaviour'.

95. Frank Ursell, Chief Executive Officer of the Registered Nursing Homes Association, made a similar point:

    with a very wide ranging definition of abuse as soon as you use the word abuse you trigger the defence mechanisms … I would be happier if we could have some differentiation between the two [abuse and poor practice] so we can get a more effective and quicker response to it.[80]

96. Help the Aged noted it might be embarrassing for the abused person to admit abuse, creating a reluctance to report incidents. They further pointed out: "Older people are often fearful of the consequences of talking openly about abuse. They may have been 'punished' for speaking openly on a previous occasion; be conscious of how dependent on the perpetrator they are; have emotional ties to the perpetrator; or be unable to communicate what is happening to them."[81] They continued:

    It is unrealistic to expect older people themselves to 'whistle blow' and raise the alarm when they experience or witness an incident of abuse. Frequently the perpetrator of the abuse will be in a position of power over the older person and so the consequences of complaining, as well as the fear of the consequences are strong inhibitors for older people … Research found that victims of abuse frequently remained in abusive situations because they did not know how and where to get the practical advice and the information they needed to leave.[82]

97. This underlines the importance of support from fully independent third parties, and the need for advocates for older people. A memorandum submitted to us by Ann Abraham, the Parliamentary and Health Service Ombudsman, also emphasised the importance of supporting older people to help them complain when things went wrong.[83] The East Sussex Head of Service, Adult Protection, identified the role of the Care for Carers counsel which took the lead in representing local issues for carers and, as a voluntary support group offers guidance in an appropriate way. Help the Aged extended this approach with its support for the development of comprehensive and fully funded networks of advocates for older people. Such advocates should be encouraged to make themselves available to older people who were particularly isolated and without other sources of support.[84] It recommended that the Mental Incapacity Bill should include a guarantee of access to advocacy support.

98. One area in which further policy might be useful concerns the implementation of the No Secrets guidance and the development of vulnerable adults' protection committees. The memorandum from the ADSS pointed out that while many local authorities had established such committees:

    This is not, however, a requirement; the committees are not funded by any national allocation, indeed there is currently no agreed funding formula and nor are they encouraged by any key performance indicators.[85]

99. We believe that formal complaint procedures may be inadequate to support older people wishing to complain about the way they have been treated. We assume that the new Patient Advice and Liaison Services will be aware of this shortcoming and hope that they will be instrumental in ensuring that people are aware of their rights to complain and are assured that their complaints will be taken seriously and treated fairly.

100. We agree with the ADSS that there is a case for further guidance to require all local authorities to establish multi-agency vulnerable adults' protection committees. We are aware of good practice that exists in the local development of such committees, and recommend that this should inform the requirements of the guidance.

101. We strongly endorse any measures that make available advocacy services for older people. We acknowledge that imposing additional tiers of bureaucracy, and entailing additional costs to stretched budgets would not be welcome. So we recommend that the Government takes steps to facilitate a network of voluntary organisations to take up the role of visitors and advocates, perhaps offering training and guidance to ensure uniformity of standards.

Case review

102. We were struck by the absence of a regulatory review process for vulnerable adults in care, as compared with the situation pertaining to children. In particular, people living in care homes appear not to benefit from regular reviews of their circumstances (including medical reviews). We believe that many of those older people are living in care settings that may be inappropriate for their needs. We explored this issue with our witnesses. Ms Anne Parker, for NCSC, drew our attention to the 'light touch' that is generally characteristic of policies towards vulnerable adults compared with child protection measures. Dame Deirdre Hine, for CHI, wondered whether the lack of review was leading to the loss of rehabilitation opportunities for residents in care homes. CHI had undertaken considerable work on improving child protection measures within the NHS, including a self-assessment tool to allow organisations to audit whether they were successfully meeting the needs of children. Dame Deirdre suggested that the successor body (Commision for Healthcare Audit and Inspection) could consider whether a similar tool might be devised "so that the NHS is continually reassessing the way in which it meets the needs of older people."[86]

103. Raymond Warburton, Head of Section, Elder Abuse and Social Care at the Department of Health told us that arrangements for reviewing cases would improve from April 2004 with the implementation of the Single Assessment Process[87] "which requires a review including issues to do with clinical diagnosis, medication, people's rehabilitation needs, issues to do with safety, abuse, neglect, relationships and a whole range of matters."[88]

104. We are aware that the process of restitution for continuing care that is being carried out under strategic health authorities (which involves retrospective reviews of individual cases where people have not met the criteria for NHS continuing care) has highlighted a number of shortcomings in relation to record keeping and case reviews. The poor quality of records, and the lack of regular review of cases is apparent. Moreover, some records clearly indicate abusive practices taking place, but nothing being done to intervene.

105. We welcome the introduction of the Single Assessment Process and the opportunities that it presents for regularly reviewing the care of older people. This process requires people's needs to be reviewed within three months of their placement in a care home, or their receiving a service in their own home, and at least annually thereafter. We believe it is vital that these targets are met in all authorities, and we recommend that the Department should monitor the compliance of authorities, and should report on the outcomes of the process, including the success in achieving rehabilitation objectives that enable older people to return to their own home after a short period of support in a care home.

Changing the culture

106. Written evidence from the NCSC observed that "the single most important way to tackle elder abuse is to raise awareness of the way that older people should be treated by society as a whole, and the standards of care and behaviour to which they are entitled."[89] We agree that a clearer understanding and better information about the standards of care that people should be able to expect should help in tackling both the unintentional abuse reflective of poor practice, as well as ensuring that abusive behaviour is more likely to be challenged.

107. Help the Aged, and other witnesses, made the point that in tackling elder abuse it is essential to bring about a fundamental change both in the culture of organisations, and — more profoundly — in the attitudes of society. Awareness of elder abuse remains low, and people are insufficiently conscious of what behaviour constitutes abuse and should simply not be tolerated. Challenges by society to ageist and discriminatory attitudes will bring about change over time. In seeking a change of culture that recognises the human rights of older people, and the fact that any abuse is a violation of those rights, we believe that the NSF for Older People could do more. The NSF is, in our view, very welcome for the explicit message it presents that age discrimination is unacceptable. Professor Ian Philp for the Department told us that the NSF created a "framework for change that emphasised treating old people with dignity and respect", but acknowledged that there were not specific levers within the NSF concerned with targeting elder abuse. Professor Philp referred us to the review of the NSF that is being undertaken by CHI, the Social Services Inspectorate and the Audit Commission, and suggested that the implementation of the Single Assessment Process provided an opportunity for inquiry to be made into the presence of any abuse: "We have within the single assessment process for the first time the possibility of systematically and proactively identifying and managing older people at risk of or receiving abuse."[90]

108. Tackling the problem of elder abuse requires not just specific strategies, but also a general emphasis on raising standards and improving the regulation of health and social care services. We recognise the range of measures that the Government has taken to raise standards of care. In particular, the introduction of the NSF for Older People provides an opportunity to drive up standards. The development of regulation of care services is also welcome, but we recognise that this is a gradual process that will not bring change overnight.

109. We urge those undertaking the review of the NSF for Older People to pay particular attention to opportunities for tackling elder abuse. We welcome the potential for the Single Assessment Process to address the possibility of abuse in all assessments of older people. However, we believe that more can, and should, be done. This may require the development of additional standards and milestones within the NSF.

110. There are no standards for adult protection contained within the NSF. In order to ensure consistent good practice, we recommend that this omission is rectified. The policies and procedures set out in No Secrets could be used to form the benchmark of a NSF standard. This action would allow for quality performance-management and audit, both at local and national level.

111. AEA commented on the need to "recognise that all nations and cultures are different, often with unique histories, traditions, religions and experiences and that these need to be taken into consideration when responding to issues as sensitive as elder abuse."[91] They contended that while it was difficult for mainstream communities to recognise and admit abuse of older people, it was doubly so for some minority communities who might feel alienated. AEA also recognised that the definition of elder abuse might vary from culture to culture, making detection even more difficult.

112. The CDNA suggested that "cultural differences and language barriers can be a trigger for abuse."[92] If care workers failed to recognise the cultural, religious and ethnic diversity of those they are caring for, this could be considered a further form of elder abuse, depriving the individual of their personal identity and leading to low-esteem.[93]

113. We recommend that advocates on elder abuse drawn from black and minority ethnic communities should be identified, trained and deployed. Further, we recommend that training given to social care workers relating to ethnicity is assessed to ensure it takes proper account of elder abuse.

70   Ev 88 Back

71   Ev 90 Back

72   Q 115  Back

73   Q 40 Back

74   Ev 145 Back

75   Q 115 Back

76   Q 1 Back

77   Q 5 Back

78   Q 18 Back

79   Ev 62 Back

80   QQ 48-9 Back

81   Ev 45 Back

82   Ev 47 Back

83   Ev 201 Back

84   Ev 48 Back

85   Ev 81 Back

86   Q 132 Back

87   Single Assessment Process - Instead of social workers, health visitors, housing officers, doctors, etc. duplicating elements of each other's assessments, under SAP one professional-generally from the first agency the client meets-will carry out an overview assessment of a person's needs to see if it is appropriate to refer them to other professionals for specialist assessments. See Community Care, 18-24 March 2004, p 17 Back

88   Q 184 Back

89   Ev 109 Back

90   Q 177 Back

91   Ev 20 Back

92   Ev 66 Back

93   Ev 21 Back

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