No secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse.

Foreword There can be no secrets and no hiding place when it comes to exposing the abuse of vulnerable adults.

We are also committed to providing greater protection to victims and witnesses, and the Government is actively implementing the measures proposed in 'Speaking Up for Justice', the report on the treatment of vulnerable or intimidated witnesses in the criminal justice system. That report recognised that there were concerns about both the identification and reporting of crime against vulnerable adults in care settings, and endorsed the proposals made by the Association of Directors of Social Services, and others, that a national policy should be developed for the protection of vulnerable adults. It was agreed that local multi-agency codes of practice would be the best way forward.

The development of these codes of practice should be co-ordinated locally by each local authority social services department. To support this process this guidance is being issued under Section 7 of the Local Authority Social Services Act 1970. Government departments have worked closely together on the preparation of this guidance and we commend it to local authority social services departments, the police service, and the health service. It will also be of interest to the independent sector, as well as users and carers. John Hutton John Denham Charles Clarke Department of Health Department of Health Home Office

INTRODUCTION 1.1 In recent years several serious incidents have demonstrated the need for immediate action to ensure that vulnerable adults, who are at risk of abuse, receive protection and support. The Government gives a high priority to such action and sees local statutory agencies and other relevant agencies as important partners in ensuring such action is taken wherever needed. This guidance builds on the Government's respect for human rights and results from its firm intention to close a significant gap in the delivery of those rights alongside the coming into force of the Human Rights Act 1998.

1.2 The aim should be to create a framework for action within which all responsible agencies work together to ensure a coherent policy for the protection of vulnerable adults at risk of abuse and a consistent and effective response to any circumstances giving ground for concern or formal complaints or expressions of anxiety. The agencies' primary aim should be to prevent abuse where possible but, if the preventive strategy fails, agencies should ensure that robust procedures are in place for dealing with incidents of abuse.

The circumstances in which harm and exploitation occur are known to be extremely diverse, as is the membership of the at-risk group. The challenge has been to identify the next step forward in responding to this diversity. page 6 - Section 1 1.3 This guidance is issued in furtherance of the Government's commitment to develop such policies at national and local level. It is commended to all commissioners and providers of health and social care services including primary care groups, regulators of such care services and appropriate criminal justice agencies. These statutory agencies should work together in partnership (as advocated in the Health Act 1999) to ensure that appropriate policies, procedures and practices are in place and implemented locally. They should do so in collaboration with all agencies involved in the public, voluntary and private sectors and they should also consult service users, their carers and representative groups.

1.4 Local authority social services departments should play a co-ordinating role in developing the local policies and procedures for the protection of vulnerable adults from abuse. Social services departments should note that this guidance is issued under Section 7 of the Local Authority Social Services Act 1970, which requires local authorities in their social services functions to act under the general guidance of the Secretary of State. As such, this document does not have the full force of statute, but should be complied with unless local circumstances indicate exceptional reasons which justify a variation.

1.5 This document gives guidance to local agencies who have a responsibility to investigate and take action when a vulnerable adult is believed to be suffering abuse. It offers a structure and content for the development of local inter-agency policies, procedures and joint protocols which will draw on good practice nationally and locally. Coherent strategies should be developed, in all areas of the country, by all the statutory, voluntary and private agencies that work with vulnerable adults.

1.6 Structure of this document. Section 2 covers issues of definition. Sections 3, 4, 5 and 6 provide guidance about the protection from abuse of vulnerable adults by the creation of a multi-agency administrative framework (Section 3), the development of inter-agency policies and strategies (Sections 4 and 5), and the formulation of inter-agency operational procedures designed to implement those policies when instances of abuse or suspected abuse come to light (Section 6). Section 7 discusses the provision of broader guidance for staff, users, carers and members of the public.

1.7 When developing operational guidance, local agencies should refer to the publications dealing with the abuse of vulnerable adults which appear in Appendix II. Section 1 - page 7 * See also Making decisions - a report issued in the light of responses to the consultation on the Law Commission's document (1999).

2. DEFINING WHO IS AT RISK AND IN WHAT WAY 2.1 In defining abuse for the purpose of both national and local guidance it is important to clarify the following factors: Definitions which adults are 'vulnerable'? what actions or omissions constitute abuse? who may be the abuser(s)? in what circumstances may abuse occur? patterns of abuse; and what degree of abuse justifies intervention? 2.2 Which adults are vulnerable? In this guidance 'adult' means a person aged 18 years or over. 2.3 The broad definition of a 'vulnerable adult' referred to in the 1997 Consultation Paper Who decides?,* issued by the Lord Chancellor's Department, is a person: "who is or may be in need of community care services by reason of mental or other disability, age or illness; and page 8 - Section 2 who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation". 2.4 For the purposes of this guidance 'community care services' will be taken to include all care services provided in any setting or context. 2.5

What constitutes abuse? In drawing up guidance locally, it needs to be recognised that the term 'abuse' can be subject to wide interpretation. The starting point for a definition is the following statement: Abuse is a violation of an individual's human and civil rights by any other person or persons. In giving substance to that statement, however, consideration needs to be given to a number of factors.

2.6 Abuse may consist of a single act or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.

2.7 A consensus has emerged identifying the following main different forms of abuse:

physical abuse, including hitting, slapping, pushing, kicking, misuse of medication, restraint, or inappropriate sanctions;

sexual abuse, including rape and sexual assault or sexual acts to which the vulnerable adult has not consented, or could not consent or was pressured into consenting;

psychological abuse, including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks;

financial or material abuse, including theft, fraud, exploitation, pressure in connection with wills, property or inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits;

neglect and acts of omission, including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating; and

discriminatory abuse, including racist, sexist, that based on a person's disability, and other forms of harassment, slurs or similar treatment.

Section 2 - page 9 Any or all of these types of abuse may be perpetrated as the result of deliberate intent, negligence or ignorance.

2.8 Incidents of abuse may be multiple, either to one person in a continuing relationship or service context, or to more than one person at a time. This makes it important to look beyond the single incident or breach in standards to underlying dynamics and patterns of harm. Some instances of abuse will constitute a criminal offence.

In this respect vulnerable adults are entitled to the protection of the law in the same way as any other member of the public. In addition, statutory offences have been created which specifically protect those who may be incapacitated in various ways. Examples of actions which may constitute criminal offences are assault, whether physical or psychological, sexual assault and rape, theft, fraud or other forms of financial exploitation, and certain forms of discrimination, whether on racial or gender grounds.

Alleged criminal offences differ from all other non-criminal forms of abuse in that the responsibility for initiating action invariably rests with the state in the form of the police and the Crown Prosecution Service (private prosecutions are theoretically possible but wholly exceptional in practice). Accordingly, when complaints about alleged abuse suggest that a criminal offence may have been committed it is imperative that reference should be made to the police as a matter of urgency.

Criminal investigation by the police takes priority over all other lines of enquiry. 2.9 Neglect and poor professional practice also need to be taken into account. This may take the form of isolated incidents of poor or unsatisfactory professional practice, at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other.

Repeated instances of poor care may be an indication of more serious problems and this is sometimes referred to as institutional abuse. 2.10 Who may be the abuser? Vulnerable adult(s) may be abused by a wide range of people including relatives and family members, professional staff, paid care workers, volunteers, other service users, neighbours, friends and associates, people who deliberately exploit vulnerable people and strangers.

2.11 There is often particular concern when abuse is perpetrated by someone in a position of power or authority who uses his or her position to the detriment of the health, safety, welfare and general wellbeing of a vulnerable person.

2.12 Agencies not only have a responsibility to all vulnerable adults who have been abused but may also have responsibilities in relation to some perpetrators of abuse. The roles, powers and duties of the various agencies in relation to the perpetrator will vary depending on whether the latter is:

Section 2 a member of staff, proprietor or service manager; a member of a recognised professional group; a volunteer or member of a community group such as place of worship or social club another service user; a spouse, relative or member of the person's social network; a carer; ie: someone who is eligible for an assessment under the Carers (Recognition and Services) Act 1996; a neighbour, member of the public or stranger; or a person who deliberately targets vulnerable people in order to exploit them. Adults at Risk


Who is a Vulnerable Adult? This may be any person 18 years or over who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of themselves or unable to protect themselves against significant harm or exploitation.

What is abuse? Abuse is the mistreatment, violation or neglect of a person by another or group of others. It can occur as a single incident or as part of a repeated pattern. It can be spontaneous or pre-meditated.

Anyone who's been abused in therapy will know all about the nice/nasty tactics employed by abusive therapists. Never mind all the self disclosure and so called 'Transferrance'.

Who is abused? Any person may be the subject of abuse, male or female. Those who are physically, mentally or emotionally dependent on others are often the most vulnerable.

Well Unconditional Positive Regard - pretending that you care about someone when you don't. Is a very quick to build up emotional dependency. And the sudden withdrawal of that support for whatever reason is abusive..

Are there different kinds of abuse? There are several categories of abuse; Physical abuse; e.g. pushing, punching, shaking, pinching, slapping, restraint, withholding care or medication Neglect; e.g. failures to meet someone's care needs, either deliberate or unintentional

Physical abuse can take place in therapy, and with regards to medication, subscribing dangerous drugs without due care is very common.

Sexual abuse; e.g. the vulnerable adult is involved in sexual activity for which they do not, or are unable to give their consent.

Consent does not exist in therapy. Its a simple as that. The power is always with the therapist.

Emotional abuse; e.g. verbal threats, offensive or belittling remarks or other behaviour that causes distress or concern to another person

Most clients often put up with a tremendous amount of abuse believing that its part of there treatment. And if they Do complain - they are often told they resisting, and its the abuse is the only way they can get better.

Psychological abuse, including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks;

When it comes to therapy - most of which is voluntary - something that you feel you need because you have a problem that you cannot deal with on your own, the latter sentence must apply.

Financial abuse; e.g. another person uses the resources of the vulnerable.

Abusers in therapy often begin their abuse by stepping up the amount of appointments - creating dependency and of course increasing their income.

Who Abuses? The vulnerable person usually knows the abuser. They may be; A family member A friend or neighbour A paid or volunteer care worker A health worker, social worker or other professional.

Wherever there are vulnerable people, you will find abusers. One question that always needs to asked is why abusers ever joined the organisation they did - if not to bring them into more contact with people who they can abuse.

Where does the Abuse happen? Vulnerable adults can be abused in any setting. Examples include; In their home A carers home Residential Home or Day Centre Nursing Home. At work or education centre.

And a therapy room.

What should I do ? If you are being abused or are concerned about someone you know, it is very important to tell someone.

And be prepared to be co-abused and disbelieved.

Remember that every adult has the right to: a life free from fear to be treated with dignity to have their choices respected and not be forced to do anything against their will. If you are concerned that you or a vulnerable person you know may be at risk of abuse, please do not ignore it.