Select Committee on Health Minutes of Evidence


Memorandum by Action on Elder Abuse (EA35)

CONTENTS

  1.  About the charity

    —  Background information on Action on Elder Abuse.

  2.  About research

    —  The absence of an overall national research strategy.

    —  Issues to be considered in future research.

    —  The robustness of research evidence and potential shortcomings.

  3.  Characteristics of abuse—the Elder Abuse Response Line

    —  The relevance of the Elder Abuse Response Line.

    —  Parameters of data collection and reporting by Action on Elder Abuse.

    —  Who contacts the helpline and how valid is their information?

  4.  Characteristics of abuse—Types of elder abuse and general prevalence

    —  The types of elder abuse.

    —  Prevalence of elder abuse types.

  5.  Characteristics of abuse—Issues relating to certain types of abuse

    —  Sexual abuse.

    —  Neglect.

    —  Financial abuse.

  6.  Characteristics of abuse—Who are the Abusers?

    —  Gender.

    —  Relationship of the abuser to the victim.

  7.  Characteristics of abuse—Who are the victims?

    —  Gender.

    —  Age.

  8.  Characteristics of abuse—Minority Ethnic communities

  9.  Characteristics of abuse—Perceptions that influence our understanding of abuse

    —  Concepts of crime and ageing.

    —  Understanding abuse.

  10.  Theoretical Models

  11.  Characteristics of abuse—Settings of abuse

    —  Where abuse occurs.

    —  Abuse varies with settings.

    —  Care homes.

    —  Hospitals.

    —  Domiciliary care.

    —  Conclusions.

  12.  Successful interventions

    —  Underlying principles.

    —  Collaborative working.

    —  Developing unique strategies.

    —  Employment screening.

    —  Addressing poor practice: Training.

    —  Addressing poor practice: Culture.

    —  Expanding choice.

    —  Encouraging healthy questions.

    —  Empowerment.

    —  Funding of adult protection.

    —  Vulnerable witnesses.

    —  Whistleblowing.

  13.  Informal carers

  14.  Formal carers

    —  Criminal Records checks and the Protection of Vulnerable Adults list.

    —  The General Social Care Council and the Nursing and Midwifery Council:

    —  Specific issues relating to the GSCC.

    —  Specific issues relating to the NMC.

    —  The National Care Standards Commission.

    —  Terminology and approach towards grieving relatives.

    —  Lack of focus on outcomes.

    —  Lack of consistency in standards of inspection.

    —  Thresholds of unacceptable practices.

    —  The National Services Framework.


SUMMARY

  Section 1 provides some background about Action on Elder Abuse (AEA), advising that it has been working in this field for 10 years and provides advice and guidance in a variety of ways, including through its national helpline.

  Section 2 advises that there is no overall national research strategy (but points out that it is important not to perceive the issue of prevalence—whether extensive or not—as a guide to the level of urgency or priority that should be given to tackling these abuses). It suggests some parameters for new research and draws attention to what current research data is available, including the OPCS survey that suggests between 5% and 9% of older people face some abuse—between 500,000 and 900,000 older people.

  Overall it suggests that the information available is limited, but taken collectively implies a level of abuse that is significant eg the data available from the Community and District Nursing Association, the National Care Standards Commission, the Liberal Democratic Party (on medication abuse), and an AEA sampling of Care Home Inspection Reports.

  Section 3 provides some background to the Elder Abuse Response Line, the helpline operated for the last six years by AEA, and explains the parameters of data collection, what can be learned from the statistics of the line, and the numbers involved (5,273 people). It goes on to explain that the majority of people who contact are relatives (38%) older people themselves (29%) and paid workers (19%), and suggests some of the reasons why people contact AEA (eg unhappiness with regulators, and the failure of whistleblowing). Finally, it confirms that (83%) of abuse calls contain sufficient information to be classed as demonstrable abuse.

  Section 4 defines the five types of abuse identified by AEA: Physical, Psychological, Sexual, Physical and Neglect. It also gives examples from the recent media for each of these categories. It continues by indicating that psychological abuse (35%) is the most numerous type reported, followed by financial (20%) and physical abuse (20%), and finally neglect (10%). It says that sexual abuse, while small at 3%, is the only category slowly increasing. It indicates that abuse is affected by gender, with financial abuse and neglect more prevalent with men, and physical and psychological abuse more prevalent with women.

  Section 5 looks at issues relating to certain types of abuse, and considers the prevalence and issues associated with sexual abuse; the extent of neglect (including pressures sores) and the failure to use "duty of care" case law and vulnerable witness support mechanisms; and issues around the financial abuse of older people.

  Section 6 looks at abusers and explains that there are more men (40%) than women (26%) reported to AEA, with male abusers being predomintly family members (69%). But, while the majority of female abusers are also family members (50%), it indicates that a significant proportion (32%) is also identified as paid staff. It particularly notes that, in nearly a third of circumstances (30%), the abuse is perpetrated by more than one person in collusion and that, while 22% of this "collusive abuse is by family members, a staggering 56% is perpetrated by paid staff ie abusive practices that are institutional and passed from one worker to another. It also shows that the majority of abusers are related to their victim (47%), with paid workers being the next highest category (31%). It stresses there is no evidence to support the argument that abuse is perpetrated by stressed carers. Finally it lists the different types of abusing staff, and the different types of abusing relatives.

  Section 7 looks at victims and identifies that the majority (67%) are women, 22% are men, and in a smaller percentage of cases (11%) both men and women are facing abuse at the same time, with more than half of these (52%) in some form of institutional support, primarily care homes. It looks at the demographic picture, and indicates that more than three-quarters of abuse (75.8%) is suffered by people who are over the age of 70 years, with 11.5% of that abuse affecting people over the age of 90 years. It notes that men have a "threat" age band between 70 and 89 years of age (67.9% of all abuse), women between 65 and 94 years of age (84% of all abuse), and for both genders a particularly critical period between 80 and 84 years of age.

  Section 8 points out that there is no research into abuse within minority communities, but looks at some of the information that was supplied to an AEA conference on this issue in 1998. The section includes information on Asian, Chinese and Jewish communities.

  Section 9 focuses upon perceptions that influence our understanding of abuse. It looks at concepts of crime and ageing and why abuses are often not seen or pursued as crimes. It points out that, regardless of age, each person is entitled to the protection of basic human rights. It also looks at the spectrum of abuse, covering physical assault by a family member through to bad practices of paid staff. It suggest that beginning to see elders as objects rather than human is the foundation on which a continuum of petty slights and abuses build into active mistreatment. Finally it suggests that abused older people should be perceived as citizens rather than victims, and that the whole range of citizenship rights should be brought to bear on the problem.

  Section 10 explores the theoretical concepts that underpin abuse, looking at intra-individual dynamics, inter-generational transmission of violence, dependency, stress, and social isolation. It also argues that the dynamics of abuse are very complex and argues that compiling any list of "types" or risk factors is rarely comprehensive; so the aim should be to encourage questions about the lives, support needs and choices of the person in question. It also points out that Roger Clough provide a comprehensive list of potential institutional abuse factors back in 1988.

  Section 11 indicates that in the vast majority of circumstances (98%) abuse occurs in only one place and is not replicated elsewhere, with most abuse occuring in someone's own home (67%), (which is not surprising as this is where the majority of older people live).

  However, 21% of reports to the helpline concerned care homes (formerly known as residential homes and nursing homes) where less than 5% of the older population actually live. It points out that some care homes are using the threat of litigation as a means of controlling complaints or avoiding bad publicity, and gives examples. Hospital settings and sheltered housing each accounted for 4% of all calls.

  It suggests that, in simplistic terms, it would be possible to suggest that financial and psychological abuses could be associated with domiciliary settings, while physical abuse and neglect could be associated with institutions (with relatives primarily perpetrating abuse in domiciliary settings).

  The section also draws attention to the realities of abuse within hospital settings and quotes from the Inquiry by the Commission for Health Improvement into abuse on the Rowan Ward in Manchester, with a key message being that the same issues keep coming up and the NHS does not seem to be learning. It suggests that little has changed in hospitals since the Health Advisory Service Report in 2000, and quotes from a recent study in Coventry into the management of elder abuse within hospital settings.

  Finally, it focuses on domiciliary care where there are around 204,000 domiciliary care workers and approximately 50,000 new recruits each year, and suggests that no matter what systems or monitoring controls that are established it will never be possible to guarantee, by external monitoring alone, that abusive activities are not occurring. It argues that good quality domiciliary care is reliant upon training, peer group monitoring and the culture that is created within and between teams.

  It suggests that the reality is that it is impossible to reach a conclusion that implies a greater risk in one setting as opposed to another. It is more likely that the nature of the risk is different.

  Section 12 considers the underlying principles of protection, arguing that prevention is better than intervention and that this should be integral to the work of social workers etc. It suggests that good adult protection includes collaborative working between agencies; the need to resist pressures that can be intense—heavy caseloads ; budget and time constraints; resource and training difficulties; the temptation to see an older person's refusal of help as an opportunity to close the case, or evict, or ignore; and the need to develop unique strategies that are different from child protection.

  It argues that, for paid staff, we should try to screen abusers out of the sector before they are employed using Criminal Records Bureau checks that are fast and efficient, and the introduction of the POVA (Protection of Vulnerable Adults) list: the register of known abusers. It argues strongly for training as one guaranteed method of reducing the potential for abuse, including training for providers, inspectors and investigators, and for a focus on culture change within agencies. It points out that the absence of choice within the social care market can assist abuse ie if a service provider needs to be closed down there must be an alternative for those people who are dependent on their services, or there must be an alternative way of maintaining the service independent of that provider.

  It also argues that we need to develop a culture that is not restricted by professional boundaries, but which encourages practitioners to seek other opinions and advice, including addressing the failures of whistle blowing. It suggests we neeed climates where it is acceptable to question and to challenge without repercussions.

  It also considers the need to empower victims, and to adequately fund No Secrets and In Safe Hands. It indicates that there is a postcode lottery of adult protection, with investment totally dependent upon the financial and other constraints peculiar to the local area.

  Finally, it argues that vulnerable witnesses support mechanisms should be employed to support older people.

  Section 13 reinforces the message that informal carers (ie those who are actually providing the hands on care) are not automatic abusers. However, it recognises that abuse by family members, neighbours and friends are the most difficult to immediately identify and resolve, and suggests that this can only be challenged by sensitising people who are peripheral to the older person ie by raising public awareness, and by integrating abuse awareness into the training of all staff. It also suggests that a greater use of advocacy would help raise awareness and assist older people to complain. It argues that providing opportunities that reduce secrecy and that allow families to interact with wider societal practices would contribute to a possible reduction in abuse ie increasing the potential for actual or prospective victims, and informal carers, to fully access their rights as citizens.

  Section 14 looks at the issues associated with providing formal care. It suggests that implementation of important initiatives do not always prove successful, that important proposals are sometimes delayed or weakened for pragmatic reasons, and that key agencies and providers are often not "signed up" to the reality of change. It argues that in part this situation is caused by the difficulties associated with introducing regulation into what is theoretically a free market, in part associated with poor implementation planning that unnecessarily creates resistance where there should be enthusiasm, and in part caused by a degree of governmental timidity that prevents them from following through on initiatives that are sometimes controversial and sometimes expensive.

  It strongly criticises the delays in CRB checks and the introduction of the POVA list, and regrets that the Government raised expectations of protection but then failed to deliver on those expectations, leaving vulnerable people directly at risk as a result.

  It contrasts the development of the General Social Care Council with that of the Nursing and Midwifery Council and expresses concern at some retrograde decisions being taken by the NMC. It gives examples of such concerns, including that of allowing a convicted child sex abuser to continue as a nurse. It argues that the GSCC should concentrate on registering basic grade staff, and that the decisions of the NMC need external evaluation.

  It then looks at the work of the National Care Standards Commission and identifies some good progress at setting foundations for the replacement regulator. It considers whether standards and inspection are sufficient to establish quality provision, and argues that we also need the investment of resources, the provision of training, and an active support for service providers in creating cultures that are intolerant of abuse.

  It notes however, that at times it appears as though the priority for the Commission is not the resolute pursuance of quality care for vulnerable people but is instead a desire to maintain a good public image and a positive relationship with providers. It looks in detail, with examples, at a range of concerns about the Commission, including terminology and approach toward grieving relatives, the lack of focus on outcomes, the lack of robustness in challenging poor practice, the lack of consistency in standards of inspection, and the need to establish thresholds of unacceptable practices.

  Finally, the selection looks at the National Services Framework and argues, with examples, that it is not making the impact on NHS abuse that is required.

  Section 15 finally looks at other issues, not previously addressed, including funding shortfalls, NHS responsibilities, the role of policies and procedures, and issues associated with sheltered housing.


RECOMMENDATIONS WITHIN THE MEMORANDUM

Research

  1.  That a national research strategy is established, within which researchers are encouraged or commissioned to operate.

  2.  That focused research be commissioned to establish the factors contributing to elder abuse within minority communities.

  3.  That further research be commissioned into the control of medication within care services, and that the NCSC is required to publish statistical details on the prevalence of medication abuse identified within its inspection processes.

Police/CPS/legislation

  4.  That advice be issued to police forces clarifying the advantages of implementing vulnerable witnesses strategies for anyone who has been the victim of elder abuse (as defined by the AEA definition and categories).

  5.  That the use of this case law be brought to the attention of the CPS and all police forces and encouragement be given to its active use in situations that appear to indicate wilful neglect.

  6.  That (a) a review is undertaken with regard to the decisions of the CPS taken in the last two years, where elder abuse cases have not been pursued because prosecution was felt not to be "in the public interest" and (b) subsequent guidance is devised and issued.

  7.  That legislation be drafted that relates to the neglect or cruelty of an adult eg "anyone who has attained the age of 16 years and has the custody, charge or care of a vulnerable adult and who wilfully assaults, ill treats, neglects, abandons, or exposes him or her, or causes of procures him or her to be assaulted, ill treated, neglected, abandoned or exposed in a manner likely to cause him unnecessary suffering or injury to health, guilty of an offence".

  8.  That an urgent exploration is undertaken into the most appropriate legal terminology to adequately define a "vulnerable adult", including circumstances in which vulnerability does not arise solely through a lack of mental capacity.

Minority communities

  9.  That minority ethnic advocates on elder abuse be identified trained and deployed.

Data collecting and reporting

  10.  That a national data collection strategy is established, which defines what constitutes an Adult Protection referral, sets monitoring and reporting standards and provides on-going data on the nature and prevalence of abuse reporting and investigation.

  11.  That any national data collection strategy should include obtaining data from hospitals and primary care services.

GSCC/NMC

  12.  That, with immediate effect, priority be given to the registration of residential care staff and domiciliary care workers.

  13.  That, as a matter of urgency, there should be an independent review of the progress made by the NMC in meeting the objectives defined in legislation, with particular regard to the protection of the public.

NCSC

  14.  That there is an urgent review of the Inspection Strategy established by the Care Standards Act and used by the NCSC to focus attention on outcomes; and identify additional methods, other than inspection visits, to establish quality of care and absence of abuse.

  15.  That, if not already written guidance is established, detailing abusive circumstances in which enforcement action is mandatory; and that mandatory training is provided to all Inspectors in understanding the dynamics of abuse, warning signs, and action to be taken.

CRB/POVA

  16.  That immediate steps are taken to ensure the introduction of the POVA list as soon as practicable, and no later than 1 April 2004.

  17.  That sufficient funding is invested in the Criminal Records Bureau to ensure a standard turnaround of no more than one week between appropriately submitted enquiry and the provision of data.

Powers of attorney

  18.  That all Powers of Attorney be the subject of recording and control, with two levels of registration:

    (a)  those that have been established, but are not yet in force; and

    (b)  those that are in force either due to lack of capacity by the vulnerable person, or where a witnessed decision has been taken to bring them into force earlier.

  19.  That the current limited status of unregistered Powers of Attorney to be given greater publicity, particularly within high risk groups.

Training

  20.  That mandatory training is given to health care staff with regard to the nature of elder abuse, the warning signs and what action can be taken. This training to be available to hospital and primary care teams, including District Nurses and ancillary staff.

Human rights and providers

  21.  That, full compliance with the articles of the Human Rights Act are made a pre-condition of registration of care services under the Care Standards Act (as proposed by the Help the Aged).

Adult protection

  22.  That a review of all local authority adult protection policies is undertaken by the DoH to establish levels of consistency and areas requiring improvement.

  23.  That current protection guidance (ie No Secrets and In Safe Hands) be given legislative status, rather than that of Section 7 guidance.

  24.  That Adult Protection processes are ring-fenced financed as part of government funding to local authorities.

  25.  That all regulators are required to ensure that their policies and procedures are supportive of adult protection procedures, and cross-refer in relation to abuse, ie that one regulator informs another where abusive practices fall within their respective remits.

Funding social care

  26.  That the current funding of social and health care be the subject of an independent enquiry to establish the true costs of service provision, whether there are any shortfalls, and how these can best be met.


BACKGROUND INFORMATION ON ACTION ON ELDER ABUSE

  Action on Elder Abuse (AEA) is a charity that was established in 1993 with the aim of preventing the abuse of older people. It is a membership organisation with over 500 individual and group members throughout the United Kingdom. These include older people, local and national voluntary organisations, academics, health authorities and trusts, and social services departments (often represented by Adult Protection Coordinators).

  The charity is seeking an environment in which the abuse of older people is no longer tolerated. We are seeking to encourage public and practitioner recognition of elder abuse and to facilitate policies, procedures and cultures that both abhor and challenge such abuse.

  We believe it is vital that:

    —  it is recognised that elder abuse exists and that it may have a profound effect on the quality of life for older people;

    —  both the rights and autonomy of the older person and their possible need to be protected from abuse are recognised;

    —  all older people have the confidence, knowledge and support to take the action they choose to counter abuse;

    —  health and social care practitioners at all levels are trained to recognise the different types of abuse and to respond to the needs of both the abused and the abuser;

    —  both health and social service purchasers and providers have staff and services that are responsive to the needs of the abused and the abuser;

    —  the responses of all statutory, voluntary and independent agencies are collaborative and appropriate; and

    —  a broad range of research is undertaken to expand knowledge of the issues.

  Practical activities of AEA include providing up to date information for its members; running conferences on elder abuse and related issues (including an annual two day event that brings together academics, practitioners and voluntary sector representatives to consider current developments and challenges); giving presentations to a wide range of organisations; producing leaflets, resource materials and reports for practitioners and the public; and acting as a resource for practitioners, television, radio and the press.

  For the last six years the charity has operated the only confidential helpline service relating to the abuse of older people. The service assists callers to identify the options available to them in challenging abuse, provides information by letter, telephone, or e mail—including for older people themselves, their families and friends—and also assists callers to raise their concerns with statutory bodies. The service was launched nationally in November 1997 and has now taken in excess of 10,000 calls (including requests for information).

  In addition to providing practical assistance to callers the helpline provides the only source of national statistical information on the nature of elder abuse, the environments of abuse, who are abusers and who are the victims. This information has been used by academics, researchers and the Department of Health and is also regularly quoted by the media.

  AEA also maintains a press cuttings service and posts examples of reported abuse onto the charity's website. On average there are 35 examples of abuse identified per month through this process, invariably being reported in local newspapers.

  The definition of elder abuse developed by AEA is very specific and is focused upon a breach of trust. This is important because it allows us to concentrate specifically on those abuses where it would be reasonable for the older person to have trusted the abuser (eg relatives, staff who are employed to perform tasks on their behalf etc). As such it excludes abuse perpetrated by strangers (eg distraction burglary or mugging):

    "A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person."

  This definition differs from that used within "No Secrets"[1] in that it does not restrict attention to just those older people who "are or may be in need of community care services" or who "cannot take care of themselves" or "protect himself or herself from significant harm of exploitation".

  By its nature the "No Secrets" definition is based on a health/social care model, ie it assumes that a vulnerable person must be in need of external support, and it ignores the emotional/psychological impact of an abusive relationship. This consequently ignores a range of abuses that are psychological in nature but which may not be readily definable as "significant harm or exploitation".

  The Health Committee inquiry has chosen to use the AEA definition as its starting point in examining the prevalence and causes of abuse of older people.

  However, it is important to note the context in which this Inquiry is being held. This was adequately described by Holstein back in 1996:

    "For those who work with abused and neglected older adults the likelihood of achieving an ideal solution is slim. While the public may be appalled at newspaper descriptions of elder mistreatment, that dismay rarely translates into political action. Despite outrage, few understand the roots of the problem that lead to elder abuse and neglect and therefore, few assume responsibility for activities designed to address these deeper causes. It is unlikely that this picture will change in the immediate future".[2]

  There is no doubt that, since 1996, political action has occurred, eg No Secrets/In Safe Hands, the Care Standards Act, the National Services Framework for Older People. It is important however, to consider the level of success achieved by these actions, and quantifiable outcomes that have been achieved.



SECTION TWO

About Research

2(i)   The absence of an overall national research strategy

  Bridget Penhale, Lecturer in Social Work at the University of Hull, noted in 1999 that research into elder abuse in the UK has been limited but fairly consistent[3]. From quite modest beginnings in the late 1980s there has been a steady stream of relatively small-scale studies of different aspects of abuse. AEA produced an annotated bibliography of such research in 1995[4] and this identified over 61 separate pieces of research activity that had either been completed or were in the process of completion at that time. However, as was also noted by Bridget Penhale, the lack of any overall national research strategy suggested that small-scale studies of this type were taking place without any coherent overall view as to the usefulness of such an approach. She concluded that this could lead to a situation in which the potential value of further such research work was questionable, as the validity and reliability of each completed piece of research could be disputed. The principal reasons for this were that different research projects tended to look at different aspects of the problem and used different methodologies and small-scale samples. Comparing data could therefore become virtually impossible.

  The consequence of this lack of an overall national research strategy is a danger that "elder abuse in Britain is emerging as a social problem not on the basis of empirical research but on account of action within the social and health care professions based on anecdotal evidence of many forms of elder abuse in several diverse settings"[5]. This argument could be equally valid for the development of strategies such as "No Secrets" and "In Safe Hands"[6].

  Consequently it would not be unreasonable to conclude that there is inadequate research data on the prevalence and extent of elder abuse. It is therefore astonishing that no British Government has understood their public responsibility and obligation to fund research that will enable us to understand the nature of abuse.

  Regardless, however, it is important not to dismiss out of hand the research information that is available as it does provide some indication of the range of abuses being perpetrated and suggests some level of the scale of the problem.

  It is also important not to perceive the issue of prevalence—whether extensive or not—as a guide to the level of urgency or priority that should be given to tackling these abuses.

  Certainly there is a strong view among practitioners, academics and those active in the field of abuse prevention—including Trustees of AEA—that the results of research and complaints process reflect the tip of a very large iceberg.

  Each individual instance of abuse is a crime, often perpetrated against an extremely vulnerable member of society. Each individual instance has a profound impact upon the abused person, and has been known to lead to their subsequent death—even where the abuse itself may be generally perceived as non-life-threatening.

2(ii)   Issues to be considered in future research

  Action on Elder Abuse received funding from the Department of Health in 2002 to host a half-day seminar of academics, researchers and practitioners, with the aim of identifying potential elder abuse research objectives and stimulating joint working around this issue.

  The seminar participants concluded that:

  (a)  there needed to be a balance between practical and theoretical frameworks, and that it should be recognised that there were no age barriers for the participation in abuse;

  (b)  It was felt important at the outset to clarify definitions to be used in the context of elder abuse in order to establish the theoretical framework in which research could be undertaken. Such definitions should include the following key components:

    —  an understanding of the scale and variance of vulnerability, including the impact of perceived as well as actual vulnerability;

    —  an understanding of abuse and its different components eg financial, sexual, physical, psychological, social; neglect;

    —  an understanding of abuse in its different settings eg home, institution, sheltered housing; day care;

    —  an understanding of abuse in terms of the different responses required eg research, direct services, information provision, advocacy;

    —  the role of differing types of carers, the interaction between them and those in receipt of such caring, and the dynamics of caring that might contribute to or exacerbate abuse; and

    —  whether or not an element of trust is required between the abuser and the abused (in relation to the definition of abuse).

  (c)  It was also felt important to clarify and understand the ethical issues relating to elder abuse research. (Measurement and definition of abuse of older adults is difficult and the problem is becoming compounded by the reluctance of some ethics committees to grant permission to investigate the problem, especially if the research involves interviews with older adults claiming to be abused.) [7]

  Key areas that require investigation include the development of theoretical explanations and models that take account of the characteristics of abuse, including:





    —  timing, triggers and potential causes; and

    —  demographic features including ethnicity, income and disability.

  However, it was recognised that the key issues involved were:

    —  the difficulty in identifying existing data in order to inform future work;

    —  the need to develop common recording systems;

    —  when to use intervention as opposed to non intervention in protection work;

    —  whether there are predictors of violence and, if so, how they can be identified?

    —  whether there are particular characteristics of a "victim" or of an "abuser"?

    —  how to effectively and meaningfully involve individuals in research design;

    —  how to ensure the perspective of "victims" and/or their advocates/representatives is built into the process; and

    —  how to involve individuals with specific disadvantages/vulnerabilities (eg mental health problems or cognitive impairments, language difficulties).

  Finally, any future research needs to be informed by current emerging legislation that impacts upon all citizens eg Human Rights Act, the Mental Incapacity Bill etc.

Recommendation:

  That a national research strategy is established, within which researchers are encouraged or commissioned to operate.

2(iii)   The robustness of research evidence and potential shortcomings

  There has been only one study on the community prevalence of elder abuse in the UK[8]. To overcome some of the difficulties encountered with research methodology a routine social survey was used—the Office of population Censuses and Surveys (OPCS) Omnibus survey. This was a representative sampling survey that took place in 100 different sites throughout Britain during May 1992, involving 2,130 people (593 adults aged over 60 years). The survey excluded older people in institutions and those who were too ill or disabled to participate. This is an important limitation, as it excluded some older people who may been at greater risk of abuse, and certainly at greater risk of harm from any given abuse.

  Three categories of abuse were surveyed—physical, oral and financial. Oral abuse was measured by asking whether a close family member or relative had recently frightened them by shouting, insulting them or speaking roughly to them. Physical abuse was measured by asking whether any close family member had pushed, slapped, shoved or been physically rough with them in any other way. The questions about financial abuse asked whether any close family member had taken money or property from them without their consent.

  Of the 593 over-60s surveyed, 5% reported having been orally abused, 2% reported physical abuse and 2% financial abuse. The study did not identify the extent of multiple abuses and did not identify the timeframe involved in these abuses. It also included questions to 1,366 people who were in regular close contact with an older person, using the same abuse criteria. This indicated higher rates of oral abuse (9%) but a lower rate for physical abuse (0.6%) There has not been a replication of this study and attempts to conduct large-scales studies of such aspects as risk factors (an attempt to repeat North American work in order to see if the findings were relevant to the UK) have not received funding support.

  While some of the research difficulties were overcome by this approach it was nevertheless limited in scope. It remains, however, the only indicator of the scale of potential elder abuse within the UK, and is mirrored by research in other countries eg Finland 5%, Australia 4.6%, America 3.2%, Canada 4%.[9]

  In the UK, if these percentages were to be applied to the older population, they would indicate that between 5% and 9% older people were being subjected to oral abuse, equating to between 500,000 and 900,000 people.

  However, as was noted by a Council of Europe report on Elder Abuse[10], the problem common to all European countries is the absence of a policy for monitoring and recording statistics on violence within the family in general and specifically violence against older people. This is equally true within the U.K. where, with the introduction of No Secrets in England and In Safe Hands in Wales, there was the potential to gather qualitative and quantitative data on the nature of reported adult abuse in general and elder abuse in particular. Despite information being gathered at local level there has been no impetus to gather, analyse or report on this information from a national perspective.

  Without a national data collection strategy there is no consistency between local authority areas as to what constitutes an adult protection referral (eg what is a referral and what is a complaint) or how to quantify outcomes that are meaningful for the abused person. In some cases there is confusion between categorising a referral as "domestic violence" or "elder abuse", and in some authorities a referral is not counted if it relates to a service user who is part of an unrelated but active case. It is consequently most difficult to compare or understand trends or patterns of abuse.

  Overall, therefore, the information available is limited, but taken collectively it implies a level of abuse that is significant.

  For example, in 1990 Homer interviewed 51 carers looking after very dependent older people, all of whom were receiving respite care in a geriatric ward. Standard research definitions of abuse were used: [11]
Abuse reported by
NumbersCarer Patient
Physical71
Verbal219
Neglect69


  Source: Homer and Gilleard 1990.

  More recently, the Community and District Nursing Association (CDNA) published the results of a survey of nurse members in February 2003[12]. The survey was conducted during November/December 2002 and the findings of the survey were compiled by the Labour Research Department. Over 700 nurses responded to the survey and the vast majority (88%) indicated that they had encountered elder abuse within their work, while 12% reported that this was on a daily, weekly or monthly basis.

  Additionally, in November 2003 Paul Burstow, Liberal Democrat Shadow Secretary of State for Health, published an updated report into the misuse of medication in care homes[13].

  The primary conclusions of this report were that up to 22,233 elderly nursing home residents in England could be under sedation without medical grounds, and that the majority of elder people prescribed anti-psychotic drugs in nursing homes are given the drugs inappropriately.

  To some extent these general concerns are also reflected in the Inspections carried out by the Care Standards Commission over the last 12 months.

  The Commission regulates 24,782 registered services and 2,106 non-registered services, of which 43% are services for older people. The annual report of the Commission does not separate services for older people and services for younger adults so it is not possible to identify the number of inspections relating just to older people's services. However, it records a total of 38,280 inspections for both types of services.

  It also reported that, of the 12,685 complaints investigated, some 10% were classified as complaints about abuse, a further 28% related to "poor practices" and 23% were about adequate staffing. That suggests that at least 7,737 complaints received by the Commission related to practices that were either directly abusive or which may have contributed to abusive practices, whether directly or indirectly. We understand that this data is being analysed further by the NCSC. However, it is likely that a very high proportion relate to older people in residential care.

  The Commission took enforcement action in 2,724 cases, with the majority (2,600) being written notifications that immediate remedial action was required and 120 being statutory notices to meet certain standards within set timeframe. In only four cases was a service closed by Magistrates Court Order.

  In preparation for this submission to the Health Committee AEA sampled 100 Inspection Reports posted by the National Care Standards Committee onto its website. These were randomly selected to reflect large and small homes across the country. In 6% of inspections medication control was not examined. However, in 55% of Reports the Inspectors made recommendations for improvements. These ranged from minor recommendations such as:

    —  "obtain a copy of the Royal Pharmaceutical Society's guidelines on administration and control of medication in a care home";

through to far more serious issues recommendations that perhaps reflect the findings of the Burstow reports,

    —  "Sixteen products prescribed for specific individuals were being used on other named Service Users. One product had expired. Some labels had been changed by staff. Of the names on the products one had moved from the home and two Service Users had died. This raises four areas of concern, these being: potential cross infection risk, potential reaction to products that have not been prescribed, trained staff breaching the Nursing Midwifery Council's standards for the administration of medicines and using products without the knowledge of General Practitioner's".

  Each individual piece of research, while not part of a national research strategy, provides an indicator that suggests a significant level of abuse. To obtain a more robust picture of prevalence, however, would entail the commissioning of specific research (as suggested in section 2 (ii) above).

Recommendation:

  That a national data collection strategy is established, which defines what constitutes an Adult Protection referral, sets monitoring and reporting standards and provides on-going data on the nature and prevalence of abuse reporting and investigation.

Recommendation:

  That further research be commissioned into the control of medication within care services, and that the NCSC is required to publish statistical details on the prevalence of medication abuse identified within its Inspection processes.







SECTION THREE

Characteristics of Abuse: The Elder Abuse Response Helpline

3(i)   The relevance of the Elder Abuse Response Helpline

  The helpline provided by Action on Elder Abuse has been operating since 1995 and was extended nationally in November 1997. The service is available weekdays between 10.00 am and 4.30 pm on a freephone number: 0808 808 8141, and it is provided by AEA, using specially trained staff and volunteers. Its primary limitation is that it can only give an indication of the nature of abuse from the perspective of those able (either mentally or physically) and willing to contact a telephone helpline. Because of the nature of some environments and the dynamics of some abusive relationships it cannot reflect the experiences of those who cannot confidentially access a telephone and speak in private, although it does have contact with people who escape, either temporarily or permanently, from such restrictions.

  Additionally, it can only reflect the contact of those who have obtained information about its services, and these are widely publicised through leaflets, posters, information campaigns, word-of-mouth, and media work. Each occasion the helpline is publicised through television or radio it receives a significant increase in calls (eg the recent McIntyre Investigates programme "Who cares for Granny?" generated an additional 94 calls to the line. One event on the Kilroy programme generated the equivalent of a month of calls in one week).

  Elder abuse, like other subjects of public anxiety, is one in which individuals who are affected (in various ways) may seek advice from an expert, anonymised source of help. The nature of contact established through such a helpline is complex: it is not simply a matter of reporting an incident but a dialogue between anonymous voices in which callers decide the level and type of information they are willing to impart. As with other advice lines it also serves as an information source for those involved in training and education, and also those operating within the arena of adult protection but who feel the need for expert advice and guidance[14].

  Unlike individual Adult Protection Committees or Coordinators who may receive periodic referrals relating to elder abuse that are complex, the helpline staff are immersed in the dynamics of elder abuse and the strategies of response and are therefore utilised as a source of expertise.

  Consequently, while it is important to acknowledge that a helpline by its very nature has certain intrinsic limitations, it is also important to recognise that the Elder Abuse Response Line provides a unique insight into the nature of elder abuse within the UK.

3(ii)   Parameters of the data collection and reporting by AEA

  Analysis of calls to the Elder Abuse Response Helpline has been undertaken on three separate occasions. In 1997 AEA published an interim analysis of 315 calls[15] and followed this in February 2000 with an analysis of 1,421 calls[16]. More recent data, covering 5,273 abuse calls, is now available and is quoted in this Memorandum.

  In considering this information the following should be noted:

  (a)  while the number of calls evaluated has increased from 315 to 5,273, all of the analyses have returned a consistent picture in terms of the nature of elder abuse;

  (b)  the information has been gathered only from those able or willing to use a telephone helpline;

  (c)  An older person may either suffer from only one type of abuse or different types at the same time, and the abuse may occur in more than one setting. This is reflected in the figures.

  (d)  In calls about abuse in care settings or sheltered housing a few were about abuse by fellow residents. When recording details of these calls, the person who the call was about was categorised as the abused and the resident committing the abuse as the abuser.

  (e)  The categorisation of those involved as "abused" (victim) or "abuser" (perpetrator) was done by the individual helpline worker based on their expertise and judgment as a result of the information given. Similarly, the worker made other decisions—such as those about whether an incident was indeed abusive. Categorisation of practitioners' occupations, family members' relationships and place where the abuse occurred was based on information given by callers. There has been no attempt to independently verify the categorisations.

  (f)  Because of the nature of the confidential helpline, and the difficulties inherent in guiding and supporting callers who are often in distress, it has not yet been possible to establish a process whereby ethnic monitoring data can be sensitively obtained. However, it has been our experience that racial abuse usually manifests itself in one of the standard five categories detailed later.

3(iii)   Who contacts the helpline and how valid is their information

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  The two most numerous users of the helpline are relatives of those who are receiving care or support (38%)—whether that is from a paid service or through unpaid family or alternative support—and older people themselves (29%). Relatives and older people invariably contact because they are unhappy about something that is happening, or has happened, and they are unable to obtain change or redress through the immediate options available to them. In some cases this is because they are unaware of their rights (eg the existence of complaints processes or regulatory bodies), and in other cases it is because they have failed to obtain a response that is acceptable to them. This is equally true for the category of friends/neighbours (10%).

  The next highest users are paid workers (19%) who contact because they have seen something, or been told to do something, that concerns them, or because they are investigating a complaint/abuse referral and are seeking advice on options or legislation. Often where workers are seeking to report an abuse that they have witnessed they are doing so with varying levels of anxiety and fear of the consequences for themselves.

  Despite the existence of the Public Interest Disclosure Act 1998 it is not the experience of AEA that this has created a culture in which social and healthcare employees feel able to disclose abuse. Indeed, it continues to be suggested to us that disclosure can lead to loss of employment, and also pressure to physically move home to another area. In some situations these pressures may be through deliberate intent by the employer. In other cases however it may result from the whistleblower feeling unable to continue in that employment, particularly where there is a feeling that the employer did not act with sufficient resolve.

  It is important to take account of the fact that the two most numerous groups who contact us are relatives and older people themselves, because this indicates a greater willingness of such groups to take action than may be previously recognised.

  Traditionally older people are not perceived as being willing to complain (and many relatives who contact us are themselves over 65), and yet this level of contact suggests they will use a service if it specialises in their needs.

  Finally, it is worth noting that the helpline staff are skilled in identifying a call in which there is doubt or uncertainty about the content or the motivation of the caller. In some situations it quickly becomes apparent that the caller may have an ulterior motive in making allegations; they may be ex-employees who harbour grudges or they may be family members who are unhappy with a collective family decision or action. In other situations, by asking pertinent questions and using their knowledge and expertise it is possible for the helpline worker to identify allegations that are questionable, although it should be noted that sometimes this conclusion can be wrong.

  Nevertheless 83% of all abuse calls contain sufficient information to be classed as demonstrable abuse.




SECTION FOUR

Characteristics of abuse: Types of elder abuse and general prevalence

4(i)  The types of elder abuse

  AEA identifies abuse in five primary categories (Italicised examples are taken from local newspaper);

  Physical, which includes slapping, hitting, burning, head butting, scalding, bruising, pushing, restraining, and the inappropriate administration of medicines (including withholding medication), etc

9 October 2003

Weston-super-Mare

  Two nursing home owners who turned a blind eye to the widespread abuse of elderly residents for more than three years were struck off the nursing register. Allegations had included that the couple had themselves behaved inappropriately when they were seen "restraining" a woman on the toilet by pulling the back of her dress up and over her face. Other abuses included a care assistant shaking the broken arm of a resident repeatedly to stop it healing quickly, and a staff member pulling chunks of hair from the head of another resident. Residents were taken to the toilet in mixed sex groups without screens to protect their dignity. The couple were alleged to have taken no action in response to complaints by other members of staff and ordered members of staff not to record injuries to residents.

18 February 2001

Oxford

  Visitors were encouraged to ring ahead when they came to see relatives at the nursing home in Oxford. It gave the staff time to hide the stench of urine and scrape faeces off the curtains. Not that they would ever see the 89-year-old man whose suppurating pressure sores had rotted the flesh right down to his bones. He was locked away upstairs, in too much pain to move and too much confusion to cry out. For the last four months of his life Alec Taylor saw no one except the proprietor, who attempted to clean Mr Taylor's wounds by hacking at the skin around the sores with office scissors and ripping out his rotting flesh, wearing gloves he had used to scoop faeces off the sheets moments earlier.

  Psychological, which includes shouting, swearing, frightening, blaming, threatening, intimidating, ignoring, humiliating, and using what someone loves or values as a weapon against them, etc.

11 June 2003

Wakefield

  A nurse accused of running a care home like a military "boot camp" escaped being struck off the nursing register despite being found guilty of abusing mentally ill residents. At a hearing last October the Nursing and Midwifery Council head that she had told a wheelchair bound 90-year-old man suffering from dementia "Don't you fuck about with me". Other serious allegations included instructing two care assistants not to lift a 78-year-old man with dementia after he had fallen on the floor with his trousers around his ankles and was bleeding from a head wound. At a reopened hearing the NMC conduct committee decided that the nurse, who for ten years had trained other nurses, acted in a way which amounted to professional misconduct. The panel decided to issue a caution, which would remain on her records for five years.

30 July 2003

Leicester

  A care home manager has been struck off the nursing register after being found guilty of hitting, dragging and roughly treating frail, elderly residents. It was alleged that the nurse pulled their hair, slapped and pushed them, ignored their injuries and shouted at patients when they did not keep quiet. The committee found 25 out of 32 allegations had been proved from the evidence of other nurses and care assistants.

  Financial, which includes stealing or defrauding someone of goods, money, pension book or property, etc.

15 October 2003

Whitley Bay

  A senior care home worker admitted systematically plundering a resident's bank account of more than £12,000. The carer pleaded guilty to six specimen charges of theft and asked for a further 41 similar counts to be taken into consideration.

22 October 2003

Dundee

  A woman who had been employed as a home help by the council for a sheltered housing complex abused her trust by stealing from two of the residents. She stole £150 from a 72-year-old woman and £250 from an 81-year-old man. Her pleas of not guilty to stealing £80 from another flat in the complex and stealing £100 and items from another flat were accepted.

  Sexual, including forcing someone to participate in sexual actions or conversation against their wishes, etc.

16 September 2003

Kendall

  A care home nurse who was struck off the nursing register in July 2001 for making lewd suggestions to elderly residents will not be allowed back into the profession. At the time he admitted five allegations of misconduct and the committee heard how he acted inappropriately, gyrating his hips against the body of a resident and touching her buttocks.

6 August 2003

Grimsby

  A nurse who molested ten helpless women patients when they were too ill to complain was struck off the nursing register. Many of the women were in their 80s and were unable to defend themselves or report the attacks because of their ailments. On 5 December 2002 a jury convicted the nurse of ten charges of indecent assault and he was jailed for three years.

  Neglect, which includes failing to provide food, or heat or clothing, appropriate medical attention (eg leading to bed sores) or needed aids for living.

14 October 2003

Teeside

  A man who was moved from a nursing home after his family became concerned for his welfare had fallen 87 times in eleven months. When his daughter first read the report, following an investigation, she thought it was a typing error. The family also believes that pressure sores were not properly treated; he was not bathed often enough, had a poor diet, and was not given enough fluids by staff. In May last year, following the man's death, the family made a complaint to the health authority, which passed it to the Care Standards Commission. Almost a year later they received a reply from the NCSC, which agreed with some of their complaints.

10 October 2003

Ramsey

  The actions of doctors came under scrutiny from defence lawyers during a manslaughter trial. The case involves a 77-year-old woman who died seven days after being admitted to hospital with pressure sores which were described as "large and necrotic and deep into the muscle and bone". Staff at the home had failed to alert doctors. The manager of the home and his deputy are both charged with killing the woman without malice aforethought.

24 October 2003

Banff, Scotland

  A Sheriff has rapped a home proprietor and manager for "unforgivable failures" in care and a "cavalier disregard" for the welfare of residents. The two women were heavily criticised for failing to observe health, safety and care requirements, including care plans. The resident was scalded in a bath and later died.

4 (ii)  Prevalence of abuse types


  The greatest type of abuse reported to the helpline is psychological (35%), followed by financial abuse (20%) and physical abuse (20%). Neglect at 10% is the third greatest form of abuse, while the "other" category (10%) includes all those calls that are peripheral to our definition eg neighbour disputes or societal abuse. Within the last year we have noted an increase in the number of complaints relating to neglect by care staff, though this has yet to be quantified.

  When looking at abuse in more detail it is apparent that some abuses may be influenced by the gender of the victim. For example, men are more likely to face financial abuse or neglect than are women. But women are more likely to face physical or psychological abuse. The following chart demonstrates the comparisons:


Characteristics of abuse: Issues relating to certain types of abuse

5(i)   Sexual abuse:

  The only category of abuse that has seen an increase in reporting to the helpline over the last few years is that of sexual abuse (3 per cent). Analysis in February 2000 reported this type of abuse at only 1.9% and it is not apparent why there has been an increase. This may be the result of a wider awareness of the nature of elder abuse, leading to increased reporting, or it may be the result of the introduction of Adult Protection policies within each local authority area (again leading to increased awareness) or it may be the result of other factors. AEA have heard concerns by some practitioners that this may be an actual increase in abuse itself, caused by serial abusers moving from childcare environments where there is increased vigilance and controls to adult care environments that are less regulated. There is, however, no statistical evidence to support this concern, although there is the potential for this to occur where abusers perceive sexual assault and rape as being associated with power and control, rather than prompted by paedophilic tendencies.

  "Sexual offenders are attracted by the vulnerability and availability of their potential victims and those who suffer from physical and mental impairment may be especially at risk." [17]

  It is also perhaps worth recognising that sexual violence affects older women as well as those that are younger. Figures from St Mary's Sexual Assault Centre make interesting reading. From January 1987 to October 1999 there were 5,888 referrals to the Centre, of which 2.2% (131) were over the age of 50 years (129 women and 3 men). The oldest female victim was 88 years of age and the oldest male victim was 93 years old. Eighty-eight cases were in the age range 50 to 59 and twenty-three were in the age range 60 to 69. Sixteen cases were in the 70 to 79 group and four cases were over the age of 80 years. When they looked at the offender's relationship to the victim they found that only 28 cases involved strangers[18].

  In February 1992 social worker Malcolm Holt began gathering a dossier on elder sexual abuse. By May 1993 he had identified 134 cases. The ratio of female to male victims was six to one. Of the first 90 cases only two abusers were female. Eighty five percent of victims were aged 75 or over. Of the women who were sexually abused 77 suffered from dementia, 76% were frail and 48% had impaired mobility. Perhaps surprisingly, only 11 of the 77 women in the first 90 cases were abused by their husbands, whereas 43 were abused by their sons, sons-in-law, brothers and grandsons. 88% of all victims were dependent on their abuser for their care[19].

5(ii)  Neglect:

  Neglect was formally recognised as a category of abuse in "No Longer Afraid"[20] and reiterated within "No Secrets"[21], reflecting the requirements of the Human Rights Act 1998. However there is little evidence that criminal prosecutions have been readily forthcoming, even where the level of neglect by care staff has been extreme.

  A number of arguments are commonly cited as to why the criminal law is little used in elder abuse and neglect cases. These include the need for a good prospect of conviction and the requirement that prosecution is in the public interest. A high standard of proof is required and there is a preference for oral evidence. The experience of AEA is that the Crown Prosecution Service often forms the view that prosecution is not in the public interest, and there is little evidence that older people are readily considered for special support under the vulnerable witnesses processes.

  However, one of the most common indicators of neglect that comes to the attention of AEA relates to the incidence of pressure sores. Also called pressure ulcers (death of skin and underlying tissues from the effect of pressure, friction and shear) these are a quality indicator and the development of pressure sores implies neglect[22]. The magnitude of this condition is illuminating … with approximately 10% hospital inpatients developing pressure ulcers[23].

  We have little indication however that the development of pressure ulcers in older people is perceived by regulating bodies with the degree of seriousness that we believe they warrant. This issue will be addressed in a later section.

Recommendation:

  That (a) a review is undertaken with regard to the decisions of the CPS taken in the last two years, where elder abuse cases have not been pursued because prosecution was felt not to be "in the public interest" and (b) subsequent guidance is devised and issued.

Recommendation:

  That advice is issued to police forces clarifying the advantages of implementing vulnerable witnesses strategies for anyone who has been the victim of elder abuse (as defined by the AEA definition and categories).

  There is also a lack of knowledge among practitioners, the police and the Crown Prosecution Service relating to circumstances in which a member of the public can be considered to have assumed a "duty of care" under case law[24] and consequently charged for any failings in that regard.

  Although this option has been available for thirty years it has not been used, primarily because the law deals more readily with acts of commission rather than omission. In the case law in question however it was recognised that a crime was capable of commission by omission, where duty of care had been assumed. In that case a couple had assumed the care of a relative who died in appalling circumstances, severely emaciated and with infected bedsores and other problems. Both defendants were convicted of negligent manslaughter.

  The failure in the use of this case law is adequately demonstrated by the case of Margaret Panting who died last year, aged 78 years of age. It is worth noting that 70 years separated Margaret from another abuse victim, Victoria Climbie, and yet there is a marked difference in the media and public attention given to the two cases. Most people in Britain know Victoria's name. Most people in Britain have never heard of Margaret.

  In the five weeks that Margaret lived with her family she suffered some sixty injuries to her body, and the evidence at the coroner's court noted:

  "This is a case of elder abuse. This lady had been repeatedly struck blows to her body, she's been excessively gripped, she's been burnt and she's probably been cut with a sharp implement. Her body was in a considerable state. There were injuries throughout her body, including grazes, black eyes, extensive bruising to the face and chest and there were recent cuts to her stomach and chest—the sort you might make with a razor blade".

  Despite the evidence, the family have insisted that Margaret inflicted the injuries to herself. It has been testified that this was not possible. No charges for the commission of a criminal act could be brought because there is no criminal charge of joint liability and no family member would state that a criminal act had occurred. However, it would be quite appropriate to bring a charge using current case law, for a failure of duty of care ie no family member summoned medical assistance for Margaret. AEA have raised this proposal with Lord Falconer and with Baroness Scotland but, to date, this option has not been pursued.

Recommendation:

  That the use of this case law be brought to the attention of the CPS and all police forces and encouragement be given to its active use in situations that appear to indicate wilful neglect.

Recommendation:

  That legislation be drafted that relates to the neglect or cruelty of an adult eg "anyone who has attained the age of 16 years and has the custody, charge or care of a vulnerable adult and who wilfully assaults, ill treats, neglects, abandons, or exposes him or her, or causes or procures him or her to be assaulted, ill treated, neglected, abandoned or exposed in a manner likely to cause him unnecessary suffering or injury to health, guilty of an offence".

  That an urgent exploration is undertaken into the most appropriate legal terminology to adequately define a "vulnerable adult", including circumstances in which vulnerability does not arise solely through a lack of mental capacity.

5(iii)  Financial abuse:

  "Financial abuse occurs in 10% to 15% of cases involving registered enduring powers of attorney, and more often with unregistered powers. Expressed as a percentage this may seem to be a relatively minor problem, but 10,000 powers will be registered with the Court of Protection this year alone and frauds involving six figure sums are by no means unprecedented".

  Of all calls to the helpline regarding financial abuse, the misuse of unregistered powers of attorney continues to be one of the greatest concerns expressed. The ease with which abusers are apparently able to convince older people that an unregistered Power of Attorney has conveyed a level of financial control to the abuser is worrying. This is particularly so given that it is impossible to quantify how many of these unregistered documents are actually in the community.

  A predominant theme that emerges from financial abuse by families relates to the expectation of a relative that they will inherit the bulk of an older person's estate and the consequent desire to preserve as much of the estate as possible.

Recommendation:

  That all Powers of Attorney be the subject of recording and control, with two levels of registration:

  a)  those that have been established, but are not yet in force;

  b)  those that are in force either due to a lack of capacity by the vulnerable person, or where a witnessed decision has been taken to bring them into force earlier.








SECTION SIX

6(i)   Gender

  In gender terms there are more men reported to us as individual abusers (40%) than women (26%). Overwhelmingly male abusers are family members (69%). But, while this is equally true for women (50%), there are also a significant proportion (32%) of women identified as paid staff.

  This reflects the experiences of the former nursing regulator, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, who reported in 2001 that men made up just under 10% of the nursing register but accounted for more than half of those involved in professional misconduct, and represented nearly 60% of all those struck from the register. [25]

  It is particularly worth noting that, in nearly a third of circumstances (30%), the abuse is perpetrated by more than one person in collusion.

  Although 22% of this `collusive' abuse is perpetrated by family members a staggering 56% is perpetrated by paid staff ie abusive practices that are institutional and passed from one worker to another. This actually gives a two-fold message, the first being a negative one about the quality of formal care. But the second message is that this form of abuse can be addressed by culture change and training. It has the potential to be prevented.

  6 (ii)  Relationship of abusers to their victims:

  The majority of abusers are related to their victim (47%), with paid workers being the next highest category (31%).

  A major point to note however is that we are unable to support the hypothesis that the stress of unpaid/family caring leads to abusive practices. While it is accepted that such caring can be intensively stressful we receive less than 1% of calls identifying these carers as abusers. Instead, from a domestic violence perspective, it is sons and daughters first (49%) and then partners (24%) who abuse.


  The information derived from the helpline tends to support the conclusions of the 1990 Homer and Gilleard research into abuse by carers[26] and suggests that physical and oral abuse has less to do with the condition of the person who is abused and more to do with their family and living situation. That is to say, the factors giving rise to the abuse stem from household circumstances and relationships and personalities, rather than from conditions common to ageing such as immobility, incontinence and dementia. [27]

  "Verbal abuse and neglect but not physical abuse were associated with a poorer premorbid relationship with the patient. Carers who admitted to verbal abuse noted frequent arguments with the patient as a feature on their interactions with the patient before the onset of dementia." [28]

  The fact is that large numbers of carers are "under stress" but do not abuse their relatives. The crucial issue is to try to discriminate between abusing and non-abusing situations.

  The primary types of paid staffs who are identified as abusers are as follows:
Type% of calls
Care Worker (Residential and Domiciliary) 36
Nurse7
Social Worker3
Hospital Doctor2
General Practitioner2
Housing Worker4
Legal services2
Police1


  The primary groups of relatives who are identified as abusers are:
Type% of calls
Son/Daughter49
Sibling4
In law9
Partner24
Parent1
Niece/Nephew1
Other12

SECTION SEVEN

Characteristics of abuse: Who are the victims?




8(i)   Gender of the victim:

  The vast majority of those who are suffering abuse are women (67%), with 22% of men identified as victims. In a smaller percentage of cases (11%) both men and women are facing abuse at the same time, and more than half of these (52%) are in some form of institutional support, primarily care homes.

  The fact that more women than men are identified as suffering abuse is likely to be a reflection of demography rather than specific targeting. Also, it has to be remembered that the majority of men of all ages in the UK live with a partner, but vastly larger numbers of women, particularly over the age of 80, live on their own. [29]

8(ii)   Age of the victim:

  More than three quarters of abuse (75.8%) is perpetrated on people who are over the age of 70 years, with 11.5% of that abuse affecting people over the age of 90 years. Fifteen of the calls to the helpline concerned the abuse of people over the age of 100 years.

  In terms of the total number of people, both male and female, identified through the helpline the following table adequately demonstrates the age range of abuse:
MaleFemale
Age range% %
50 to 541.72.9
55 to 590.41.9
60 to 641.55.6
65 to 692.37.9
70 to 744.312.2
75 to 793.69.5
80 to 846.317.4
85 to 893.08.0
90 to 941.57.8
95 to 990.31.4
100+0.40.0


  Looking at men exclusively we can see that the "threat" age band is between 70 and 89 years of age (67.9 of all abuse):
Male
%
70 to 7416.9
75 to 7914.1
80 to 8424.9
85 to 8912.0


  For women, however, it reaches double percentage points at 65 years and continues at that level until they are at least 94 years of age (84% of all abuse):
Women
%
65 to 6910.5
70 to 7416.3
75 to 7912.7
80 to 8423.4
85 to 8910.7
90 to 9410.5


  For both genders, however, there appears to be a critical period between 80 and 84 years of age.

  In looking at abuse it is always advantageous to be a little cautious about the extent of conclusions that can be drawn from data. For example, as Jacki Pritchard noted:

  "Because of their adherence to social expectations, it is likely that many men do not disclose the abuse they suffer; therefore the real prevalence is likely to be much higher that is acknowledged either by victims or by their services. [30]"

  It is also worth noting that, while the majority of older people face a single type of abuse, a significant percentage (45%) face more than one form of abuse at the same time.

SECTION EIGHT

Characteristics of abuse:


Minority Ethnic Communities

  In July 1998 AEA organised a conference to consider issues in relation to elder abuse within minority ethnic communities. This was in keeping with the charity's recognition that all nations and cultures are different, with often unique histories, traditions, religions and experiences and that these need to be taken into consideration when responding to issues as sensitive as elder abuse. This is the same approach that is adopted by the charity toward the four nations that comprise the United Kingdom, with each requiring different approaches and strategies to be acceptable. The conference received presentations from Asian, Chinese, Jewish and Polish communities.

  In approaching this issue AEA has recognised that, while it is difficult enough for the majority communities within the United Kingdom to recognise and admit to the abuse of their older people, it can be doubly difficult for some minority communities who may already feel alienated or estranged from mainstream debates and who may feel threatened by the implications of acknowledging such a sensitive issue. There are also issues of cultural and religious perceptions and differences that impact upon the definition of abuse and its interpretation in such a context.

  "Elder Abuse in its current definition is all too often not culturally defined, or ethnic specific and therefore in order to engage in dialogue about abuse with minority ethnic communities it is important to be able to recognise what is relevant and appropriate to the specific community. In looking to develop a cultural framework for elder abuse within minority ethnic communities, information has been sought from other countries in terms of how definitions and interpretations are applied. Knowing what does and does not constitute abuse in other cultural contexts is important in the UK context because it gives some indication of how we might look at abuse in a non-conformist way. It poses some difficulties because of different cultural values and attachments towards behaviour, which may make detection problematic".[31]

  In reality this statement translates into some very fundamental issues that are complex to unravel and address. Defining what constitutes abuse from a cultural perspective can directly challenge western euro-centric beliefs and values. What should take precedence? If culturally an 80-year-old woman finds it normal and acceptable to be "chastised" or struck by her 30-year-old son, who is head of household, should Adult Protection staff intervene? And if such intervention takes place, what are the options for long-term protection?

  Insufficient work has been done in this field, and there is little relevant research or statistics. However there are key messages already available from the conference that can form the foundation of a strategy. The following are extracts from speeches given in 1998.

  Asian Communities:

  "Elder Abuse in Asian communities can occur for several reasons, some of which may be related to racism and discrimination, which in turn promote anxiety and stress. Unemployment among minority ethnic men is particularly high and therefore lack of equal opportunities reinforces poor self-image and can contribute to anti-social behaviour, alcohol problems and so on.

  Once a case of elder abuse is reported it must be seen as a priority by all sections of the community and it should be dealt with in a sensitive way. The religious, cultural and language needs of the Asian older person must be taken into consideration. Health professionals, general practitioners, the police and social services should adopt common policies and develop codes of practice, not least a full understanding of the need to observe confidentiality. To reveal an incidence of elder abuse is to become exposed and rendered more vulnerable".

  Jewish communities:

  Perspectives within each minority community are similar in some matters, in terms of factors that can lead to abuse. For example, the following observation was made in relation to the Jewish community but parts of it could be universally considered:

  "Elders, particularly those living outside of their countries of origin, become very dependent on younger members of the family who are, in general, more easily absorbed into the dominant culture. Language difficulties, lack of familiarity with local customs and a different appearance or dress contribute to a heavy reliance on family members to act as intermediaries in everyday life.

  Of the total Jewish population of 285,000 in the UK in 1998 the elder population was estimated by the Board of Deputies of British Jews to be 62,500. However, the London Jewish News in the same year suggested 14 identified cases of abuse out of 1,400 referrals received during the previous quarter. It is quite possible that this is a misleading figure. The experiences of the Jewish people during the Nazi period have potentially created a strong desire to hide and remain anonymous".32[32]

  Fundamentally it needs to be recognised that, when staff in caring professions fail to recognise cultural, religious and ethnic diversity among those for whom they care, this could be interpreted as a form of abuse because it intrinsically denies that person his or her personal identity and can lead to low self-esteem. Additionally, in terms of age, it may be more appropriate to think of some ethnic elders as perceiving themselves to be old from the age of 50 years.

  "Elder Abuse as defined and recognised within the majority population does not present itself in quite the same terms within the Chinese community. The commonly supported myth of extended family support, and the stereotype of Chinese older people giving the appearance of being happy and content were contributing factors."

  Shirley Wan, Chinese Mental Health Project

Recommendation:

  That minority ethnic advocates on elder abuse be identified, trained and deployed.

Recommendation:

  That focused research be commissioned to establish the factors contributing to elder abuse within minority communities.

SECTION NINE

Characteristics of abuse: Perceptions that influence our understanding of abuse


10 (i)  Concepts of crime and ageing:

  There are at least two issues that are important when considering the concept of "elder abuse".

  The first issue is to recognise that many of these abuses could also be considered crimes (eg theft, assault, neglect, rape, breach of the Human Rights Act) and by classifying them as something different there is a real danger of lessening the impact or importance of the acts themselves, and thereby lessening the consequent importance of the victim in comparison with younger age groups. As a society, we do not readily view the assault of a 90-year-old in the same way as an assault on a 30-year-old. Partly this is about perceptions of ageing but it is about why the older person is assaulted.

  Regardless of age, each person is entitled to the protection of basic human rights. We would therefore support the arguments made by Help the Aged that "the necessary safeguarding of human rights, particularly those protected under Articles 2 (the right to life), 3 (to protection from inhuman and degrading treatment), and 8 (the right to respect for private and family life) must be secured by the positive actions of the State if they cannot be protected by individual redress".[33]

  To put this in context, where committed acts are defined as prosecutable crimes in law, it would be worth considering how often they are actually viewed as crimes in reality, and how many people are prosecuted. In avoiding or ignoring the issue of criminality there is the danger of colluding in the discrimination against the older person, and in so doing leaving them outside of ordinary civil and human rights. In short, while many protective concepts within social policy are necessarily applicable to elder abuse (and there is much to learn from the fields of domestic violence, child protection and learning disability) there are also differences with regard to older people, no less because of the inevitability of ageing and increased vulnerability.

  There are many derogatory stereotypes of older people: "senile", "crumbly", "wrinkly", "gaga", "old git", and "geriatric". But as Norman pointed out in her paper on ageism in 1987, "we don't call a sick child a pediatric, or a woman having a hysterectomy, an obstetric". She went on further to declare that the words used about old age were invariably infantilising: "old folk", "old girls", and "second childhood".[34]

  And it is this derogatory approach to the individual older person that can translate into the global view of a standardised group who are burdensome within society. As Chris Phillipson[35] argued, ageing has been seen as an increasing problem since the birth of the welfare state—enforced retirement, "elderly medicines", the loss of `self into a homogenous group of "elderly", and an increasing dependency which "increases the burden on the hard working, non-elderly population". Phillipson and others argue that this belief is not borne out of research, and state that few older people ever require or use the welfare system.

  However, by "constructing" older people as both dependent and a burden, it implies that society has developed a feeling that all people over 65 years need care. And by nurturing such a dependent (and growing) population we as a society make older people much more vulnerable. Hence the challenge is to see beyond individual prejudices and recognise that dependency is often enforced, and that we should consequently seek to work in a way which empowers people to take control over their own future and not "infantilise them".[36]

10 (ii)  Understanding abuse

  The second issue is to consider what we actually mean by abuse. For example, can a grandchild who punches an 80 year old, disabled grandparent be placed in the same category as the care worker who forgets to knock on a resident's door before entering, or who provides direct personal care to an older person without any social interaction?

  Clearly, the first scenario is grounded in the idea of "intent to inflict harm", and the concepts of abuse or assault fit relatively easily; while the second is perhaps less clear, as it is less likely that the care worker intended to inflict harm. It is this second category that is often described as "poor practice".

  We believe that this is about concepts of dependency. If the resident doesn't complain, that does not mean that this is not abuse. There is need to look at how behaviour is experienced by the recipient (in this case the resident), in order to understand whether the practice is abusive. Would you want to be treated in that way? Would the resident choose to be treated in that way if they were able bodied and could have a greater say in the intervention that is occurring? If the answer to these questions is negative, then the practices employed could well be abusive, and in effect could also constitute an assault or intimidation, as in the earlier example.

  Although the five types of abuse already described are the usual categories used by organisations, the over-arching definitions also need to include an understanding of institutional abuse (including an awareness of institutional racism.) This term can be seen from the perspective of individual institutions that employ regimes, which are essentially abusive in nature, as well as environments that are systematically abusive in their treatment, including ageism and ingrained racism. This was graphically illustrated by the conditions within Nye Bevan Lodge, a local authority home in Southwark, South London, where:

  "elderly, often confused residents were made to eat their own faeces, left unattended, physically manhandled, forced to pay money to care staff and even helped to die".[37]

  In effect, regarding a scenario primarily from a client-centred perspective (eg such as proposed in the National Services Framework for Older People) immediately assists in reinforcing the importance of that individual, instead of simply relying on preconceived notions of "norms" of older people. There is a large body of writing on the institutional provision of services and the prevalence and reasons for institutional abuse. [38]In short, perhaps Biggs, Phillipson and Kingston's (1995) brief sentence conveys most poignantly what we all need to consider:

  "Beginning to see elders as objects rather than human is the foundation on which a continuum of petty slights and abuses build into active mistreatment." [p84]

10 (iii)  The citizenship of victims

  Increasingly social care policy, influenced by Better Government for Older People (BGOP) is drawing attention to the need to place independent living and protection of older people within a wider citizenship framework. Prevention, protection and support thus being framed from a single policy focus, (No Secrets) into the wider intentions of community planning, social inclusion. crime and disorder, regeneration, neighbourhood renewal and supporting people etc. Such a move of policy focus seeks to underpin the wider and albeit implicit intentions of No Secrets.

  Rather than regarding vulnerable older people as primarily clients and patients needing protection, citizenship "seeks to reinforce the mutual obligations (between the individual and society) inherent in social inclusion policies". AEA in partnership with BGOP and PAVA is presently exploring "community based and led approaches" secured in the engagement of older people and demonstrating the necessity for "joined up" governance at local, national and UK levels.

  Furthermore, regulation needs to equally extend its focus to capture this change in strategic direction and hence reframe standards to include not only effective engagement but how far "patients, residents and clients" exercise control over their own lives, encouraging staffing regimes and organisational cultures to be underpinned by and through citizenship empowerment.

SECTION TEN

Characteristics of abuse theoretical models

  Various academics and practitioners have identified predisposing factors within any abusive situation.

  Bennett et al in 1997[39] aimed to examine the likelihood of the five most cited "risk factors" being effective in determining that abuse is occurring. This is a brief description of the five:

  Intra-lndividual Dynamics—Does the carer have a history of alcohol dependency or mental ill-health? Many previous studies had shown that these were certainly risk factors. However, there was then a query about what comes first—the stress of caring leading to the use of alcohol, or alcohol dependence making it less likely to cope with the caring role? This caused doubts as to whether this was an effective indicator of abuse?

  Inter-generational Transmission of Violence—This considered whether abuse was an extension of domestic violence into older age, or whether children of previously abusive parents subsequently perpetrated the violent activity on their dependant mother/father. Bennett et al found no evidence of either of these in their study, but this may have been because it involved private aspects of human life and was therefore notoriously difficult to penetrate in a traditional academic way.

  Dependency—This tends to be the "logical" explanation for elder abuse. However, dependency is a multi-tiered and complicated issue, which can rarely be taken on face value. Dependency can result from the benefits trap for carers, or the degree to which the "cared-for person" needs support. This is certainly a major issue for consideration in any social or health care assessment (including carers' needs assessment).

  Stress—this can easily be viewed from the perspective of the anecdotal belief that the stress of caring automatically leads to abuse. Indeed, this is too simplified a description of a predisposing reason for abuse to occur. The help line run by Action on Elder Abuse has produced research to indicate that only 1% of calls to Elder Abuse. Response Line were about abuse perpetrated by a primary carer. Far more likely was that the abuser would be a removed relative or a paid worker. Therefore, this assumption needs to be handled carefully for the sake of the carer and the cared-for person.

  Social Isolation—Research has suggested that isolation may well be a predisposing factor for abuse. This is a potentially important factor because 36% of those living in care homes and 19% of those living in private households are rarely visited by relatives or friends (with 6% of care home residents and 2% of those living at home receiving no visits at all). [40]

  However it is also possible that the older person is living with someone, but has few social ties outside of that relationship. This could even be within a communal setting.

  Pillemer and Finklehor (1989) found that "abuser deviance" was an important casual factor. They concluded that "elder abusers appear to be severely troubled individuals with histories of anti-social behaviour or instability'. [41]Mervyn Eastman highlighted the influence of pathological family cultures as a cause of violence and cruelty by abusive family members. [42]

  Penhale, Parker and Kingston[43] concluded their discussion of Risk Factors by saying:

    "Mental health, alcohol and/or substance misuse . . . (etc) . . . are important factors to consider in a comprehensive assessment. However, it is not possible for practitioners to confidently predict levels of risk of abuse simply by identifying these factors alone."

  Research by McCreadie et al[44] sought to predict a "diagnosis" of abuse by GPs in two locations. GPs were seven times more likely to have identified a case of physical or verbal abuse or neglect if they had also identified patients in five or more risk situations for abuse. The most commonly identified risk situations involved alcohol consumption, dementia and problems of a household member, including problems of a carer in their own right.

  However, the difficulty of compiling any list of "types" or risk factors is that it is rarely comprehensive; so the aim should always be to encourage questions about the lives, support needs and choices of the person in question. In other words, just because someone lives alone and perhaps has a daughter with long-term mental health problems as a carer, this does not automatically indicate a predisposition toward abuse. Similarly, someone displaying behaviour not on the "list" of indicators does not mean that they are safe and not being abused. The premise of good adult protection needs to be that information, behaviour or clues should not be judged simply on the basis of "tick boxes" or "prejudices". The aim should be to spend time drawing together the information surrounding the individual concerned, within the context of their life and within the boundaries of the policy and procedure of any particular authority.

  Roger Clough, back in 1988, indicated a comprehensive list of factors that potentially indicate a re-disposition toward abuse in institutions:

    "There have been a series of complaints over a long period, relating to more than one member of staff; the establishment is run-down and basic arrangements for laundry and hygiene are poor, for example a pervasive smell of urine: there are staff shortages and staff sickness: senior staff are on holiday: there is little supervision of staff and they are able to develop their own patterns of work (we know little of what happens at night time): staff have been in charge of the unit for a considerable period of time: there is a high turnover of staff; staff drink alcohol regularly during breaks or when on duty; there is uncertainty about the future of the establishment; there are few visitors; residents are highly dependent on staff for personal care; residents go out little or have few contacts; a particular resident has no-one taking an active interest in him or her; there is discord among the staff team or between staff and managers; the residents are troublesome, when their care makes heavy demands or when the task to be carried out is unpleasant. [45]

  Finally Whittaker has suggested that abuse between two people can occur only if a power imbalance exists between them; one person perceives himself and is perceived by the other as being more powerful whilst the other perceives herself and is perceived as being relatively powerless. These beliefs and perceptions are not necessarily conscious but are derived from the detailed routines of daily life and these establishment of patterns of interaction which confirm and reinforce the relative positions of one as more powerful and the other as less powerful. [46]

SECTION ELEVEN

Characteristics of abuse settings of abuse

12 (i)  Where abuse occurs:














  In the vast majority of circumstances (98%) abuse occurs in only one place and is not replicated elsewhere.


  Most abuse occurs in someone's own home (67%), which is not surprising as this is where the majority of older people live and where it is very difficult to monitor and establish the level of poor practice or relationships.

  However 21% of reports to the helpline concern care homes (formerly known as residential homes and nursing homes) where less than 5% of the older population actually live. This is a disproportionate figure, made more stark by the reality that callers need to be able to access a telephone in confidence—something not easy in a care home.

  In this context it is worth noting that care homes continue to provide services to highly dependent people:

  "Overall 57% of women and 48% of men in care homes had a severe personal care disability, that is needed assistance with one or more self-care tasks, compared with 4% of men and 2% of women living in private households. Assistance with dressing was the most common need, followed by help with using the toilet, transfer from bed or chair, washing and feeding. For each self-care task, higher proportions of women than men needed assistance." [47]

  Hospital settings and sheltered housing each account for 4% of all calls. With regard to hospitals we believe that this is an under-reporting. In part this can be attributed to the nature of hospital environments, and in part attributed to the functions that hospitals are performing with regard to older people.

12(ii)   Abuse varies with the setting

  Analysis of the types of abuse that occur in individual settings indicates that it is to some degree dependent upon environmental factors.


  For example, psychological abuse is greater in sheltered housing (46%) and in someone's own home (38%) than it is in care homes (27%) or hospitals (25%).

  However, physical abuse is greater in hospitals (26%) and care homes (25%) than it is in someone's own home (18%) or sheltered housing (10%). Financial abuse mirrors that of psychological abuse in that it is greater in sheltered housing (23%). and in someone's own home (24%) than it is in care homes (14%) or hospitals (8%).

  Neglect mirrors that of physical abuse in that it is greater in hospitals (23%) and care homes (18%) than it is in someone's own home (6%) or sheltered housing (5%).

  The percentages of sexual abuse are too small to quantify.

  In simplistic terms, therefore, it would be possible to suggest that financial and psychological abuses could be associated with domiciliary settings, while physical abuse and neglect could be associated with institutions.

  Within a domiciliary environment, it is predominantly relatives who perpetrate abuse. Paid workers, however, are represented as follows:
Psychological11%
Physical8%
Financial18%
Neglect22%
Sexual7%



12(iii)   Care Homes

  It has been suggested that care homes are primarily businesses with the social and health needs of residents being secondary to that reality. Nazarko in 1995 suggested:

  "Nursing homes are run as businesses with the aim of maximising profits by reducing costs. They are labour intensive businesses and their greatest cost is staff wages, nursing home proprietors seek to maximise profits by paying below the Whitley Council scales[48]."

  That perspective, however, ignores the fact that there are many good quality home environments, where the primary concern has always been the welfare of the residents. But the situation was adversely affected by the introduction of a social care, market, which sought to use a contract culture to regulate price and quality. There is no evidence that either objective was actually achieved by this strategy and it could be argued that many of the difficulties now facing social care provision have their roots in the social care market approach.

  Most providers of residential homes are independent small businesses owning one or two homes, with the very small homes tending to specialise in care for younger people with physical or multiple disabilities.[49] In such small settings, particularly those run by husband and wife teams, patterns of power in families are particularly likely to be reproduced, and the position of staff who are not involved in ownership of the business may be especially weak. For these small homes the impact of minimum standards and inspection may be particularly felt as, by their nature, they are a hybrid of business and family and therefore not easily geared to external requirements and evaluation.

  The bigger providers (eg BUPA, Westminster Health Care, Four Seasons etc) may be better equipped by their scale of operations to respond to the development of minimum standards, but there are issues for them in ensuring a consistent relationship between their various divisions/parts/homes (which may span several regions) and the regulators.



  However, we have been told of some companies who have used litigation, or legal actions, as a means of controlling complaints or avoiding bad publicity. For example, earlier this year the Channel 4 Trevor MacDonald show undertook undercover filming in two nursing homes. The footage was shared with AEA and demonstrated levels of abuse and bad practice similar in nature to that broadcast by Channel 5 in October. [50]It was primarily degrading and humiliating treatment, rather than extreme acts of cruelty.

  We witnessed scenes of a small, old woman being threatened that a catheter would be inserted into her if she continued to ask for the toilet, scenes where a care worker barged through an old man's door at 5.30 am, switched the light on, pulled back his bed covers, pulled down his pyjamas and ripped away his incontinence pad. He was still in the foetal position and just beginning to wake up as she put another pad on him, pulled up the pyjamas and the bedclothes again, switched the light off and walked out. Not a word spoken to him and the whole process took less than one and a half minutes. And we witnessed heart-wrenching scenes of an old woman sobbing in the night, alone and disorientated having only recently been moved into the home, but without a call bell as the system had been broken for weeks. When the reporter asked a member of staff how residents were expected to call for help if the system wasn't working, the worker looked genuinely puzzled at the question, thought for a few moments and then shrugged as she turned back to watch the TV once more.

  The sounds of that sobbing, down a darkened corridor late at night is what keeps us using the image of the "silent scream". Who can hear it? And how can the public hear it when the programme will never be transmitted?

  In response to the footage the homeowner fell back on litigation. He engaged a solicitor to obtain statements from every resident to the effect that they did not want their faces broadcast, and that they were happy in the home. Every resident signed, including those who were in the E.M.I unit with dementia or confusion! And. although we raised this immediately with the National Care Standards Commission, because it is difficult to believe that coercion did not play a part in this process, we are still waiting for them to tell us what they have done in response'. [51]

  Granada, in a letter to residents dated 27th June 2003, expressed the view that, "our report and the criticism it raises are very well founded and our enquiries legitimate, concerning as they do a matter of substantial interest: the proper care of the vulnerable elderly. We are satisfied with the veracity of our material and the validity of our work: we stand by our journalism."

  From an institutional perspective the factors that appear broadly consistent with abuse were adequately described by Richard Clough in 1988 (see Section 10 above), and seem to be associated with the culture and environment of the institution: poor environment, poor staff support and morale, poor role models, and poor reinforcement of good practice. Certainly, closed institutions have the potential to generate abuse.

  It has not been the experience of AEA however that abuse is directly associated with the low level of pay of care staff, in fact we have seen examples of excellent support provided by very low paid workers.

12(iv)  Hospitals:

  "We have had a succession of public enquiries pointing up the grave inadequacies in public hospitals. . .(but) little has changed for the better in some of them. . .I am determined that this gap between the good and the bad shall not remain as wide as it is today." [52]

  Despite the determination of the then Secretary of state for Social Services in 1979 we are still witnessing levels of institutional abuse of older people in hospitals that is alarming.

  On 24 September 2003 the Commission for Health Improvement (CH1) published the conclusions of an inquiry into abuse at Rowan Ward in Manchester. It adequately confirmed recognition of known abuse factors:

  CHI found that Rowan ward had many of the known risk factors for abuse—poor institutionalised environment, low staffing levels, high use of bank and agency staff, little staff development, poor supervision, a lack of knowledge of incident reporting and a closed inward looking culture. [53]

  In publishing this information the Acting Chief Executive of CHI made a most blunt statement about the failure of the NHS to learn lessons from previous Inquires of this type.

  "The care received by vulnerable older people on Rowan ward was unacceptable, but we are seriously concerned that circumstances surrounding this investigation are not unique.

  CHI has completed two previous investigations into the care of older people and has continual requests for investigations in this area. The same issues keep coming up and the NHS does not seem to be learning. The care of older people nationally is very concerning NHS managers and commissioners should take a good look at this report and ensure recommendations are embedded in their own services. Organisations must learn to monitor closely what happens on older people `s wards and open up wards to external visitors and patients' advocates."

  Staff and patient representatives told CHI that Rowan Ward had become a "forgotten service", after other trust services were relocated to another site in 2001. The relocation reduced support and maintenance services to Rowan ward and security was a major concern for staff, patients and carers. The trust's model of nursing care in older people's services was old fashioned and its culture was not open and learning. For example, on Rowan ward patients' clothing was changed and hygiene needs addressed according to a routine rather than when the need arose. There were claims and counter claims of bullying and harassment with senior staff claiming they were threatened with industrial action if modernisation was suggested and nursing assistants reporting that they were humiliated and bullied. The trust's overall systems to improve care and safeguard patients were very poor.

  CHI found very little awareness across the trust of national policy to protect vulnerable adults or of monitoring of the implementation of the National Service Framework for Older People.

  The trust lacked a unified reporting system for incidents, which hampered analysis and learning from things that had gone wrong. The absence of central trust records of any accidents or incidents on Rowan ward between February 1999 and July 2002 may have contributed to a lack of awareness of problems in older people's services. Some serious injuries, including a scald and unexplained bruising, were not reported centrally. Neither were incidents of patients leaving the ward and putting themselves at risk. Also worrying were audits showing a number of problems with the prescribing and administration of medicine across the trust. For example, there was evidence that unqualified staff commonly gave medicine on adult and older people's wards. (Quoted from the CHI report into Rowan Ward).

  The Health Advisory Service 2000 report "Not because they are old"[54] listed a number of themes that led to poor quality hospital care for older people. These themes remain equally valid today, and include:

    —  Delays during admission to hospital.

    —  Problems with the physical environment, equipment and supplies.

    —  Staff shortages, a high use of agency staff and junior staff making sometimes very major decisions.

    —  The non-availability and poor quality of food and drink.

    —  Lack of assistance with eating and drinking.

    —  Lack of privacy and dignity.

    —  Poor communication to patients and their relatives.

    —  Confusion in boundaries of care between practitioners.

    —  Poor discharge arrangements.

  A recent study in Coventry[55] into the management of elder abuse within hospital settings found that:

    —  Knowledge and awareness surrounding the issues of elder abuse were extremely poor. More worryingly, this often included an inability to recognise abuse when it presented and a failure to report abuse when it was identified.

    —  Despite most staff being aware that their role included looking for indicators of abuse, this was not being carried out in a systematic way.

    —  There was a significant lack of training across all professions with regard to elder abuse. Over 97 per cent of staff surveyed indicated that they wanted formal/further training in the identification and management of elder abuse.

    —  There was an identified need for policies, procedures and guidance to be produced that would assist in the identification and management of elder abuse.

  Help the Aged in its submission earlier this year on human rights[56] gave five examples of abusive hospital practices, taken from letters received as part of the Dignity on the Ward campaign:

  "A nurse unceremoniously lifted her shift garment they had put on her and exposed her completely in front of my son and I. It seemed terrible to me for her to be treated in such an undignified and humiliating manner".

    The nurses insisted that he get up and out of bed, despite his poorly condition and his helpless protestations, they insisted on ramming him into a wooden `high chair', with a bar across to keep him in position, quite oblivious of the fact that he had a cracked vertebra, in addition to curvature of the spine, and there he had to sit in agony until he was released."

  "Every day without fail and regardless of my time of arrival I had to change my father as all his clothes were permanently soaked in urine."

  "She was most upset because she kept on asking for a bed pan and no one arrive, or on many occasions, arrived too late and she wet herself. She was both embarrassed and hurt at the reaction she got to having wet the bed. She ended up with no dignity at all."

  "Her meal would be on the tray cold and hardly touched. More often than not her teeth would be on the locker at the other side of the bed, well away from the chair on which she was sitting. At no time was she encouraged to eat, the food was not cut into bite size pieces and no person seemed to be responsible to see that the patients received nourishment."

12(v)  Domiciliary care

  Within someone's own home an older person may receive formal support (Home Help or District Nurse) or informal care through a relative or friend. Three quarters of older people who live with the person they care for receive no regular visits from health or social services. Only one in ten older carers who live with the person they look after receive home care. [57]








  It is estimated (by the United Kingdom Home Care Association) that there are around 204,000 domiciliary care workers and approximately 50,000 new recruits each year.

  In a domiciliary setting the Elder Abuse Response helpline suggests that at least 13% of abusers are paid staffs. We strongly believe that this is under-representation of the scale of the problem within this sector. These are domiciliary care workers (Home Helps).

  Domiciliary care remains the most unregulated of care services, relying on market forces and a contract culture to maintain standards. It will not be inspected until April next year.

  Since the 1990 Community Care Act the nature of domiciliary care provision has changed considerably, as local authorities were required to stimulate the market and encourage the growth of private sector provision. This has resulted in an explosion of small, often locally based agencies that have previously had little statutory standards to achieve.

  Domiciliary care by its nature is based upon one-to-one relationships between (often) single workers and isolated, dependent individuals. Many of these workers provide excellent services and are valued and respected by the older people in receipt of their support and it would be wrong not to acknowledge this reality.

  However, it is intrinsic to this service that such relationships are difficult to manage within professional parameters, and are certainly difficult to monitor and inspect. Home Care staff who subscribe to good practices, whether as a consequence of training or supervision or personal values, are statistically in the majority. However, the very nature of the home care service lends itself to the potential for abuse because of the relationships that are established, the opportunities that present, and the isolated one-to-one relationships that are inevitably created.

  Additionally, however, the nature of the social care market within domiciliary care lends itself to the potential for abuse. It is the nature of the market that it is based upon quantity of work, rather than quality ie the more service users that a carer can support results in a more cost-effective service. The tendency of local authorities to drive down costs through "spot purchasing" care for older people has contributed to this problem.

  No matter what systems or monitoring controls that are established it will never be possible to guarantee, by external monitoring alone, that abusive activities are not occurring. Good quality domiciliary care, therefore, is reliant upon training, peer group monitoring and the culture that is created within and between teams. It is also dependent upon commissioners of service giving greater priority to the provision of quality and consistency of that service, with less emphasis on how many care hours can be purchased at absolutely minimum costs.

12(vi)   CONCLUSIONS

  The reality is that it is impossible to reach a conclusion that implies a greater risk in one setting as opposed to another. It is more likely that the nature of the risk is different.

  Institutions can create closed and collusive environments that have the potential for institutional abuse, but they also have the potential to use peer group reinforcement and support as a means of reinforcing good practice. This is not so easily available within formal domiciliary care services, where there is a greater probability of isolated working. However there are management practices within domiciliary care that can overcome this difficulty.

  Conversely, however, there is less likelihood that abusive practices are automatically transferred from worker to worker in domiciliary settings, primarily because of the potential for a domiciliary worker to develop their own "style" of working. The primary difference relates to the unique one-to-one relationship that can be developed between domiciliary worker and service user and which has the potential to be exploited in a way that is not so readily available within an institutional setting.

  Fundamentally, the factors contributing to the abuse may differ, the circumstances and type of abuse may differ, but the basic impact upon the abused person remains consistent.

  However, where care is provided more formally, there is now regulation through minimum standards and inspection and this obviously is not available for informal care.

SECTION TWELVE  SUCCESSFUL INTERVENTIONS

(i)   Underlying principles

  In considering successful intervention strategies we believe that it is necessary to start from the perspective that prevention is always better than intervention. We think that this approach should be inherent within adult protection policies and procedures, because the reality of protective work is very often about reducing the potential for abuse rather than stopping the act itself.

  Adopting this approach is important because the dynamics of elder abuse are often similar to those within the domestic violence settings ie there can be a victim who is unable to perceive him/herself as such and who is therefore unable to accept the options for escape/protection that are immediately available.

  In the absence of an immediate intervention strategy therefore, it is crucial that practitioners are taught to switch toward preventative work rather than concluding that nothing can be done and closing the case. While it might not be possible to provide protection to the older person at that precise moment, it might be possible to work towards providing protection in six months time instead, once the victim's confidence has been gained and they have been assisted to recognise and accept the options available to them.

  One of our concerns is that this preventative approach is sometimes absent from current protective casework, with practitioners asserting that there is no legislative framework within which to operate. While this perception is in fact inaccurate, it demonstrates the need for training at all levels with regard to adult protection and elder abuse.

(ii)   Collaborative working

  Successful adult protection requires multi-layered strategies that operate simultaneously and it needs co-ordination between agencies, the sharing of information and a willingness to seek expert advice from others.

  This invariably involves strong leadership from the top down, co-ordination between practitioners, liaison that keeps the older person at the centre of planning, and empowerment. None of this is complex, but all of it requires resistance to pressures that can be intense—heavy caseloads; budget and time constraints; resource and training difficulties; the temptation to see an older person's refusal of help as an opportunity to close the case, or evict, or ignore.

  There have been too many cases in other abuse settings where everyone knew a little bit of the picture, but no one shared, where no one took the lead and everyone failed. We do not need to repeat child protection errors in order to learn them again in adult protection.

(iii)   Developing unique strategies

  It is not appropriate to simply import child protection strategies into adult protection, because they may not necessarily work. Adults with capacity have choice, and while they may be frail and vulnerable, they have the right to exercise that choice and control as they wish. It is therefore important to take what is appropriate from the experiences of other abuse scenarios, but then tailor it to meet the needs of adults.

  A good example of how strategies may not easily "import" into this field would be to consider `places of safety'. In child protection this can be a ready option to ensure the security of a vulnerable child. But with an older adult such a strategy might be disastrous. Not only might the victim refuse, but also it might be the very thing that the abuser wants—in order to gain possession of the family home. And the older victim might subsequently die from the move. So we need to think creatively about this new area of protection.

  Much more work needs to be done to develop unique strategies for adult protection, and these will only clearly emerge when practitioners have gained greater expertise in this field, have received quality training and have had the opportunity to share their experiences and learn from each other.

(iv)   Employment screening

  We believe it is important to prevent potential or known abusers entering the sector in the first place, rather than react to them post-abuse. That must involve screening out potential employee-abusers before they become care staff. To do this effectively employers need Criminal Records Bureau checks that are fast and efficient, and the introduction of the POVA (Protection of Vulnerable Adults) list: the register of known abusers.

  It also means the integration of regulatory systems, so that abusers identified within one sector can be simultaneously prevented from switching to another sector and repeating abuse.

(v)   Addressing poor practice: Training

  The experience of the AEA helpline is that poor practice forms the greatest percentage of abuse perpetrated by paid staff. Consequently, AEA strongly promotes training as one guaranteed method of reducing the potential for such abuse.

  This approach has been informed by research in both America and the U.K., which indicates that training can directly impact upon levels of abuse. In 1988 and 1991 Pillemer conducted research into abuse within nursing homes and concluded that the quality of care was shown to have been better in homes that could afford to hire staff with better training and where staff/patient ratios were relatively high. Nurses and nursing aides with lower levels of education were likely to have more negative attitudes towards older people. [58]British research has subsequently confirmed this conclusion. [59]

  Appropriate training however is required throughout the sector, including for providers, inspectors and investigators.

  Providers need training in how to provide quality care—and increasing numbers of experienced social and health care staff are beginning to question training strategies that rely either on theory, without practical training in caring techniques, or which are not in reality a training process at all eg National Vocational Qualifications, which assess current skills and knowledge but do not develop new practical skills.


  Regulatory inspectors in social and health care need training appropriate to the services they are inspecting ie an inspector of nursing homes should have a good knowledge of nursing practice. But they also need training in understanding what constitutes abuse, what are unacceptable thresholds that warrant enforcement action, how their role should integrate with adult protection policies, and how to focus on outcomes instead of processes.

  Investigators need training in how to investigate, what options can be considered when seeking solutions, and what legislation can be utilised to progress protection.

  And abuse training needs to be integrated into the professional programmes for Nurses, Doctors—including General Practitioners—pharmaceutical advisers in Primary Care Trusts etc. We believe it is only by making adult protection training an integral part of mainstream development that the scale of the problem can be effectively challenged.

(vi)   Addressing poor practice: Culture

  We believe that the culture of an organisation can encourage abuse. In our experience it is not linked to low pay—there are many poorly paid staff providing excellent care. But if boundaries are not maintained and reinforced, they can lead to abuse. For example, the care worker who casually barges into a resident's room without knocking is breaking through a boundary. Once that becomes the norm, without being challenged by managers or peers, then the next boundary is ready to be breached. And so on until a very serious act occurs.

  So culture is important and that can only be affected by training, supervision, setting realistic standards, monitoring them and reacting accordingly. And such reactions should not just be about punitive action. The provider who is maintaining a quality environment and responding to an abusive staff member needs access to good advice and guidance, and that support should be available from the relevant regulator.

(vii)   Expanding choice

  The absence of choice within the social care market can assist abuse.

  If a service provider needs to be closed down, there must be an alternative place for those people who are dependent on their services, or there must be an alternative way of maintaining the service independent of that provider.

  Without some room for such manouvre the balance of regulation and control will slip and the ultimate sanction will not be available. This will invariably mean that abusive situations will continue longer than is acceptable while regulators seek to "work" with a failing service, or it will mean that another service provider eventually will have to pick up the pieces.

  Consequently we need to investigate ways in which the care sector can be adequately financed and supported, whether through increased funding, local formulae for agreeing costs, direct provision or some other strategy.

(viii)   Encouraging healthy questions

  We need to develop a culture that is not restricted by professional boundaries, but which encourages practitioners to seek other opinions and advice. And we need to address the failures in whistle blowing. We need to create a climate where it is acceptable to question, to challenge, to say "Excuse me. . .?" without there being repercussions.

  And we need regulation that encourages! For example, right now the Nursing and Midwifery Council gives no protection to a Nurse who whistle-blows. So it is not surprising that so few actually come forward.

  Fundamentally, we need to prevent secrecy, not encourage it, because the abuser thrives in secrecy. Close a door and have no one watching, and who knows what can happen? Whether that person is in his or her own home or a care home, secrecy gives opportunity and someone will exploit that opportunity!

(ix)   Empowerment

  We need to look genuinely at empowerment. Recent research in England into Adult Protection showed that the vast majority of local authorities had met their statutory responsibility in enabling procedures (97 per cent). But they had failed miserably to publicise the existence of those procedures[60]. Less than 2% had invested in systems to tell people of the existence of Protection. Which raises the basic questions: What value is a Human Right if you don't know about it? What value is a Human Right if you can't access it?

  People need to be able to make informed choices, without pressure, without coercion, and without the advice giver having any secondary loyalties. We cannot infantalise adults and there is a real danger that decisions are taken "in the best interests" the victim, but without their consent. And this is all too easy where there is doubt about someone's capacity to make decisions.

  But if we take away someone's right to make a decision—or fail to identify what they would have wanted—and we do it in the name of protection, then we run the risk of becoming abusers ourselves.

(x)   Funding of adult protection

  Both No Secrets and In Safe Hands were important steps toward the protection of some of the most vulnerable members of society. But they placed major responsibilities on key agencies without any financial assistance to achieve those aims. The absence of any "pump-priming" has consequently led to a postcode lottery of adult protection, and the degree to which a local authority has invested in the process is totally dependent upon the financial and other constraints peculiar to the local area.

  As a consequence, some areas have dedicated staff, others have placed the responsibilities on existing staff, and still others are withdrawing from positions established last year. There is no co-ordinated training on adult protection issues and some local authorities are very conspicuous by their absence from the adult protection environment. For example, very few London Authorities have established a high profile on this issue.

  Ring fenced funding of these processes is crucial to future developments, and this was certainly recognised in the Republic of Ireland where the establishment of Elder Abuse teams in each Health Board was accompanied by

73,000 each.

(xi)   Vulnerable witnesses

  There is a very real danger in assuming that a witness who is very old does not have a good memory, will not make a good witness, or will not want to undergo the stress of a trial where his or her evidence will be tested.

  The real difficulties that may be presented in some cases, particularly where there is little other evidence apart from that of the victim, should not be underestimated, but we believe that situations should always be examined on a case by case basis and the use of Vulnerable Witness support mechanisms automatically considered.

(xii)   Whistle blowing

  The reality of whistle blowing in social or health care is that it challenges individual security and relationships, and serves to identify only certain types of abuse. It is also only staff that are seen as legitimate whistle blowers, as residents, service users or relatives are often not seen to possess the status, expertise or professionalism and are instead perceived as complainants or witnesses.

  Whistle blowing also has another characteristic in that it appears only to be worth it if the abuse or neglect is so blatant that an individual feels it is worth paying the price. [61]

  We believe that whistle blowing can be a crucial component in strategies to combat abuse, but this will only happen when the act itself becomes integrated into the wider philosophies of good practice, codes of conduct, and expected activities ie when professional bodies perceive a failure to whistle-blow as an unacceptable breach of their codes of conduct.

SECTION THIRTEEN

Informal Carers

  As has been indicated previously, it is not the experience of the helpline that informal carers (ie those who are actually providing the hands-on care) are abusers. That is not to say that there is not a proportion of such abusers but, predominantly it is sons and daughters and partners, and others who are not direct care givers, who abuse.

  Of all areas of abuse, however, acts perpetrated by family members, neighbours and friends are the most difficult to immediately identify and resolve. Often it can only be challenged by sensitising people who are peripheral to the older person (eg other neighbours, postal workers, milk deliverers, church visitors) as well as practitioners and others (GPs, dentists, domiciliary staff, A&E staff) and this involves (a) raising public awareness and (b) integrating abuse awareness into the training of all staff.

  Additionally, there continue to be large associations of retired people, and increasingly popular retirement courses, that could be utilised to raise awareness and assist people to act as "alerters" of abuse.

  We also believe that a greater use of advocacy would assist in raising awareness and assisting older people to raise issues of concern. AEA is currently engaged in a three year, DoH funded programme to train and accredit advocates in understanding the dynamics of abuse, and in appropriately advocating for elder abuse victims.

  Very often the nature of family abuse is confusing and complex and is not easy to resolve. Providing opportunities that reduce secrecy and allow families to interact with wider societal practices would contribute to a possible reduction in abuse ie increasing the potential for actual or prospective victims, and informal carers, to fully access their rights as citizens.

SECTION FOURTEEN

Formal Carers

  To a significant degree the Government has begun the process of introducing legislation and guidance that sets quality standards or offers the opportunity of protection to vulnerable adults and these initiatives have been strongly welcomed by AEA.

  However we have concerns that the implementation does not always prove successful, that important proposals are sometimes delayed or weakened for pragmatic reasons, and that key agencies and providers are often not "signed up" to the reality of change.

  In part we believe that this situation is caused by the difficulties associated with introducing regulation into what is theoretically a free market. In part it is associated with poor implementation planning that unnecessarily creates resistance where there should be enthusiasm. And in part we believe it is caused by a degree of governmental timidity that prevents them from following through on initiatives that are sometimes controversial and sometimes expensive.

  Whatever the reasons however, the result is that we are not always seeing the impact initially anticipated from these changes. The following section explores this issue and considers whether the difficulties rest with the initiatives themselves, with funding, or with the method of implementation.

(i)   Criminal Records checks and the Protection of Vulnerable Adults list

  While registers that hold information on criminal or disciplinary activity do not by themselves guarantee that abusers cannot enter the social and health care system, they are key components to reducing the opportunity of such access. For certain occupations that allow unsupervised one-to-one access to vulnerable people (eg domiciliary care) they are crucial tools for protection.

  However, to make Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks effective there needs to be a very quick turnaround in information, otherwise the protective processes hinder recruitment activity (and there is a strong view within the care home sector that this is already happening). Such delays inevitably lead to frustration and resentment by service providers who already find it very difficult to recruit good quality staff.

  On 1st November 2002[62] the then Minister of State at the Home Office, Lord Falconer of Thoroton, announced that the Home Secretary had agreed with the Secretaries of State for Health and Education a number of measures to defer the existing or proposed requirements on certain occupations or office holders to obtain a CRB disclosure. The effect of these decisions was that the following groups of staff no longer required a CRB check:

    (i)  anyone employed in a care home prior to 1 April 2002. (Deadline for disclosure moved from 31 March 2003 to some unknown time in 2004);

    (ii)  Nurses supplied by nurse agencies; and Workers supplied by domiciliary agencies.


  In addition he announced that the Secretary of State for Health had agreed to postpone the implementation of the Protection of Vulnerable Adults (POVA) list provided for in the Care Standards Act.

  On 27 November 2002[63], Lord Falconer failed to reply to a suggestion that additional resources were required for the Criminal Records Bureau. Instead he justified the delays on the basis that they had to "make the numbers (applying for CRB checks) so that they could be sufficiently processed. He also stated that he "had to make hard choices about where those priorities are—children in residential care, new staff in care homes, doctors, people who foster—situations where we think there is a real priority".

  This reiterated a statement made by the Prime Minister on 13 November[64] that "we are trying to focus on those who may have implications for the most vulnerable in our society. . . .And we should concentrate on those that are . . .those in the most . . . in the categories where there may be the most risk."

  These decisions were not based upon a comparison of risk factors but were justified by the absence of data on the prevalence of elder abuse. The situation consequently has become highly damaging. The Government raised expectations of protection but then failed to deliver on those expectations, and vulnerable people have been left directly at risk as a result. It clearly was not acceptable for Lord Falconer to address these concerns by indicating that "these people were at risk prior to the CRB anyway".

  Additionally, the situation continues to be confusing. Although a care home provider cannot directly employ a new member of staff without a CRB check, they can do so if they receive them through an Agency that does not need to undertake such a check.

  This also implies a picture of government priorities, which can best be described as a hierarchy of vulnerability. Children cannot be placed at risk of abuse but vulnerable adults can. The Government had already accepted that the abuse of vulnerable adults occurs and that legislation and regulation was required. These postponements were therefore based upon financial expediency and not a reduction of need and that is unacceptable.

  Running a quality care service is a balance of tensions between funding, staffing, quality and humanity (amongst other things). When any of those tensions cause the balance to be upset there will be problems. When there are already difficulties in recruiting staff it does not help to have a protective measure (like CRB checks) that makes the situation even more difficult. Despite robust statements from the Government there are too many good providers saying that checks are still taking months to achieve and this needs to be recognised and addressed. But the answer cannot be to undermine protective measures; it has to be to make them work. There is nothing wrong with the concept of CRB checks or a POVA list. There is a lot wrong with under-resourcing such initiatives.

Recommendation:

  That sufficient funding is invested in the Criminal Records Bureau to ensure a standard turnaround of no more than one week between appropriately submitted enquiry and the provision of data.

Recommendation:

  That immediate steps are taken to ensure the introduction of the POVA list as soon as practicable, and no later than 1 April 2004.

(ii)   The General Social Care Council and the Nursing and Midwifery Council

  Both the GSCC and the NMC have similar aims and objectives and perform similar functions. The primary difference between them is that the GSCC is a new body while the NMC has inherited the mantle of the old UKCC (United Kingdom Central Council for Nurses, Midwives and Health Visitors).

  The General Social Care Council (GSCC) was launched in 2001 as a new body, while the Nursing and Midwifery Council (NMC) was established in April 2002 and succeeded the former UKCC.

  The primary functions of both bodies are to promote the highest standards of care for the benefit and protection of the people who use services and the wider public. They both either currently or will maintain a register of social care staff or nurses, promote a code of practice and set the standards for education and training.

  That however is where comparisons must end. Thereafter, the approach of the two bodies toward the challenges facing them is very different. While the GSCC has embraced its objectives in a very positive manner, the NMC has weakened or undermined a number of key objectives. This approach was adequately demonstrated by Adrian Reyes-Hughes, Director of Policy and Standards at the NMC, who stated in a public consultation letter dated 26 September 2002 that "although these requirements present challenges, the Council has no choice but to introduce them".

  Examples of this different approach can be found in the following: both bodies are required to satisfy themselves that registrants are of good character and are "physically and mentally fit".

  For good character the GSCC has decided that applicants should disclose any relevant issues such as disciplinary history and criminal convictions. Details are confirmed by their employers, who are asked to endorse each application based on their knowledge of the person and any criminal records checks they have done. As a further check, the GSCC also ask a manager who knows the applicant to verify the identity of the applicant to make sure they are who they say they are. The GSCC advises that their Registration Committee, made up of lay people and qualified social care workers, may consider disclosures about character. They also reassure applicants by telling them that disclosing a criminal conviction will not necessarily prevent someone from being registered—each case will be considered individually.

  The NMC have decided that, for good character, registrants simply vouch for each other, or the applicant can make a personal declaration when joining a training programme. In renewal terms it implies an "old boys club" relationship whereby registrants simply validate each other. Despite pointing out that such an approach could not cope with those situations in which nurses engage in institutional abuse and share abusive practices (eg the nurse mother who vouches for the nurse daughter) the NMC have confirmed this approach.

  For health verification the GSCC have decided that applicants will be asked to declare any health conditions that could affect their ability to do the job safely. Again, they indicate that telling them about a health condition will not necessarily prevent someone from being registered, but could lead to conditions being placed on their registration so that they can work safely. The health requirement is not a bar to registering for people with disabilities. They also advise that the Registration Committee may call for medical reports to help them assess declared health conditions and determine applicants' suitability for registration. They may decide to approve registration but place conditions on it.

  The NMC have decided that applicants should make a personal statement.

(ii)(a)   Specific issues relating to the GSCC

  The initial priority group for registration by the GSCC is the 70,000 qualified social workers, followed by care home managers and residential childcare workers. The Government established this priority and there may be more government pronouncements that could affect the speed of such registration. In addition, there may be a government initiative to ensure that another grouping in the social care workforce should be treated as a priority group alongside social workers. [65]

  It is estimated that over a million people work in social care services in England. Of these staff, 80% have no relevant professional qualifications. The largest group amongst professionally qualified staff is qualified social workers. About 65% of social care staff work in the private and voluntary sectors. [66]Residential Care is the largest source of employment, followed by domiciliary care, accounting for over half the total workforce. [67]

  On current figures it has been estimated that it will take between 10 and 18 years to successfully register all social care staff. Given the nature of the social care workforce it is our view that the registration of care staff (ie those who are not professionally qualified) should therefore be given precedence over professionally qualified staff who rarely have access to vulnerable people on a daily one-to-one basis.

Recommendation:

  That, with immediate effect, priority be given to the registration of residential care staff and domiciliary care workers.

(ii)(b)   Specific issues relating to the NMC

  Earlier this year the NMC engaged in public consultation on whether or not to change the level of proof required in professional conduct hearings from criminal (beyond reasonable doubt) to civil (balance of probabilities). During this time period they simultaneously reduced the number of professional conduct hearings that were being held each month in order to balance their finances.

  Many organisations and individuals supported the move to the civil standard of proof because they felt it would protect the public more effectively. Some people argued that the civil standard would allow hearings to be more flexible, making it more suitable for the NMC. However others, primarily nurses and their trade unions, opposed the change on the basis that a higher standard of proof was more appropriate when dealing with a person's livelihood.

  Earlier this month they announced that they intended to keep the level of proof at the criminal level. This effectively excludes many issues of concern that would result in disciplinary action in most other professions.

    "We have decided that public protection is best served by admitting more evidence rather than changing the standard of proof. This will also ensure practitioners continue to receive a fair hearing. The NMC has left the way open to reconsider its position in the light of other regulators' experience of using the civil standard." [68]

  We believe that, contained within this statement by Jonathan Asbridge, President of the NMC, are key messages about the problems facing the NMC. Firstly, switching to a criminal level of evidence would not reduce the fairness of the conduct hearings for nurses —otherwise, by implication, our Court system must be unfair—and it is worrying that the NMC (and nurses) perceive it as such. And secondly, the decision to admit additional evidence to hearings inevitably draws questions as to why such evidence is being excluded in the first place.

  It is certainly impossible, in our view, to relate the decisions taken by the NMC over the last 18 months with the commitments given Mr Asbridge when he first took up the position,

    "Trust should be earned, not inherited. Greater confidence to question and challenge all professions must be a good thing. The NMC is clear that its primary focus is the public and public protection".

  Earlier this year AEA advised the NMC that it was losing the faith of the public and was increasingly being seen as an extension of the nurses' trade unions. Since then nothing has occurred to alleviate that concern.

  To indicate the seriousness of the situation we wrote to Adrian Reyes-Hughes on 16 October 2002 and brought his attention to our concern about NMC decisions, and in particular a decision to allow a convicted child abuser to remain on the nurses register:

    "I must express my total disbelief at the recent decision by the NMC professional conduct committee to allow this nurse to remain on the register because he has given an undertaking not to work with children". This man has been placed on the Sex Offenders Register for 10 years but continues to deny his actions, despite his conviction. The very obvious issues that arise in this decision are:

    (i)  He had already acted deceptively by failing to declare his conviction to the NMC. This does not indicate a predisposition to honesty; or a commitment to the principles implicit in nursing.

    (ii)  He had no choice but to give the NMC an undertaking not to work with children. He is on the Sex Offenders Register.

    (iii)  He continues to deny his crimes, which cannot give anyone confidence in his undertaking.

    (iv)  There appears to be no evidence as to his motivation in carrying out these crimes. What evidence does the NMC have that vulnerable older people will be safe from his actions? What makes the NMC confident that he will not prey on older people? How does the committee justify the view that "the clients in his care are not at risk"?

  In response the NMC indicated that they had no control or veto over the decisions of individual professional conduct committees, that the Council did not have the power to appeal against the decision of one of its professional conduct committees, that the fact that the nurse was supported by the RCN, his current employers and numerous colleagues "obviously had an influence on the decision made by the Committee", and that training has been provided to all those sitting on professional conduct committees.

  To put our concerns in context we supplied the NMC with a list of identified nurse abuse issues that had come to our attention in the first six months of 2002:

Abuse cases 2002

  11 April  Disciplinary hearing on Nurse Manager responsible for two care homes. He admitted keeping £3,500 of benefit money, which should have been paid to a resident. He has paid the money back and will not be struck off but has received a five-year caution.

  12 April  Care home nurse who slapped and swore at resident with dementia, when he strayed towards an out of bounds kitchen, was found guilty of common assault at a hearing in Leicester Magistrates' Court.

  13 April  Nurse given an official caution after pleading guilty to five charges of misconduct at a Hebburn old people's home. She left elderly patients alone in dining rooms, used suction pumps on them too often and locked them in their rooms.

  15 April  Nurse who abandoned epileptic 80 year-old lady in her wheelchair told she can carry on working in care sector. Also said to have scalded a 57 year-old disabled woman for crying too much. Nurse now taken courses.






  16 April  Nurse who humiliated a patient at Cheyne House nursing home (in North Carlton nr Lincoln) by pouring cranberry juice over her head has been struck off. Other abuse detailed.

  17 April  Liverpool nurse struck off after found guilty of professional misconduct. She allegedly beat an elderly woman with a TV remote control at care home in Crosby and deliberately shook a bottle of soda water before undoing the lid and squirting resident.

  18 April  Nurse at home in Co. Durham struck off. She ridiculed Pope in front of devout catholic (leaving her in tears). Also, a carer had to grab nurse's hand to stop her poking male victim in the eye after nurse had twisted his nose. Residents lived in fear.

  19 April  Nurse failed to recognise and respect the uniqueness and dignity of a patient and did not respond to her religious beliefs in an appropriate manner. "A nurse working with frail patients should be beyond reproach . . ." said NMC.

  26 April  Nurse, who admitted to seven charges including head butting an 89 year old man who has since died, has been struck off the nursing register "in order to protect the public".

  26 April  Nurse, who put a patient back to bed after she fell and broke her leg and left her there for five hours, has been struck off. The incident took place in BUPA run West Ridings nursing home where the lady has returned after being rushed to hospital.

  26 April  Nurse has admitted assaulting two women in their 90s and holding a hand towel over mouth of 92-year old but denied inserting flannel into mouth of 99-year old and slapping her face. Sheriff awaiting medical report on nurse, sentence deferred until 4 June.

  2 May  Owner of The Firs Nursing and Residential Home (closed in 1997) has been struck off. She was found guilty of four offences of professional misconduct, which included leaving the residents in the care of untrained staff while she took time away from the home and leaving keys of medicine cabinet to her daughter as well as leaving drugs in open view.

  17 May  A psychiatric nurse faces being struck off after he was convicted of attacking an 81-year old patient in a nursing home; The incident took place at Abercorn Nursing Home in Lanarkshire. In another incident he twisted a lady's arm up her back when she refused to get undressed and take a bath. The nurse has lost his job and sentencing has been deferred pending reports.

  17 May  Nurse who told an elderly patient it was "about time she died" was struck off. She also called another old lady "silly and smelly" and ordered staff not to wash or change other residents. Her two year reign of terror took place at Cotswold Nursing and Residential Home near Burford, Oxon.

  24 May  Nursing home care manager who left a blind 86-year old woman to lie on the floor in her own excrement without food for six and a half hours and also told colleagues to ignore cries for help from a 76-year old woman has not been struck off the nursing register but has merely been let off with a caution. The offences took place at St Catherine's Nursing Home in Nantwich. One resident's daughter spoke in defence of manager saying she was an excellent nurse.

  5 June  A cruel nurse has admitted assaulting a 99-year old and a 92-year old at Argyll Lodge Nursing Home in Helensburgh last summer. Sheriff at Kumbarton Sheriff Court has called for further reports. Nurse will be sentenced next month.

  6 June  A 35 year-old male nurse has been struck off the Nursing Register by NMC after being found guilty of seven charges of misconduct. They included ramming a paper towel into a terrified pensioner's mouth, force feeding another so she nearly choked and using abusive language. Incidents took place at Holmewood's Manor Nursing Home and Blackwell Care Home near Alfreton.

  8 June  Nurse at Doncaster care home has been found guilty of misconduct but the NMC have rejected claims that she sprayed water in the face of an 89 year-old patient. Nurse claimed she threw away a small quantity of drugs found in treatment room because she did not want the patients to find them. Hearing has been adjourned.

  26 June  Nursing Home Manager who stole from patients at Elm Lodge Nursing Home in Thorne has been struck off the nursing register. He was convicted of theft and false accounting and jailed for two months.

  27 June  Matron of Templehouse Nursing Home in Mossblwon near Ayr was struck off after being found guilty of assaulting four frail patients in her care. The NMC heard how she routinely lashed out at the three elderly women and one man. All four were suffering from senile dementia and did not complain but she was reported to police after concerned care assistants witnessed the beatings.

  28 June  A nurse, who lied about his age because he thought he stood a better chance of employment if he said he was younger, has been accused of a catalogue of attacks spanning his employment at three separate care homes. The attacks, allegedly, took place at Burston House Hospital at Diss, Overbury House nursing home in Norwich and Bilney Hall nursing home in Dereham. All the assaults were witnessed by other care workers and included laying into a frail old man "like a professional boxer".

  On current track record it is difficult to see how the public can have any confidence in the workings of the Nursing and Midwifery Council. Certainly we continue to have grave reservations about its ability to deliver change in accordance with the spirit and intent of the new regulations.

Recommendation :

  That, as a matter of urgency, there should be an independent review of the progress made by the NMC in meeting the objectives defined in legislation, with particular regard to the protection of the public.

(iii)   The National Care Standards Commission

  The NCSC[69] represents a major initiative by the Government, intended to establish consistent standards of care provision, and it has successfully brought together staff from over 230 previous regulators. It has been responsible for maintaining inspections at the same time as integrating staff into a new organisation, and this has been done against a background in which the demise of the Commission was announced just days after its commencement.

  In effectively pursuing its statutory duties the Commission has significant opportunities to identify poor practice and/or abuse. It is the Commission's duty to ensure that where such practice and abuse is identified that this is properly referred and investigated. In addition the Commission has recourse to a range of statutory powers that may aid investigation, compliance with statutory requirements and where necessary the cancellation of registration. [70]

  A major contribution to the reinforcement of adult protection procedures has been made by the NCSC in establishing an Adult Protection Protocol, agreed with the Association of Directors of Social Services and the Association of Chief Police Officers. We believe that this protocol will significantly improve the collaboration between the Commission as a regulator and Adult Protection teams across the country, and will reduce those occasions in which vulnerable adults "fall between the two stools". This is an excellent document and we commend it—and the commitment to good practice that it represents—to the Inquiry.

  The establishment of minimum standards on the one hand and a consistent approach to inspection on the other is crucial to the improvement of care practice. We therefore strongly welcomed the establishment of the Commission, but expressed some concerns about the lack of "joined up" planning that led to its almost immediate termination and replacement by the new Commission for Social Care Improvement (CSCI).

  Standards and Inspections are an important part of adult protection but there are inherent limitations on what it is possible to validate through an inspection process. As a means of establishing the quality of environmental factors, as a means of confirming the existence of policies and systems, and as a means of directly accessing staff and service users it could be considered successful. If it is used to advise and guide—and this is relevant primarily for providers who are willing to improve practice—it can be helpful and supportive. But it is highly questionable whether one announced and one unannounced inspection of a care provider can identify and challenge subtle abuses, practices that are psychologically abusive, or practices that are institutional in nature. AEA has witnessed undercover footage of staff within care homes joking that homes get two Christmases, the normal December one and then the day that an Inspector makes an announced visit. Such footage has also included care staff confirming that they regularly mislead Inspectors.

  But whatever about the inspection of care homes—fixed institutions in which it is at least theoretically possible to observe the interaction of groups of staff with groups of residents—we have grave concerns about the mechanics of inspecting domiciliary care. Leaving aside the fact that it is possible to verify the existence of policies and procedures we have very real concerns about the likelihood of genuinely inspecting the quality of care provided by domiciliary services. The very nature of the service—often one-to-one contact in closed and isolated environments—militates against genuine external evaluation.

  Consequently we believe that the imposition of minimum standards and subsequent inspection are only one—very important—part of the process of improving overall care quality. Another very important part must include the investment of resources, the provision of training, and an active support for service providers in creating cultures that are intolerant of abuse. The lessons that can be learnt from the Hospital "Ward Matron", the setter of standards and expectations, should not be lost on us. Progress cannot be made by the imposition of standards and inspection from the outside. It must include a strategy that is inclusive of providers and which assists them to achieve and maintain quality standards. That is different from turning a blind eye to abusive practices, or downgrading their seriousness, in a false belief that this equates with collaborative regulation. It does not. It equates with collusion.

  While there is much to be commended in the establishment of the NCSC, the very strong principled messages about quality care that have been given by some of its senior team, and the quality work that has been undertaken by many Inspectors, we do have a number of concerns relating to its ability to deliver consistency and the degree to which it has compromised on some issues.

  At times it appears as though the priority for the Commission is not the resolute pursuance of quality care for vulnerable people but is instead a desire to maintain a good public image and a positive relationship with providers. While we both applaud and support the desire of the Commission to work with providers to improve service provision, there has to be a threshold for that strategy, a level of abuse and seriousness in terms of the impact of abuse or neglect that commands immediate enforcement and closure. To do less is to condone and collude, and to leave it to someone else (whether relative, victim or next homeowner) to pick up the pieces.

  We would not wish to see these concerns carried forward into the new CSCI.

  Key areas of concern for us in terms of the Commission are:

(iii)(a)   terminology and approach toward grieving relatives

  We have repeatedly expressed concerns to the Commission that, while we recognise that they must ensure responses to relatives are legally accurate and appropriate, the style and approach of responses are harsh and abrupt and, in parts, somewhat dismissive. In some cases the style and construction of reports are more appropriate to internal NCSC Board meetings than as a means to advise and inform complainants. It appears as though the Commission has difficulty in balancing the need to be legally accurate with an ability to communicate sensitively and appropriately.

  In that context we have examples of the Commission telling a grieving relative that the weight loss of her mother was probably due to the death process. We have examples of an 80 year-old relative being invited to a meeting with an NCSC Area Manager, only to find that the Area Manager had not even had the professionalism to read the file in advance. (And, if an organisation like AEA can only get responses like "we'll get back to you on that" what hope is there for relatives?) We have examples of Inspectors refusing to divulge information under a misinformed interpretation of the Data Protection Act, and this includes delaying the provision of information to a police investigation. We have examples of NCSC staff misrepresenting No Secrets to relatives. We have examples of grade 5 pressure sores resulting in NCSC recommendations to improve record keeping, rather than addressing the neglectful practices that led to the development of the sore. And we have examples of NCSC staff undermining Adult Protection strategies.

  We find it unacceptable that the transfer of responsibilities from former regulators to the Commission resulted in abuse situations being effectively unchallenged, with the Commission refusing to accept any responsibility for the actions or decisions that had occurred prior to their existence. While we accept that there might be legal problems in such a transfer of responsibilities it cannot be right that complainants were left with no redress for the abuse of themselves or their loved ones. This is an unacceptable situation and must not be repeated when responsibilities transfer to CSCI.

(iii)(b)   lack of focus on outcomes

  We have concerns that the focus of much inspection work is on processes rather than outcomes. Regrettably we find it necessary to state the obvious, the existence of a policy or procedure is not in itself evidence that an action is being taken in accordance with the requirements of legislation. Despite this however, NCSC Inspections reports clearly indicate that it is often material documentation that is used to evidence practice, rather than statements of staff or residents and rather than Inspectors witnessing activity.

  The National Minimum Standards for Care Homes states:

  "The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance in accordance with written policies".

  This is an important Standard as it reflects the intent to prevent elder abuse. For the avoidance of doubt, its focus is on the registered person ensuring protection, with this intent being backed by written policies.

  In preparation for this submission to the Health Committee AEA sampled 100 Inspection Reports posted by the National Care Standards Committee onto its website. These were randomly selected to reflect large and small homes across the country.

  In 6% of Inspections the Inspector had not assessed this Standard. In 28% of cases a written policy was missing or incomplete and in 25% of cases no training had been given to staff on recognising or responding to elder abuse. But, of grave concern to AEA, in only 7% of cases had the Inspector sought to validate what was being said by Homes staff through conversation with Service Users. There were good examples within that 7% of Inspectors approaching this issue appropriately,

    "Service users spoken with said that they were not afraid of staff and that the staff were kind."

    "Service users spoke of being able to approach the manager if they had any concerns about their lives at the home".

  But in the majority of cases there was no evidence within the relevant section, or the body of the Reports, to indicate that such validation had occurred. While it is probable that the NCSC would argue that individual sections of Reports should not be considered in isolation or that the Inspectors impressions are implicit within the totality of Reports we do not agree. The dynamics of abuse are subtle and complex. The identification of abuse requires an understanding of those dynamics that we do not perceive within Inspection Reports, and this lack of understanding is often evidenced to us by complainants.

  (iii)(c)   lack of robustness in challenging poor practice

    "The caller's father had died following admission to the home, she believed due to neglect. When she spoke to the NCSC she was told by the Inspector that he had a good relationship with the home owner, and asked if she would like to come down and discuss things before making a complaint. The caller had refused and was taking the complaint forward."

    "The Agency care worker had contacted the NCSC about another care worker who had seven confirmed cases of theft from clients recorded against her, but was continuing to work. The NCSC had told her they could not do anything until the new regulations came into effect."

Recommendation:

  That there is an urgent review of the Inspection Strategy established by the Care Standards Act and used by the NCSC to:

  (a)  focus attention on outcomes; and

  (b)  identify additional methods, other than inspection visits, to establish quality of care and absence of abuse

Recommendation:

  That, full compliance with the articles of the Human Rights Act are made a pre-condition of registration of care services under the Care standards Act.

  (as proposed by Help the Aged)

  (iii)(d)   lack of consistency in standards of inspection

Observation A:

  "There are areas of good practice highlighted in this report, particularly the assessment of new admissions to the home and well documented care planning provided by the manager. Several sets of care documentation were seen during the visit. There was evidence of thoughtful and holistic care planning, regularly reviewed."

Observation B:

  "Daily records should be expanded to provide more than merely a record of physical care given to service users. Care documentation and accident records were seen by both inspectors, and some inconsistency was evident in the standard achieved. Some service users had thorough and well reviewed care plans in terms of physical needs being met, but all demonstrated a lack of care planning to meet social needs in an individual manner. In two instances, scratching and bruising were recorded in the daily record of a service user, but this had not been carried forward to the accident and incident book. One service user had lost a significant amount of weight. However the care plan did not reflect this problem, and there was no evidence of referral to a doctor or dietician."

  The above observations were made by the same inspector about the same care home, with just 10 weeks between them. This however was the home from which Mrs Frances Hales was admitted to hospital with a necrotic sacral pressure sore measuring 5cm by 5 cm. She also had a reddened area on one hip and a shallow granulating area on the other. She did not have capacity and was therefore unable to articulate her concerns and she was heavily dependent upon the home for all activities of daily living. She died shortly after her admittance to hospital.

  Unfortunately it has been our experience that there is a degree of inconsistency between the quality of inspections undertaken. While some variation is understandable, given the nature of amalgamating inspectors from 230 separate agencies to create one body, we do not see evidence of a willingness to acknowledge errors or learn from such processes. One Inspector may feel it appropriate to define an activity as abusive, while another will consider it poor practice and take lesser action in response. It is not possible for us to quantify the extent of this problem, but it is a regular issue that comes to our attention.

(iii)(e)   thresholds of unacceptable practices.

  Following on from the above paragraph, there must be established thresholds below which any desire to "work with" a provider is superceded by the responsibility to protect service users. The development of necrotic pressure sores, the failure to obtain medication because of institutional practices, or unexplained injuries and bruising that leads to hospitalisation would all be good examples of extreme situations involving the NCSC where enforcement action was not taken and low key messages were instead given to the home managers.

    "She had pain in her neck, multiple bruising to her face, arms and legs, and a dressing covered a laceration to her left elbow. Her left arm was extensively bruised. Her right wrist was swollen and extensively bruised and she was totally unable to use this arm. Subsequent X-rays indicated she had a colles' fracture to her right wrist and her neck was placed in a collar. Photographs taken just before she was removed to A&E clearly show the arm as broken".[71]

  In the above case, no referral was made to the Local Authority Adult Protection Team, no referral was made to the Nursing and Midwifery Council, and no nurse admitted knowing about or dressing the lacerations.



  Instead the NCSC recommendations focused upon the reinforcement of existing NMC guidelines; the need for pre-admission assessments; the need to develop care plans; the need to monitor residents; the need to keep daily logs; the need to report and log changes to resident's conditions; the need to control and obtain prior approval for the administering of "homely" remedies. Somewhere within this process the painful death of an old woman was lost.

Recommendation:

  That,

  (a)  if not already written guidance is established, detailing abusive circumstances in which enforcement action is mandatory; and

  (b)  that mandatory training is provided to all Inspectors in understanding the dynamics of abuse, warning signs, and action to be taken.

(iv)   The National Services Framework

  With the launch of No Secrets in 2000 and the subsequent production of the National Services Framework for Older People in 2001 it was anticipated that some fundamental issues within the National Health Service (eg lack of awareness, lack of training, staff attitudes and approach) would be addressed. Unfortunately there appears little evidence of this. When we talk to practitioner members within the NHS we are often told that there appears to be a view among many NHS senior staff that adult protection and elder abuse is now being addressed by social services departments, and that consequently issues can be referred sideways if and when they arise. In reality we believe that the situation is far different, with key issues relating to the training of NHS staff being neglected.

  A major flaw within the NSF is that it does not link or cross-refer to No Secrets, and in fact does not even address elder abuse as an identified category requiring attention. Considering the realities of wards like Rowan Ward in Manchester and the CHI report (see Section 11) this is unsustainable as an approach. Without links into Adult Protection there are vital areas of health practice and development that are being masked and diluted, and this was perhaps starkly illustrated by the CHI observations with regard to Rowan, where older people were systematically subjected to physical and psychological abuse. It is against this backdrop that the NSF should be evaluated and, in its present form, found wanting,

  "Many staff feel that older age services are disadvantaged within the trust. There is little evidence of progressive practice in older age inpatient services and the trust does not put enough emphasis on patient experience. There are several mixed specialty wards for older age patients. Older age patients are cared for in wards that vary considerably in terms of environment, facilities and activities available to patients; some are unsatisfactory. The trust's culture has been described .as resistant to change.

  Within the health community, older age mental health services have not been a priority and are not mentioned in the local delivery plan. Responsibility and accountability for the quality of care is unclear.

  There is little evidence of systematic implementation and monitoring of the NSFs in the health community. The trust drew up action plans in response to the NSFs for older people and mental health but there has been no regular reporting on progress to the board. There is no strong leadership or accountability for NSF monitoring externally or internally, and they have not been used to drive change. There is a confused system of performance management with different people taking responsibility for the NSF delivery and targets. Most staff interviewed by CHl were confused about the NSFs: some had not even heard of them.

  CHI was told that progress is slow on some of the targets that relate to older age mental health services including single assessment. There has been no internal audit of progress against the NSF targets. The trust reports that an audit of the NSF for older age is now being undertaken.

  Since the NSF for Older People is more recent than the NHS for Mental Health, and there are fewer specific targets, the process is less developed and there has not been any specific monitoring. In terms of monitoring, older age services have been generally lower in priority than acute services or working age adult mental health services; older age mental health services are even lower. It has been described as "the Cinderella of Cinderellas".

  The strategic health authority acknowledges that momentum for the NSF for Older People has, to some extent, been lost. There is little evidence of achievement or progress in older age mental health services. The local delivery plan does not contain any targets specifically for older age mental health services. There is no baseline information for single assessment and the steps to achieve the April 2004 target have not been outlined. The NSF agenda has been swamped by policy imperatives such as NHS funded nursing care and there has been no resource to support its implementation. [72]

  Despite the failure to include a specific Standard on elder abuse within the NSF it would still be possible for its interpretation and implementation to challenge abusive practices. Currently however there is nothing within NSF documentation or "champions toolkits" that reflect this approach. The Standards however are open to such interpretation:

  Standard 1: rooting out age discrimination, could include ageist approaches that encourage abuse, rather than just focus on exclusion from treatment.

  Standard 2: Person centred care, should include the emerging single assessment process and specific risk assessment protocols covering abuse and integrated provision of services.

  Standard 3: Intermediate care, could include the unnecessary admission of many older people into long-term residential and nursing care.

  Standard 4: General hospital care, could include specific training of all staff in relation to the identification and challenging of abuse, as well as the establishment of triggers within A&E to respond to potential victims.

  Standard 6: Falls, could extend to initiating appropriate responses and assessments of older people who have suffered falls, to take account of the possibility of non-accidental injury.

  Standard 7: Mental Health in Older people, could include consideration of the dynamics that might lead to abuse and what models of intervention are most appropriate.

  Standard 8: The promotion of health and active life in older age, could include an abuse prevention strategy.

(v)   Conclusions

  Legislation and regulation require good quality consultation to ensure they are appropriate and relevant to the sector involved, coupled to sensible implementation planning. But initiatives also require adequate funding and the political will to follow through, even where they might prove unpopular but are necessary.

  A good example of where the Government raised expectations and then mishandled implementation relates to criminal records checks and the POVA list of known abusers. This mishandling has made everyone—providers, regulators and charities such as AEA—unhappy.

  The imposition of standards and inspection is crucial to the establishment of quality care, but must be supported by equally valid investment in the training, education and culture change of those responsible for the provision of care. One strategy without the other is unlikely to be successful.

  Some regulators have approached their responsibilities better than others, and in part we believe this has resulted from a "weakening of the message" emanating from government. The current approach by the GSCC is to be welcomed, and the introduction of CSCI next year gives an opportunity to pull adult protection/inspection back onto course. Some regulators need to be re-evaluated in terms of the decisions they are taking.

SECTION FIFTEEN

Additional Recommendations

  Recommendations not contained within the body of the Memorandum.


(i)   Funding

  There is no doubt that some of the failings in current adult protection and social and health care provision relates to inadequate funding. The postcode lottery of adult protection is a direct consequence of (a) adult protection guidance not having the same degree of priority as children's legislation and (b) No Secrets and In Safe Hands not receiving any central funding.

Recommendation:

  (c)   That, current adult protection guidance (ie No Secrets and In Safe Hands) be given legislative status, rather than that of Section 7 guidance;

  (d)  That Adult Protection processes are ring-fenced financed as part of government funding to local authorities.

  There is also a huge question mark over whether or not care homes and domiciliary services are receiving sufficient revenue to allow them to provide quality care and meet new statutory responsibilities. This needs to be independently evaluated and recommendations brought forward.

Recommendation:

  That the current funding of social and health care be the subject of an independent enquiry to establish the true costs of service provision, whether there any shortfalls, and how these can best be met.

(ii)   NHS responsibilities

  The effectiveness of the NSF in combating elder abuse has yet to be proved and there continue to be grave concerns about how it was constructed and whether or not it will achieve change without the introduction of an emphasis on abuse. Health staffs are often in unique positions to identify and respond to abuse and have the potential to filter isolated abuse scenarios in a way that is not readily available to other staff eg District Nurses, A&E staff

Recommendation:

  That any national data collection strategy should include obtaining data from hospitals and primary care services.

Recommendation:

  That mandatory training is given to health care staff with regard to the nature of elder abuse, the warning signs and what action can be taken . . . This training to be available to hospital and primary care teams, including District Nurses and ancillary staff.

(iii)   Policies and procedures

  The development of meaningful policies and protocols are crucial to:

    —  sensitise workers to elder abuse and neglect and promote education;

    —  develop a consistent response to cases;

    —  facilitate accurate data collection. [73]

  But such an approach needs to be integrated across professions and regulators so that the potential for an abused person to be lost within systems is consequently reduced. Currently this is not happening, although it should be noted that good progress is being made within Wales.

  Local authorities should be more proactive in ensuring that the public and other professionals are aware of and can easily obtain guidance and policies on dealing with abuse of vulnerable adults.

Recommendation:

  That a review of all local authority adult protection policies is undertaken by the DoH to establish levels of consistency and areas requiring improvement.

  Local authorities should publicise the route for referral of cases of suspected abuse ensuring that all vulnerable adults can be referred. Callers should not be expected to phone one department after another to find someone to accept the referral (eg in Lincolnshire a housing support worker was advised that referral of a vulnerable adult could not be accepted as the adult concerned (a single homeless person) was not elderly, learning or physically disabled, or mentally ill).

Recommendation:

  That all regulators are required to ensure that their policies and procedures are supportive of adult protection procedures, and cross-refer in relation to abuse ie that one regulator informs another where abusive practices fall within their respective remits.

(iv)   Sheltered Housing

  There must be rigorous enforcement of the Supporting People quality standards by Administering Authorities, particularly the Core Service Objective C1.3 "Protection from abuse" which requires:

    —  support providers to have "robust up-to-date procedures for avoiding and responding to actual or suspected abuse or neglect" which are "fully understood by staff";

    —  service users to be aware of the procedures for reporting abuse or neglect.

  The Housing Inspectorate and Audit Commission should treat this aspect of their inspections with the utmost priority.

  Local authorities should be obliged to involve housing organisations when cases of elder abuse are reported to them, to avoid the situation in which, following a referral of abuse, housing staff are excluded from strategy meetings, monitoring arrangements etc, despite their often unique position.

November 2003






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71   Letter from AEA to Ron Kerr, Chief Executive of the NCSC, dated 10 February 2003. Back

72   Commission for Health Improvement investigations (2003) "Investigation into matters arising from care on Rowan Ward, Manchester Mental Health and Social Care Trust",TSO. Back

73   Watson, EA, Patterson, C, Maciboric-Sohor, S, Grek, A, Greenslade, L, (1995) "Policies". Back


 
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