Guidance Four - Potential indicators of abuse

Introduction

Possible Indicators of Abuse

• lack of respect shown to an individual;
• signs of a sub-standard service offered to an individual;
• repeated exclusion from rights afforded to citizens such as health, education, employment, criminal justice and civic status.

• any injury not fully explained by the history given;
• injuries inconsistent with the lifestyle of the vulnerable adult;
• bruises and/or welts on face, lips, mouth, torso, arms, back, buttocks, thighs;
• clusters of injuries forming regular patterns;
• burns;
• friction burns, rope or electric appliance burns;
• multiple fractures;
• lacerations or abrasions to mouth, lips, gums, eyes, external genitalia;
• marks on body, including slap marks, finger marks;
• injuries at different stages of healing;
• medication misuse.

Sexual abuse including; rape and sexual assault or sexual acts to which the vulnerable adult has not consented, or is incapable of giving informed consent or was pressured into consenting. This may involve contact or non-contact abuse (e.g. touch, masturbation, being photographed, teasing, inappropriate touching) may be indicated by:

• significant change in sexual behaviour or attitude;
• pregnancy;
• wetting or soiling;
• poor concentration;
• vulnerable adult appearing withdrawn, depressed, stressed;
• unusual difficulty in walking or sitting;
• torn, stained or bloody underclothing;
• bruises, bleeding, pain or itching in genital area;
• sexually transmitted diseases, urinary tract or vaginal infection, love bites;
• bruising to thighs or upper arms.

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 may be indicated by:

• change in appetite;
• low self esteem, deference, passivity and resignation;
• unexplained fear, defensiveness, ambivalence;
• emotional withdrawal;
• sleep disturbance.

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 may be indicated by:

• unexplained sudden inability to pay bills or maintain lifestyle;
• unusual or inappropriate bank account activity;
• withholding money;
• recent change of deeds or title of property;
• unusual interest shown by family or other in the person’s assets;
• person managing financial affairs is evasive or uncooperative;
• misappropriation of benefits and/or use of the person’s money by other members of the household;
• fraud or intimidation in connection with wills, property or other assets.

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 may be indicated by:

• physical condition of person is poor e.g. bed sores, unwashed, ulcers;
• clothing in poor condition e.g. unclean, wet, ragged;
• inadequate physical environment;
• inadequate diet;
• untreated injuries or medical problems;
• inconsistent or reluctant contact with health or social care agencies;
• failure to engage in social interaction;
• malnutrition when not living alone;
• inadequate heating;
• failure to give prescribed medication;
• poor personal hygiene;
• failure to provide access to key services such as health care, dentistry, prostheses.

Institutional abuse; Neglect and poor professional practice in care settings, also need to be taken into account. It may take the form of isolated incidents of poor practice at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other. It can occur when the routines, systems, communications and norms of an institution compel individuals to sacrifice their preferred lifestyle and cultural diversity to the needs of that institution. Repeated instances of poor care may be an indication of more serious problems. Institutional Abuse may be indicated by:

• inappropriate or poor care;
• misuse of medication;
• restraint;
• sensory deprivation e.g. denial of use of spectacles, hearing aid etc;
• lack of respect shown to personal dignity;
• lack of flexibility and choice: e.g. mealtimes and bedtimes, choice of food;
• lack of personal clothing or possessions;
• lack of privacy;
• lack of adequate procedures e.g. for medication, financial management;
• controlling relationships between staff and service users;
• poor professional practice.

This can be further broken down into six groups of early indicators relating to:

The behaviours, actions and decisions of managers. Such early indicators might include signs of:

• Weak, ineffective leadership;
• Lack of supervision and staff meetings;
• Managers who lack knowledge or experience of working with vulnerable adults;

Services where bank or agency staff are frequently used and where there is high staff turnover, staff sickness or shortages.

The behaviours and actions of staff. Early indicators include:

• Signs that staff do not value vulnerable adults and do not treat them with dignity;
• Staff lacking knowledge and skills in important areas of practice such as the safe management of challenging behaviour, recognising and responding appropriately to abuse, correct management of individuals’ money;
• Staff developing inappropriate or exploitative relationships with the people they support;
• Staff failing to listen to individuals’ choices, or undermining their choices;
• Staff who do not have a clear understanding of important concepts such as choice making and consent.

The behaviours and actions of vulnerable adults. These include:

• Changes in individuals’ abilities, communication, emotions and behaviours;
• Signs that individuals behave differently with different members of staff or are happier in other settings;
• Signs that some individuals may hurt, bully or exploit other individuals;
• Signs associated with a lack of well being such as self-harm, inappropriate sexualised behaviours, injuries.

Isolation. These include signs that:

• People who live in the service are being cut off from contact with families, friends and professionals;
• People who work in the service are being cut off from information and ideas about best, contemporary practice;
• Staff are hostile and unwelcoming towards people from outside the service.

Service design, placement planning and commissioning. This includes signs that:

• The individuals are incompatible, or that vulnerable people may be placed alongside individuals with a history of abuse;
• That individuals are placed in a service which is widely acknowledged to be unsuitable to meet their needs;
• Needs identified in assessments or care plans are not being met.

Fundamental care and the quality of the environment. This includes signs that:

• The service is unable to keep people safe, meet their care needs and treat them with dignity;
• Individuals have little to do;
• The environment is in a poor state or cold / unclean.

Patterns of abuse/abusing

Patterns of abuse and abusing vary and reflect very different dynamics. They include:

• serial abusing, in which the perpetrator seeks out and ‘grooms’ vulnerable individuals. Sexual abuse usually falls into this pattern, as do forms of financial abuse;
• long term abuse in the context of an ongoing family relationship such as domestic violence between spouses or generations;
• opportunistic abuse such as theft occurring because money is easily accessible;
• situational abuse which arises because pressures have built up and/or because of difficult or challenging behaviour;
• neglect of a person’s needs because those around him or her are not able to be responsible for their care - for example if the carer has difficulties attributable to issues such as debt, alcohol misuse or mental health problems;
• institutional abuse featuring poor care standards, lack of positive responses to complex needs, rigid routines, inadequate staffing and insufficient knowledge base within the service;
• unacceptable ‘treatments’ or programmes which include sanctions or punishment such as withholding of food or drink, seclusion, unnecessary and unauthorised use of control and restraint or over-medication.

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