SOUTH GLOUCESTERSHIRE

SAFEGUARDING ADULTS BOARD

RESPONDING TO ORGANISATIONAL ABUSE

PRACTICE GUIDANCE

SAB Approval:8th September 2016

Update: Two years

Contents

1About This Guidance3

2Definition4

3Identifying Organisational Abuse5

4Whistle-blowing7

5Indicators for Large Scale Investigations7

6The Trigger Threshold8

7Partnership Working: Key Points9

8Organising Large Scale Investigations 10

9Organisational Abuse: Safeguarding Closure 13

10Publicity and Media13

Appendices

1.The Large Scale Investigation Checklist

2.Predisposing Factors That May Contribute To AbuseinOrganisational Settings

1About This Guidance

These guidelines are to supplement the Multi Agency Policy(joint with Bath and North East Somerset, Bristol, North Somerset and Somerset) and the South Gloucestershire Multi agency procedures both of which were ratified by the South Gloucestershire Safeguarding Adults Board in June 2016. These proceduresoutline themulti-agencyresponse should be when the concerns are about an organisation, examples of when they can apply are:

  • A safeguarding concern about an individual has been received and the investigation gives rise to concerns that other adults may have been abused or be atrisk of abuse in a regulated or commissioned care/support/health setting, such as care homes including nursing homes, domiciliary care services, ‘Supported Living’ settings (including ‘floating support’), hospitals and other health settings. This may also apply where support is being provided from an unregulated service to a number of people.
  • A whistleblowing referral has been made giving rise to safeguarding concerns
  • A number of concerns about a provider, have been reported via the monitoring system set up by the Organisational safeguarding team and/or via the service monitoringsystem set up by the Local Authority Commissioning and Contracts Team or the commissioning Clinical Commissioning Group(CCG).
  • An alert has been triggered by the local intelligence and information group (made up of the local Council, CQC and Clinical Commissioning Group).
  • A CQC inspection identifies significant concerns
  • Partner agencies may report concerns about a service e.g. through reviews by CHC, or one of the specialist health teams offering support to care homes.

This guidance should be read in conjunction with the South Gloucestershire Safeguarding Adults Policy and Procedures. In setting out this specific guidance on organisational, there is a clear expectation of awareness, understanding and adherence to the more detailed policy and procedures, including adherence to timescales. These policies and procedures are available on the South Gloucestershire website under Safeguarding:

While this document is management guidance, adherence to its content is expected unless there is clear justification for not doing so.

This guidance may also be used in other circumstances where a number of

adults have experienced abuse, or are at risk of abuse; for example

where an individual, or group of individuals, have targeted anumber of service users.

Large scale investigations will involve a wide range of agencies concerned

with both the protection of individual adults and quality of care issues.Understanding of, and interaction with, the role of the Police and criminal investigation, and CQC as the regulator with inspection and enforcement powers, including emergency powers, will be important to ensuring an effective response to organisational safeguarding concerns.

Careful planning and co-operative multi agency working is required at all

stages of the investigation.

The only exception is where the concern is about a prison.The Care Act 2014 specifically excludes the process from covering prisons, however it does stress that advice and support can be sought from SAB members by the prison service.

2Definition

Key definitions can be found in the policy document and come from the Care Act 2014 and its statutory guidance. Within this the types of adult abuse are listed as:

PhysicalDomestic Abuse

SexualModern slavery

PsychologicalOrganisational

Neglect and acts of omissionDiscriminatory

Financial/materialSelf-neglect

The Care Act 2014 statutory guidance (14.9) makes it clear that safeguarding is not a substitute for

  • Providers ‘responsibilities to provide safe and high quality care and support
  • Commissioners regularly assuring themselves of the safety and effectiveness of commissioned services
  • The Care Quality commission (CQC) ensuring that regulated providers comply with the fundamental standards of care or by taking enforcement action
  • The core duties of the police to prevent and detect crime and protect life and property.

It differentiates between 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 instancesof poor care may be an indication of more serious problems and this can constitute organisational abuse...

Not all abuse that occurs within care services will be organisational; some incidents between service users or actions by individual members of staff may occur without any failings on the part of the organisation. Organisational abuse refers to those incidents that derive to a significant extent from an organisation’s practice and culture (particularly reflected in the behaviour and attitudes of managers and staff), policies and procedures.

This guidance aims to reflect the Department of Health’s Agenda for “Dignity in Care”; as outlined in the following statement.

High quality care services that respect people’s dignity should:

  1. Have a zero tolerance of all forms of abuse.
  1. Support people with the same respect you would want for yourself or a member of your family.
  1. Treat each person as an individual by offering a personalised service.
  1. Enable people to optimise the maximum possible level of independence, choice and control.
  1. Enable people to express their needs and wants.
  1. Respect people’s right to privacy and dignity.
  1. Ensure people feel able to complain without fear of consequences.
  1. Engage with family members and carers as care partners.
  1. Assist people to maintain confidence and a positive self-esteem.
  1. Act to alleviate people’s loneliness and isolation.

3Identifying Organisational Abuse (Also See App. 3)

There is a need for assessment and judgement in determining when poor practice becomes an adult safeguarding issue. Addressing Four Key Questions will support the decision to initiate anorganisational abuse investigation:

  1. Is the incident of atype to indicate organisational abuse?
  1. Is the incident of a nature to indicate organisational abuse?
  1. Is the incident of a degree to indicate organisational abuse?
  1. Relating to these 3 questions, is there a pattern and prevalence of concerns about the organisation?

Indicators of Organisational Abuse - Signs and Symptoms

The following are examples only.

The Type of Incident

  • Inappropriate or poor care
  • Restricted access to required health or social care services
  • Misuse or inappropriate use of medication
  • Neglect of service user(s)
  • Absent or inadequate policies and procedures
  • Misuse of restraint or inappropriate restraint methods
  • Unauthorised Deprivation of Liberty
  • Non-adherence to the Mental Capacity Act
  • Sensory deprivation - denial of spectacles, hearing aids
  • Restricted mobility – denial of access to mobility aids
  • Restricted access to toilet/bathing facilities
  • High number of complaints, accidents or incidents
  • Care regime exhibits lack of choice, flexibility and control
  • Care regime impersonal and lacks respect for dignity
  • Lack of personal clothing and possessions
  • Denial of visitors or phone calls

The Nature of the Incident

  • Is the behaviour widespread within the setting?
  • It is evidenced as repeated instances
  • Is it generally accepted within the setting?
  • Is it sanctioned by supervisory and management staff?
  • Is there an absence of effective management monitoring and oversight?
  • Are there environmental factors that adversely affect the quality of care?
  • Are there systematic deficits embedded in the care setting?

The Degree evidenced by the Incident

  • The vulnerability of service users
  • The nature and extent of the abuse
  • The length of time is has been occurring
  • The impact on service user(s)
  • The risk of repeated or escalated incidents

The Pattern and Prevalence of Incidents

  • Are the same incidents reported over time
  • Is there a frequency of concerns (which may encompass previous safeguarding alerts, complaints, whistleblowing, CQC inspection outcomes, contract monitoring reports etc)

In summary, common themes in organisational abuse are:

  • a history of concernsthat may not have been previously connected to a wider view of the care service/setting
  • poor standards of care
  • rigid routines
  • inadequate staffing
  • poor supervision and training of staff
  • poor recording in care plans, incident logs
  • culture and behaviours suggesting a lack of transparency and openness
  • a failure to learn from previous incidents

4Whistleblowing

A whistleblowing referral may be the catalyst for identifying wider concerns about a service. Whistleblowing should be distinguished from a complaint in that a whistleblowing referral will be made typically, by an employee of the organisation. The person may or may not have tried to raise the issue with their management. Ideally they should have done but clearly there are times when an employee will feel too intimidated to do so. Where a “whistleblowing” is actually a safeguarding concern about an individual this should be dealt with initially through individual processes to ensure that the person is safe. Where there are wider implications these may need to be followed up through organisational safeguarding processes.

It is essential that information is taken carefully from whistleblowers whatever their motives appear to be, just because someone has fallen out with an employer does not necessarily mean that the information they are passing on is not valid. As with any other enquiry this will need to be balanced with other information.

Where the whistleblowing relates to an internal council service, or a service commissioned by the Council, reference should also be made to the corporate guidance – Employee Whistle-BlowingPolicy: Guidance Notes for Managers.

5 Indicators for Large Scale Enquiries

At the point of contact/referral, and throughout the course of an individual

enquiry, all managers overseeing safeguarding enquiries will need to considerwhether the alleged abuse indicates that there could be a risk to otheradults at risk. This may arise for example when:

  • The abuse has taken place as a result of a poorly managed service.
  • The alleged perpetrator is a care worker (or group of care workers) andhas contact with a number of vulnerable people.
  • The alleged perpetrator is a service user who shares livingarrangements or services with other vulnerable people.
  • There is a history of concerns about the service

6The Trigger Threshold

As an additional safeguard to promote early recognition and response to the potential presence of organisational abuse, a trigger threshold for action has been defined and where occurring must be referred to the Safeguarding Manager for action. The threshold is –

Three safeguarding concerns within any rolling 6 month period

about the same careservice or setting will always trigger a

review of the concerns aboutthe care service or setting by the

Organisational Safeguarding Team who will then determine if

there is evidence to indicateorganisational abuse.

It should be noted that the Trigger threshold is a failsafe device;it does not replace professional judgement or preclude earlier intervention based either upon an alert(s) or other sources of information. The trigger threshold is also intended to promote proactive and early intervention in care settings or services to promote service improvement where the threshold for a large-scale investigation is not met but preventative interventions are desirable. Such interventions may be undertaken for example, by the safeguarding service, contracts section, adult social work or another organisation.

Responding to a Trigger

If the Trigger threshold is met then this must be recorded within the Organisational safeguarding records and receive a structured and recorded response

In these circumstances the Safeguarding Manager will arrange a review of the concerns and evaluation of all current sources of evidence, including making enquiries of an appropriate range of services including:–

  • The previous safeguarding history of the provider (including other services/institutions owned by the provider)
  • CQC – previous and current status of the institution/provider
  • Contracts Section – previous or current evidence of non-compliance
  • CCH Feedback – history of concerns/complaints (and positive feedback)
  • Police – past or current concerns
  • NHS –Health Professionals who may visit e.g., GPs, district nursing, Care home liaison, Frailty team etc. also if relevant the history and pattern of referrals to secondary care of emergency department attendances.
  • Practitioner views – any concerns arising from reviews etc.

The review and evaluation process may be a ‘desktop exercise’;a formal strategy discussion or strategy meetingat the discretion of the Safeguarding Manager/Lead Manager and proportionate to the Trigger issues.

The review outcome and how it has been determined must be recorded including, where safeguarding is not to proceed, how issues arising are to be followed up e.g. by a safeguarding visit to the provider; by Contracts Section, through the individual enquiries, by a visit from another service e.g.Clinical Commissioning Group, or CQC or by Care Management. All follow-up actions outside – of safeguarding – who, when what - must also be part of the record for the Trigger response. The response cannot be closed until non safeguarding outcomes have also been recorded i.e. an intention to do something is insufficient for closure purposes.

For out of area placements, commissioners must be advised of the outcome and any recommendations e.g. review of placement, review of care plan etc, should be communicated formally in writing.

7Partnership Working: Key Points

Responding toorganisational abuse is likely to require a complex coordination of different organisations both for information and for direct involvement in the investigation. Drawing upon the knowledge and expertise of Clinical Commissioning Group, CQC and Police partners will be an important early step in formulating an effective approach. It is important that everyone involved is awareof their respective roles and responsibilities and their duty to cooperate in theinvestigation.

As the “host” authority South Gloucestershire Council will lead and

Co-ordinate large scale investigations within South Gloucestershire, but multi-agency knowledge, skills andinformation sharing are essential for best practice, sound decision making andsecuring positive investigation outcomes for service users.

Who Leads?

The Safeguarding Adults Manager or Senior Practitioner will coordinateall large scale safeguarding investigations including the chairing of all strategy meetings. Exceptionally if this is not possible or the concerns are of a very severe type the Head of safeguarding should be consulted and agreement reached about an appropriate chair and co-ordinator.

Each participating organisation will nominate a lead to support the investigation. However, a specific lead – or co-leads – for the safeguarding investigation must be identified by the initial strategy meeting. Guidance on the relationship between social care and police/criminal investigation is provided in the South Gloucestershire SAB Policyand Procedures. These will need to be confirmed for each individual enquiry/investigation. The balance is between preserving evidence and enabling the police to pursue their investigation and ensuring that all residents are safe within the setting.

The strength of partnership is manifested in each principal safeguarding organisation – in particular, the Council, Police, Clinical Commissioning Group and Care Quality Commission – having a specific role and functions that dovetail to create an effective safeguarding process. Operationally, this requires careful coordination and avoidance of deference to, or dominance of, any single organisational perspective or function.

Active and co-operative behaviour by the service provider is expected and essential. Depending on the type of concerns and the level of staff involved it may or may not be appropriate for the provider to actively make enquiries. This will need to be decided in each situation. It will be important to understand the service providers own mechanisms for example, disciplinary procedures, and how any intention to deploy these relates to the safeguarding concern and aligns to the safeguarding plan. It is key that the service provider take responsibility for the abuse and the impact of it. Where their internal procedures are likely to have set/allowed a culture where abuse can take place it is essential that this become part of the investigation.

It is essential that where providers are undertaking enquiries arrangements for what these should cover, timescales and how they will be fed back are clear. Where these are not adhered to consideration must be given to how to escalate the concerns to ensure they are managed.

8Organising Large Scale Investigations

When an investigation involves a number of people who have experienced

abuse, or are at risk of abuse, the issues are often complex; involving

standards of service as well as a series of individual investigations.

A large scale investigation may require a series of individual safeguarding

adult investigations to address allegations of abuse specific to each individual.

Under The Care Act 2014, the Local Authority has lead responsibility for adult

safeguarding issues however it can delegate responsibility for enquiries to appropriate agencies. In carrying out this responsibility the Chair will co-ordinatethe overall investigation and ensure that all relevant agencies are involved.

Strategic Oversight

In most instances the process outlined below will be sufficiently robust to ensure a fully and thorough enquiry can be undertaken and arrangements made to keep people safe, however there may a small number of situations where it becomes evident that the degree and severity of the safeguarding and the complexity of the situation requires additional strategic oversight. In such instances the host authority will initiate a strategic management group inviting placing authorities, CQC, police, health, legal etc. to identify the most appropriate person to attend. This group would provide oversight to the process ensuring all areas are followed through (see ADASS guidance on “Out of Area Safeguarding Adults Arrangements June 2016 for further details).

Complex adult safeguarding enquirieswith multiple service users/victims

A safeguarding assessment should be completed for all service users who may have been subject to, or at risk from, the alleged abuse. Where this assessment shows evidence of actual abuse, an individual alert (SA1) must be completed.

Police - The SA1s should be secure emailed to the Public