APPENDIX 20
Memorandum by Oxfordshire Social &
Health Care (EA27)
ELDER ABUSE
1. INTRODUCTION
1.1 Oxfordshire Social & Health Care
is a directorate of Oxfordshire County Council. It works in partnership
with other organisations, with individuals, families, groups and
communities. It ensures that services are provided which protect
vulnerable people and enable them to be as independent as possible
and get the most out of their lives. This could be in a temporary
crisis or in a longer lasting situation.
1.2 Oxfordshire Social & Health Care
works in partnership with Thames Valley Police, Oxfordshire Primary
Health Care Trusts, Oxfordshire Radcliffe Trust, Oxfordshire Mental
Health Care and Learning Disability Trusts and the National Care
Standards Commission in addressing the abuse of older people.
1.3 Oxfordshire has an estimated population
of 628,000 of whom approximately 14% (88,000) are aged 65 or over.
1.4 Oxfordshire is a rural county, with
49% of its population living in rural areas.
1.5 The author of this memo, Hugh Ellis,
is the Vulnerable Adult Protection Worker for Oxfordshire with
responsibility for:
1.5.1 Supporting the operation of the Oxfordshire
Adult Protection Committee and its working groups.
1.5.2 Advising the Oxfordshire Adult Protection
Committee and its working groups in the operation of its duties.
1.5.3 The collection and analysis of information
in accordance with the requirements of the Oxfordshire Adult Protection
Committee.
1.5.4. Providing advice and support to colleagues
across all agencies in relation to vulnerable adult abuse and
the operation of the Oxfordshire Codes of Practice for the Protection
of All Vulnerable Adults from Abuse.
2. EVIDENCE
2.1 The information presented in this memo
is obtained from concerns, disclosures or allegations of vulnerable
adult abuse reported to the Oxfordshire Vulnerable Adult Protection
Worker. Reporting is voluntary and is subject to the usual bias.
2.2 The information relates to the period
1 January 2003 to 30 September 2003. Information can also be provided
for the year 2002.
2.3 During the period a total of 103 concerns
were reported about people over 65. This amounts to 0.3% of all
people over 65 known to Oxfordshire Social and Health Care.
2.4 What is the relationship between abusers
and their victims?
2.4.1 The majority of reports relate to
concerns of abuse being perpetrated by paid staff (39%), spouse/partner
(14%) and other relatives (37%).
2.5 Where the abuse took place
2.5.1 54% of reports related to abuse occurring
within the older person's own home. 39% related to abuse occurring
within a residential or nursing home.
2.6 Forms of abuse
2.6.1 Concerns of physical abuse appear
to be the most common. 55% of the concerns reported included physical
abuse. 46% of the concerns reported included emotional abuse.
34% of the concerns reported included financial abuse and 9% sexual
abuse.
2.6.2 In residential/nursing home settings
physical abuse was the most common with concerns being reported
in 73% of cases. Emotional abuse was reported in 50%, financial
abuse in 10% and sexual abuse in 17% of cases.
2.6.3 In the vulnerable persons own home
concerns of emotional, financial and physical abuse were evenly
reported (48-50%). Sexual abuse was reported in 5% of cases.
2.7 Multiple Abuse
2.7.1 Multiple abuse is recorded where there
are concerns that two or more forms of abuse have occurred/are
occurring within the context of one relationship. Neglect has
been categorised as multiple abuse involved physical and emotional
abuse.
2.7.2 Concerns of multiple abuse were reported
in 44% a total of cases. In residential/nursing home settings
multiple abuse was reported in 47% of cases. In the persons own
home multiple abuse was reported in 43% of cases.
2.7.3 Emotional abuse was the most commonly
reported element of multiple abuse, occurring in approximately
90% of cases.
2.8 Abuse Profiling
2.8.1 Abuse profiling looks at the types
of concern reported within the context of the relationship in
which it occurs. For example in the context of the spouse/partner
relationship approximately 80% of reported concerns involved physical
abuse only.
2.8.2 By contrast in the context of concerns
of abuse occurring within other familial relationships only 16%
of reported concerns involved physical abuse only, 64% involved
multiple forms of abuse, and 20% involved only financial abuse.
2.8.3 This appears to have much more in
common with abuse by paid staff where 25% of reported concerns
involved physical abuse only, 46% involved multiple forms of abuse,
11% involved only financial abuse, 7% emotional abuse and 11%
sexual abuse.
2.8.4 An analysis of concerns of multiple
abuse within familial relationships (excluding spouse/partner)
and by paid staff also shows similarities. Emotional abuse was
identified in 81% of cases of multiple abuse by a relative other
than spouse or partner and in 92% of cases of multiple abuse by
paid staff.
2.8.5 By contrast financial abuse was identified
as a concern in 88% of reported cases of multiple abuse by a family
member but in only 8% of reported cases of multiple abuse by paid
staff.
2.8.6 Physical abuse was identified as a
concern in 100% of reported cases of multiple abuse paid staff
but in only 38% of reported cases of multiple abuse by a family
member and in half of these cases financial abuse was also a factor.
2.9 Conclusions from abuse profiling and field
experience
2.9.1 Some carers respond to the pressures
of giving care by physical abusing the person they are caring
for. This often occurs within otherwise caring and supportive
relationships.
2.9.1.1 Example 1: A 76-year-old man
being cared for at home by his daughter was observed to have extensive
bruising and pinch marks while attending a day service. The daughter
admitted causing the injuries. The relationship between them was
observed to be close and supporting—but the task of caring
for her father both day and night led her to become physically
abusive towards him.
2.9.2 Some paid carers respond to the pressures
of giving care by physical abusing the person they are caring
for.
2.9.2.1 Example 2: A member of staff
was working an early shift at a nursing home. She arrived at work
five minutes late in the morning and was asked to work with residents
not previously known to her. One of the people she was caring
for came down to the dining hall in a very distressed state and
with bruising to the back of her hand. She stated that the staff
member had forced her to get dressed although she had wished to
remain in her room. On being questioned the staff member admitted
that she had used unacceptable physical coercion in order to help
the woman get dressed. The staff member stated that she believed
the woman had dementia and had found from other experience of
working with people with dementia that physical prompting ie placing
the woman's dress over her head, often worked. The matron reported
that the member of staff had previously been regarded as very
caring. On further investigation it was found that the staff member
had received no hand-over and believed that all the residents
had to be in the dining room for breakfast by 9 am. She was not
aware of any care plans and had received no training in supporting
people with dementia.
2.9.3 Concerns about paid staff may also
take the form of poor lifting and handling techniques and use
of other unacceptable practices within apparently otherwise caring
and supportive relationships.
2.9.3.1 Example 3: An 84-year-old man
with a moderate dementia was found to have bruising to his side
and a cut above his eye. He alleged to his daughter that staff
members had thrown him onto his bed and he had consequently banged
his head and fallen off the bed. Despite inconsistencies in the
man's account of what had happened it was found that the most
likely explanation of events was that staff had not used a hoist
to lift the man onto the bed but had opted to lift him manually
in order to save time.
2.9.4 Other single form abuse is often predatory
as in the case of sexual abuse or opportunist.
2.9.4.1 Example 4: Two elderly women
with dementia made veiled disclosures of sexual abuse, possibly
involving digital penetration, involving a male staff member at
the nursing home where they lived. No previous concerns had been
expressed about the member of staff. On searching the man's house
the police found copies of pornographic magazines specialising
in older women.
2.9.4.2 Example 5: The paid carer of
an elderly man with a learning disability was found to have pinched
£500 from his kitchen. She was known to be in financial difficulties
but in all other respects their relationship had appeared good.
2.9.5 Other forms of abuse are often underpinned
by a disrespect/indifference to the older person. In family relationships
this is primarily associated with financial abuse where the relation
is not a primary carer or physical and/or financial abuse where
the relation is not a primary carer.
2.9.5.1 Example 6: Concerns were raised
about a lady of 72 with mild dementia. Despite being very frail
she was about to be evicted by the housing association for non-payment
of rent. On investigation it was found that her son and daughter-in-law
had persuaded her to sign over c£50,000 saying they would
ensure all her rent and bills would be paid. The rent was subsequently
not paid and the social service department had to step in to pay
the rent in order to prevent her becoming homeless.
2.9.6 Concerns about abuse by staff are
also often characterised by a disrespect/indifference to the older
person associated with physical abuse. Typical of this form of
abuse is inappropriate lifting and handling, feeding etc.
2.9.7 However, a good proportion of all
abuse by paid staff appears to take place against a backdrop of
poor management, resistance to engaging with health or other services
or inappropriate use of other services and generally poor standards
of care and practice within the organisation.
2.9.7.1 Example 7: A daughter raised
concerns after visiting her 78-year-old father in the nursing
home where he lived. She discovered he had extensive bruising
to his back and inside of his forearm. He said this was the result
of a fall two days previously. She reported it to the staff whom
up until that point had been unaware of his injuries. On investigation
by the National Care Standards Commission it was found that nursing
staff had stated in their notes that the man had received full
personal care during the days following his injury. However, direct
care staff notes stated that he had "refused" care during
this period. Care Plans were found to be of very poor quality,
and overall supervision and management appeared non-existent.
Prior concerns had existed about the home in relation to a strong
smell of urine, poor general hygiene and the attitude of staff
including the manager towards residents. The Management Company
was asked to address the issues. The manager was dismissed and
significant resources, financial and managerial, were put in an
attempt to redress the situation.
2.10 Interventions
2.10.1 Interventions are most successful
when there is effective joint working, clear lines of communication
between agencies and agencies are fully aware of one another's
role, responsibility, authority and limitations at all levels.
2.10.1.1 In the example 7 above the National
Care Standards Commission undertook the lead. Initial enquiries
by the NCSC, health and social services (from two authorities)
indicated that there were deep-rooted concerns. The Management
Company was invited to a meeting involving all relevant agencies
and was required to undertake their own investigations about the
operation of the home and causation of the injuries received by
the man. Joint health and social care reviews were undertaken
with all the residents at the home.
2.10.2 Difficulties tend to occur where
good working relationships and clear lines of communication have
not been established at all levels of operation.
2.10.2.1 Example 8: District nursing
staff within a PCT had had concerns about a residential nursing
home for many years. They had frequently discussed these concerns
within the practice and had contacted the National Care Standards
Commission by telephone believing that by doing so they had fulfilled
their responsibilities. The National Care Standards Commission,
however, did not receive any formal notification and no meeting
was called. Inspections of the home did not raise sufficient concern
for further investigation. On becoming aware of the concerns the
Vulnerable Adult Protection Worker advised the agencies to meet
to formally share the information. At this meeting it was evident
that the concerns were very serious and appropriate action taken.
However, despite evidence of ongoing abuse having occurred no
criminal or civil action could be taken primarily because the
owners of the home had sold the business a short time previously
and much of the evidence had been lost. With effective communication
at an earlier stage much of the abuse could have been prevented
and action taken against those responsible.
2.10.3 It is also essential that people/agencies
are involved and are fully aware of their roles and responsibilities
at all levels.
2.10.3.1 Example 9: A member of the public
reported concerns to police and social services about a woman
who lived next to him. He was concerned because he had heard shouting
screaming and crying coming from the house. The social services
department arranged to meet with the woman whereupon she disclosed
a catalogue of physical and emotional abuse including being beaten
with a stick by the carers she lived with. A place of safety was
immediately found by social services and at the woman's request
a police investigation was carried out. The couple caring for
the woman were subsequently charged under the mental health act
and the woman found appropriate accommodation.
2.10.4 Example 9 also provides a good example
of a case of abuse by informal carers. In this circumstance it
was clear that the role of the social services department was
to assess and take the appropriate action to minimise risk and
that the investigatory role lay with the police.
2.10.5 Precedent has indicated that in terms
of the Human Rights Act 1998 there may now be duty on the part
of local authorities to ensure it takes proportional, necessary
and appropriate action to prevent abuse to vulnerable older people
where it is known to be occurring. It is also unclear the extent
to which this duty extends to other public bodies eg primary and
hospital trusts. This would benefit from clarification.
3. RECOMMENDATIONS
3.1 Elder abuse can be prevented without
radical systemic change or the investment of large amounts of
money. This would require:
3.1.1 Targets for all public authorities
for the prevention of elder abuse need to be given a far higher
priority at both local and national level.
3.1.2 All local public authorities should
be required to produce annual joint strategic plans for preventing
elder abuse
3.1.3 Regulatory bodies need to place further
emphasis on inspecting the quality of management systems and care
planning process. This requires the provision of appropriate training.
3.1.4 Local authority contract monitoring
and care plan reviewing systems should also be strengthened in
relation to the quality of management systems and care planning.
3.1.5 The anticipated POVA list needs to
be established as quickly as possible as high demands for staffing
make it easy for perpetrators dismissed for abuse to find alternative
employment.
3.1.6 Social work training needs to incorporate
vulnerable adult abuse and the legislative framework.
3.1.7 Budgeting needs to become a key assessment
area for community care assessments.
3.1.8 Local authorities need to establish
money management systems that are more flexible to user wishes
and take account of a person's varying ranges of capacity.
3.1.9 The duties and responsibilities of
individuals and agencies working older people need to be clarified
at a local and national level.
Oxfordshire Social & Health Care would be
happy to present the information presented in this memorandum
if that would be helpful to the Committee.
November 2003
| 
