Select Committee on Health Second Report

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)

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