10 Recommendations and conclusions
Defining elder abuse
1. We
are concerned that while the new Commission on Equality and Human
Rights will generally have both promotion and enforcement powers,
in respect of human rights it will have only promotion, but not
enforcement, powers. We would be very disappointed if this were
the case, and we urge the Government to enable the Commission
on Equality and Human Rights to promote and enforce both equality
and human rights on an equal basis. We believe that the credibility
of the new Commission will be seriously damaged if it is unable
to respond in this way, and if it is seen to treat the issue of
human rights as a lower priority. (Paragraph 13)
2. We recommend that
the No Secrets definition of elder abuse should be expanded
to include those individuals who do not require community care
services, for example older people living in their own homes without
the support of health and social care services, and those who
can take care of themselves. We recommend that all government
departments and statutory agencies, independent bodies, charities
and organisations working within the area of care for older people
apply this definition of elder abuse to promote consistency and
conformity throughout government and the health and social care
sector. (Paragraph 14)
The
prevalence of elder abuse
3. We recommend that
multi-disciplinary research into the subject of elder abuse should
be commissioned by the Department of Health to clarify the full
extent of elder abuse and to allow the Department for the first
time to ascertain the extent of this problem within society. (Paragraph
29)
4. At present there
exist no performance indicators which allow the measurement of
the quantity and quality of work in adult protection. We recommend
that performance indicators be established as soon as possible
to enable accurate measurement to be undertaken. In addition we
recommend that the Department uses No Secrets as a baseline
to enable progress to be determined in tackling the issue of elder
abuse. (Paragraph 30)
5. The figure of at
least half a million older people experiencing some form of abuse
at any point in time appears to offer the only estimate that is
currently available. We are disappointed that the Department has
not commissioned research to establish a more precise figure.
We recommend that data collection in this area improves, and that
the Department uses the definitions contained in No Secrets
as the basis for collecting and monitoring data both on complaints
of abuse and on proven incidents. We welcome the news that the
Department is to fund Action on Elder Abuse for two years from
financial year 2004-05 to establish a national recording system
for the incidence of adult abuse. (Paragraph 31)
The settings of elder abuse
6. 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. (Paragraph 38)
7. 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. (Paragraph 39)
8. 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. (Paragraph
44)
9. We note that the
Chair of the Rowan ward, Manchester Mental Health & Social
Care 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. (Paragraph 46)
10. 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. (Paragraph 49)
Physical abuse
11. We
believe that the incorrect prescription of medication is a serious
problem within some care homes, and that medication is, in many
cases, being used simply as a tool for the easier management of
residents. We recommend that the Government should vigorously
pursue the National Service Framework target that all people over
75 years of age should normally have their medicines reviewed
at least annually, and those taking four or more medicines should
have a review every six months. (Paragraph 65)
12. We recommend that
a review of the medication of care home residents should be conducted
by their GP every three months, or on request by the home, whichever
is more frequent, regardless of the number of medicines being
prescribed. Additionally, we recommend that action should be taken
to ensure GPs comply with the NSF milestone and that procedures
are implemented to monitor effective compliance. (Paragraph 66)
13. We recommend that
consultants with an interest in medicine and psychiatry of older
people should be encouraged to develop services to residential
and care homes in the community. Further, we recommend that an
appropriate schedule of clinical standards related to old age
services should be developed for recognition within the GMS contract
to enable GPs who wish to develop special interest in the care
of older people to do so. (Paragraph 67)
14. We recommend that
the National Care Standards Commission and its successor body
should ensure that medication systems within care homes and domiciliary
care reflect good practice and that good practice procedures that
exceed the national minimum standard are publicised. (Paragraph
68)
15. We also recommend
that the results of investigations by CHI and its successor body
relating to inappropriate medication management in the NHS should
be widely disseminated and that evidence of unacceptable practice
should trigger sanctions. We believe that close co-operation between
CHAI and the National Patient Safety Agency would aid the discovery
and dissemination of such practices. (Paragraph 69)
16. Given that physical
restraint can be exercised in both overt and subtle ways, we recommend
that the National Care Standards Commission and its successor
body publish its findings on physical restraint as a thematic
study in order that all agencies can benefit from the findings.
(Paragraph 74)
17. We welcome the
measures contained in the Domestic Violence, Crime and Victims
Bill, which we hope will provide some additional protection for
older people. (Paragraph 76)
Financial abuse
18. We
recommend that the prevention, detection and remedying of financial
abuse should be included as specific areas of policy development
by adult protection committees. (Paragraph 82)
19. We endorse the
recommendations of the Joint Committee on the Draft Mental Incapacity
Bill relating to Lasting Powers of Attorney (LPA). The Joint
Committee recommend:
· that
the Bill should make clear whether it is intended that personal
welfare decisions, excluding those relating to medical treatment,
may be taken when a donor retains capacity. Further, clarification
of the extent and limitation of the powers, as well as adequate
guidance and training for donees, are also strongly recommended;
· that,
whilst individuals should have freedom to choose their donee(s)
when making an LPA, further guidance should be provided to warn
donors of the potential for conflict. Furthermore, an additional
safeguard should be included in Codes of Practice as a mechanism
by which the Court of Protection or the Public Guardian could
monitor the use of LPAs with a view to preventing the abuse and
exploitation of a donee's powers;
· an express
duty of care should be incorporated into the draft Bill in respect
of donees acting under an LPA (and for Court Appointed Deputies).
A greater degree of accountability should be required from those
groups in order to limit the potential for abuse of their powers
and effective methods should be explored to achieve that end.
In particular, specific requirements in the form of a standard
of conduct should be included in the Codes of Practice, aimed
at those exercising formal powers under the draft Bill;
· donees
should be placed under an obligation to notify both the donor
and the Public Guardian that the donor is, or is becoming incapacitated,
thereby putting this information on the public record and opening
it up to challenge. Guidance should be provided to assist financial
institutions to deal with the operational realities of LPAs; and
· the
additional safeguard of requiring two additional persons to witness
the certification of capacity should be included where there are
no named persons for notification of the registration of an LPA.
(Paragraph 83)
20. We further recommend
that the regulatory bodies of health and social care increase
their surveillance of financial systems including the use of powers
of attorney and, in care homes, the use of residents' personal
allowances. (Paragraph 84)
Tackling elder abuse
21. 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. (Paragraph
93)
22. 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. (Paragraph 99)
23. 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. (Paragraph
100)
24. 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. (Paragraph 101)
25. 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. (Paragraph 105)
26. 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. (Paragraph 109)
27. 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. (Paragraph 110)
28. 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. (Paragraph 113)
The contribution of regulation
29. We
recommend that signed-off induction training of domiciliary and
other social care workers approved by the appropriate sector skills
council rather than attainment of NVQ level 2 should be sufficient
for them to apply for registration with the GSCC (together with
any other requirements from the GSCC relating to the applicant's
fitness to practice), with a requirement that such registered
staff achieve appropriate qualifications prior to the renewal
of their registration. (Paragraph 127)
30. We recommend that
the Government should attend to the issue of registering domiciliary
and other social care workers as a matter of the utmost urgency.
We recognise that the Government wanted to approach registration
in a measured and systematic way, and that starting with the (mostly
qualified) social workers was one way of doing that. However,
we are especially concerned that service users may be placed at
continuing risk from day-to-day contact with unregistered care
workers, a small minority of whom may be abusive working with
them on a one-to-one, unsupervised basis. We do not believe that
it is acceptable to delay their registration. We recommend strongly
that the Government should move to require the registration of
domiciliary care workers and their managers concurrently with
the other groups that it has already identified as the next priorities
for registration (residential childcare workers and managers of
care homes). (Paragraph 128)
31. We remain unconvinced
that the Department could not have commenced its preparatory work
for implementing POVA sooner, so as to identify and address the
concerns that are now further delaying its full implementation.
We welcome the announcement that the Protection of Vulnerable
Adults list will be introduced from June 2004, but we are extremely
concerned that this will not provide full implementation. While
we accept that some adjustment of the regulations may be required
in order for POVA to operate efficiently in health and social
care settings, we are uncomfortable at the prospect of any further
delays, and believe that the necessary regulations should be introduced
as a matter of urgency. In the light of continuing concerns about
potential abuse of older people taking place within the NHS and
in the independent health care sector, we urge the Government
to take all possible steps to expedite the implementation of POVA
as quickly as possible fully across both health and social care
settings. We also recommend that the Department keeps under review
the operation of the scheme. (Paragraph 144)
32. We recommend that
when the General Social Care Council opens the register to domiciliary
care workers it should also ensure that care workers who are employed
through direct payments are also able to register should they
wish to do so, and indeed should be so encouraged. We anticipate
that over time this would lead to many such personal assistants
choosing to register because of the advantage that it would offer
in demonstrating their competence and reliability to a prospective
employer. Users of direct payments would be able to check that
the person they wished to employ was registered with the GSCC,
and that they would have the same protection as any other service
user, whether or not they were using direct payments. (Paragraph
152)
33. We recommend that
the shadow Commission for Social Care Inspection, the successor
body to the National Care Standards Commission should review its
care home inspection methodology and ensure that where possible
more conversation takes place with service users to validate their
findings. (Paragraph 160)
34. We recommend that
CSCI and CHAI publish at an early date their joint plans for regulating
and ensuring that the health care needs of residents in those
settings registered as social care provision are met; that the
Minister requires the annual reports of CSCI and CHAI to include
details of their joint working and of the experience of the adequacy
of the regulation of the health care aspects of care home services
provision; and that the Government keeps under review the operation
of the respective Commissions. (Paragraph 170)
35. We recommend that
a joint inspection of the implementation of No Secrets
be undertaken by CSCI, CHAI, HM Inspectorate of Constabulary,
the Housing Inspectorate and Audit Commission along the lines
of the Safeguarding Children review. (Paragraph 172)
Certification of death in care homes and in the
domiciliary environment
36. We
recommend that in any code of practice based on the [Home Office's]
Fundamental Review, the limits of "as promptly as is practicable"
should be defined. (Paragraph 181)
37. We also support
the recommendations of the Review, (i) that statutory medical
assessors should identify, support and monitor care home death
certification by first and second certifiers as a distinct sub-group
of certification by doctors and practice; and (ii) that there
should be regular exchanges between the NCSC/CSCI offices in each
local area and their coroner and statutory medical assessor counterparts:
to exchange information, to arrange, where appropriate, joint
investigations and to identify any practical problems over verification
and certification of care home deaths and draw them to the attention
of PCTs and others as appropriate. (Paragraph 182)
38. We support further
recommendations of the Fundamental Review: that the NCSC, followed
by CSCI, should be able to raise any anxieties about an individual
death with the coroner; that these organisations should be given
on a confidential basis any information from individual death
investigations that would be relevant to their inspectorial and
regulatory functions; and that they should have reciprocal arrangements
with the coroner and the statutory medical assessor, and for their
part should make available to the relevant material from their
inspections and regulatory work. (Paragraph 183)
39. There are possible
conflicts of interest when a GP owns and runs a care home. If
the GP has the authority to sign a medical certification of the
cause of death, and is the perpetrator of abuse that resulted
in the death of an older person in their care, the opportunity
to hide the true cause of death is increased. We recommend that
stricter controls be implemented to ensure that certification
of the death of a resident in a residential or care home owned
or managed by a GP, or a close relative, should be performed by
a GP other than the owner/manager. (Paragraph 186)
40. Another area of
concern is the use of retaining fees by care homes for GPs. Such
fees are paid so that residential homes are assured of a service
by the local GP. We recommend that the practice of the payment
of retainer fees is abolished, as every patient registered with
the GP should have a right to a service from the GP without the
payment of additional retainer fees. (Paragraph 187)
| 
