Guidance Seven - Is a referral required?

Introduction

There are some concerns raised and acknowledged as such by the management of an organisation that may be appropriately dealt with internally. These may include for example; one off disagreements between two service users, where neither vulnerable adult was harmed or is considered to be particularly vulnerable to the other; one off shouting or pushing and shoving where there is deemed to be an equal power relationship.
However, it is extremely important in all situations to recognise that any kind of bullying may be considered as abusive by the victim and therefore should be recognised as such.
What degree of abuse justifies intervention? In determining how serious or extensive abuse must be to justify intervention a useful starting point can be found in Who Decides? Building on the concept of ‘significant harm’ introduced in the Children Act, the Law Commission suggested that:
"’Harm’ should be taken to include not only ill treatment (including sexual abuse and forms of ill treatment which are not physical), but also the impairment of, or an avoidable deterioration in, physical or mental health, and the impairment of physical, intellectual, emotional, social or behavioural development."
The seriousness or extent of abuse is often not clear when anxiety is first expressed. It is important, therefore, when considering the appropriateness of intervention, to approach reports of incidents or allegations with an open mind. In making any assessment of seriousness the following factors need to be considered:
The vulnerability of the individual;
The nature and extent of the abuse;
The length of time it has been occurring;
The impact on the individual; and
The risk of repeated or increasingly serious acts involving this or other vulnerable adults.
What this means in practice is working through a process of assessment to evaluate:
Is the person suffering harm or exploitation?
Is the intervention in the best interests of the vulnerable adults fitting the criteria and/or in the public interest?
Does the assessment account for the depth and conviction of the feelings of the person alleging the abuse?
No Secrets (2000), Section 2, page 12-13, Department of Health

It should also be noted that there is a real danger of staff tolerance growing with continued exposure to seemingly minor issues. This can lead to complacency, an acceptance of behaviour that would not be tolerated in other settings, and may result in incidents not being placed into the multi agency context when this would be the expected course of action. Therefore, it is important to record all incidents and monitor trends so that repeated or targeted incidents are identified and that referrals are made when abuse occurs or is alleged.

Staff responsible for referring an allegation of abuse are accountable for their decision and should use their PROFESSIONAL JUDGEMENT when deciding whether an incident should be referred to Adult Social Care. This guidance is intended to assist professionals make a judgement and will not provide the definitive answer when deciding whether to refer an incident – IF IN DOUBT, REFER.

Is a referral required?

When a member of staff is the alleged perpetrator a ZERO TOLERANCE approach to allegations of abuse should be adopted and a referral must always be made.

When using your PROFESSIONAL JUDGEMENT to determine whether an incident should be referred to Adult Social Care, you may find it useful to consider the following:

The consequences to the alleged victim;
The equality of the relationship between the alleged perpetrator and the alleged victim;
The ability of the alleged victim to consent;
The mental capacity of the alleged perpetrator to understand the consequences of their decision to act in the way that is alleged;
The intent of the alleged perpetrator;
The frequency of this and similar allegations regarding the alleged perpetrator.
You MUST refer an incident as an allegation of adult abuse if:
The alleged victim considers the actions against them to be abusive;
The alleged victim or carer is distressed, fearful or feels intimidated by the incident;
You believe that there is a deliberate attempt to cause harm or distress;
Incidents are repetitive and targeted;
A crime has been committed;
The incident involves a member of staff.

THIS LIST IS BY NO MEANS EXHAUSTIVE - IN ANY SITUATION WHERE YOU FEEL ABUSE HAS OCCURRED, A ZERO TOLERANCE APPROACH SHOULD BE ADOPTED AND A REFFERAL MUST BE MADE TO THE RELEVANT ADULT SOCIAL CARE TEAM.
You MAY decide that ‘abuse’ as defined in the Nottingham(shire) Safeguarding Adults Policy and Procedures in Guidance Three - Defining 'Vulnerable Adult' and 'Abuse' has not occurred and that the best course of action is to record, raise and acknowledge the incident with the management of your organisation, and deal with it internally if:

You believe the incident is a one off, isolated minor incident where no harm has been caused;
The incident involves actions such as shouting at each other, but where there is deemed to be an equal power relationship;
There was no deliberate attempt to cause harm or distress;
The incident did not target one individual but whoever happened to be in the vicinity at the time.

IF, AFTER CONSIDERING THE ABOVE YOU ARE IN DOUBT, YOU SHOULD MAKE A REFERRAL OR CONTACT ADULT SOCIAL CARE TO DISCUSS THE INCIDENT FURTHER.

Dealing with Concerns

The following diagram, along with the case example may help you when considering if the incident is a complaint, concern or allegation of abuse:

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Using the funnel above with the following example may assist you when considering if a Safeguarding Adults referral is required.

IF, AFTER CONSIDERING THE ABOVE YOU ARE IN DOUBT, YOU SHOULD MAKE A REFERRAL OR CONTACT ADULT SOCIAL CARE TO DISCUSS THE INCIDENT FURTHER.

Case Example:

A resident in a Care Home tells you that she has been given a cup of coffee despite never drinking it and preferring tea. The first thing that should be considered is the middle triangle; is the vulnerable adult distressed by this? Is this a one off mistake or accident? Is it likely to cause serious harm?

If the resident was given coffee as an oversight then it may be decided to treat it as a concern and resolve it immediately with an apology and ensuring the care plan is followed, which would result in ‘No Further Action’ in relation to Safeguarding Adults Procedures.

If the owner refuses to provide tea because it is too expensive and too time consuming to make pots of tea then it may be decided to treat it as a complaint. This should be reported to the Manager of the home and your own line manager and required actions should be agreed with the Home Manager. This information should also be passed to the relevant body who commission services from this organisation (for example, local authority purchasing and contracting department) AND the regulatory body (CSCI or the Healthcare Commission).

If staff are offering coffee to the resident because they know she does not like it and wish to deliberately cause distress you may decide that this is an allegation of abuse as the vulnerable adult is possibly being psychologically abused. You should make your concerns known to the Home Manager who should follow the Nottingham(shire) Multi Agency Policy and Procedures, along with your own line manager.

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