Preventing abuse

The aim of this code is to promote good practice. One important element of good practice is to guard against any kind of exploitation, neglect or abuse of residents. An environment which is constantly seeking to improve the life and care of residents automatically tends to guard against bad practice.

In spite of registration, inspection, internal monitoring, quality assurance systems and codes of practice, regrettably abuse occurs. Sometimes this may be unwitting or unintentional perhaps through ignorance or neglect. At other times, however, it may be deliberate, whether subtle or overtly cruel. There is now greater recognition of the fact that abuse does occur and a fuller understanding of how it arises.

'Elder abuse is 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.'

Action on Elder Abuse

Abuse is the harming of another individual usually by someone who is in a position of power, trust or authority over that individual. The harm may be physical, psychological or emotional or it may be directed at exploiting the vulnerability of the victim in more subtle ways (for example, through denying access to people who can come to the aid of the victim, or through misuse or misappropriation of his or her financial resources). The threat or use of punishment is also a form of abuse. Abuse may happen as a 'one-off' occurrence or it may become a regular feature of a relationship. Other people may be unaware that it is happening and for this reason it may be difficult to detect. In many cases, it is a criminal offence.

9.2.1 Physical abuse

Rough handling or unnecessary physical force, either deliberate or unintentional, used in caring for a resident is abuse. Injuries may not always be visible although often there may be bruises, broken skin, cuts, burns or broken bones. During an episode of abuse, damage to property or clothing may also occur. Restraining residents so that they cannot move, or by shutting them in a room, is abusive. However, it may sometimes be difficult to draw the dividing line between justifiable and unjustifiable restraint.

9.2.2 Verbal abuse

Shouting and swearing at someone should be regarded as abusive behaviour. In addition, speaking to a resident in a quiet but threatening way so as to make the resident fearful or to make the resident an object of ridicule is equally abusive.

9.2.3 Emotional abuse

Playing on someone's emotions to make him or her afraid, uneasy or unnecessarily dependent is another form of abuse. Exploiting a resident through using personal information gained through the caring relationship is an abuse of the trust vested in the carer.

9.2.4 Abuse through the misapplication of drugs

The use of drugs to control or restrain a resident is unacceptable unless medically required. The over-use and misuse of sedatives and other medication, which too often happens in homes, should be regarded as evidence of bad practice.

9.2.5 Financial abuse

Financial abuse includes the improper use or control of, or the withholding of, a person's money, pension book, property, bank account or other valuables.

9.2.6 Racial abuse

Victimising people, verbally insulting them and physically attacking them because of their racial or ethnic origin is abusive.

9.2.7 Sexual abuse

Forcing someone to take part in sexual activity against his or her will is abuse and a criminal offence. The force does not have to be physical. Undue emotional pressure placed on an individual may lead him or her to acquiesce in behaviour he or she finds unacceptable.

9.2.8 Neglect

The withholding of care and treatment when it is required is a form of abuse. Similarly, depriving residents of the essentials of everyday life, such as food, clothes, warmth and personal cleanliness should also be regarded as a form of abuse.

There are many reasons why abuse occurs in residential and nursing homes. They range from the individual to the institutional:

• abuse may result from the actions of individual members of staff because they lack the training, experience and management support to cope with the stresses of caring for people who require a high level of assistance;
• occasionally it may occur because individual members of staff set out deliberately to harm residents;
• more often, abuse occurs because the home, its managers and staff slip, often without realising it, into a set of attitudes which reflects low morale, defensiveness about their competence and a lack of concern and respect for residents;
• over-work, lack of appreciation, low pay and low self-esteem may all contribute to the development of an environment in which abuse becomes an accepted feature of daily life.

This demonstrates clearly the need for:

• careful staff selection procedures;
• training and management support for staff once in post;
• leadership from senior management;
• the development of a working environment which values staff, does not demand too much of them and rewards them adequately.

An environment which may provoke abuse:

• where there are inadequate staffing levels to cope with a high incidence of incontinence;
• lack of trained and experienced care staff;
• absence of staff supervision by trained and experienced managers;
• terms and conditions of employment which do not provide holidays or guarantee other basic employment rights;
• a casual approach to resident privacy where staff walk into rooms unannounced, doors are left open when residents use the toilet, staff talk about residents over their heads or divulge confidential information.

9.4 Prevention

9.4.1 Prevention of abuse policy

All homes should have an explicit prevention of abuse policy. This will demonstrate commitment at the highest level to promoting an abuse-free environment where there are policies and practices in place which ensure that institutional abuse (that is, abuse which is fostered by poor management and staffing procedures) does not occur and that abuse by individuals is identified and eradicated (through the disciplinary process, leading to dismissal where appropriate). The policy should include:

• a statement of principle that the home is committed to preventing abuse;
• an outline of training procedures in abuse prevention;
• an outline of disciplinary procedures in the event of abuse occurring;
• information about how to use the complaints procedure if abuse occurs;
• information on the range of organisations which can provide advice and support for staff.

9.4.2 Staffing procedures

The quality of life in the home is underpinned by the qualities of leadership and competence shown by the homeowner and manager. Beyond that, much depends on the calibre of the staff team. It is essential that basic good practice in staff recruitment, training and supervision is observed.

This involves:

• taking up references and character checks. It is good practice to confirm written references by telephone calls;
• including specific reference to the avoidance and prevention of abuse in job descriptions to demonstrate how seriously it is taken; induction procedures which include going over the prevention of abuse policy;
• regular supervision sessions between manager and individual staff members to provide support in coping with stressful situations and to encourage staff;
• encouraging an atmosphere where staff feel able to discuss and therefore prevent the development of potentially abusive situations;
• assuring staff that their jobs will not be threatened if they 'brow the whistle' on abusive behaviour by other staff;
• making clear in the terms and conditions of employment and in the disciplinary procedures that abusive behaviour is a dismissable offence. Instances of serious abuse should be regarded as gross misconduct and subject to instant dismissal. Lesser forms of abuse should be subject to the normal disciplinary procedure, which if repeated would lead to dismissal;
• ensuring that professional codes of conduct are observed. In addition to the internal disciplinary procedures, sanctions imposed through such codes (for example, for nurses) will apply.

If the situation is urgent, the person witnessing the abuse should:

• immediately challenge the person who is abusing the resident, even though this may be difficult to do, and try to persuade him or her to stop;
• report the incident to a senior manager straightaway.

If the immediate risk to the resident has passed a more considered approach might be helpful. The person witnessing the abuse should:

• check which of the home's policies and guidelines have been broken, or check against this code; write down all the relevant facts;
• consider using the home's complaints procedure if appropriate;
  or
• consider the most appropriate senior member of staff to approach and whether it would be helpful to have another member of staff involved;
• ask for a confidential meeting with the most senior manager appropriate at which the abuse is raised;
• the manager should then decide what action to take (for example, invoke the disciplinary procedure, take evidence, call in the police).

If the above action does not stop the abuse, or if the home's management is involved or is unwilling to take the necessary corrective action, then the person witnessing the abuse should:

• speak to another trusted member of staff if not already involved;
  or
• in larger organisations, report the matter to headquarters if insufficient attention is being paid to it by managers in the home;
  or
• seek advice from a professional or expert organisation, a homes association or registration authority;
  or
• report the matter to the registration authority.

If at any time the situation involves something which is against the law, or the resident or witness is in danger, the person concerned should:

• contact the police and ask for immediate help.

While restraint may sometimes be necessary, it should only be considered after all other courses of action have been exhausted. Commonly used methods of restraint include:

• cot-sides;
• harnesses;
• sedatives;
• baffle locks;
• arranging furniture to impede movement;
• use of night-clothes during waking hours;
• chairs whose construction immobilises people.

In some circumstances, staff themselves may be subject to abuse from residents or residents may abuse each other. Sexual advances and verbal abuse are not uncommon. Racist behaviour from and between residents can and does occur. Staff may find this difficult to talk about and handle. They may react inappropriately. Staff training and support systems are the key to managing such behaviour.