Version 1.4 November 2010
Community Services
Adult Safeguarding
Supplementary Records
Adult Safeguarding
Supplementary Health Records
Summary
This pack has been developed in response to the lack of formalised documentation to
evidence actions taken by Dudley Community Services (DCS) staff regarding recording
vulnerable adults safeguarding concerns. The following forms should be used to record
your action relating to raising of concerns relating to vulnerable adults. Also for the storage
of adult protection plans. The forms should be stored within a secure locked environment
at the staff member’s base. These forms are supplementary to the Social Services held
records.
Contents
Page
Introduction
Guidance Notes: How to report your concerns about possible Adult Abuse
Storage Guidance
Flowchart
Cause for Concerns Form
Body Charts
Index of Injuries/Concerns
2
3-5
6
7
8
9-10
11
Introduction
As a Healthcare Professional within the NHS you may be faced at some time with a case
of suspected adult abuse. These guide notes are intended to assist you as to what to do in
this situation and to provide a way to record your actions clearly. These notes are only a
brief insight and are supplementary to the main information and procedures which
are set out in the Safeguard and Protect Vulnerable Adults Policy which is available
on the web sites of Dudley Local Authority and NHS Dudley. You should ensure that
you have access to this document. In addition you must ensure that you have been on the
appropriate safeguarding training course.
This pack has been developed by the Mental Capacity Act (MCA) and Deprivation of
Liberty (DoLS) Joint Implementation Group with consultation via DCS Senior Nurse
Forum.
These guide notes will give you a quick guide to:
What is abuse
How to report abuse
What to do as a Healthcare Professional or a manager
The reporting mechanisms for you to use
The forms on which to record the alleged abuse and subsequent actions taken
The format of the process of Adult Abuse cases within Health is very similar to the
pathway that is already in place for a case where a child is involved, with the difference
that an Adult Abuse case is led by the Social Care Team within the Council.
2
What is Adult Abuse?
The Department of Health produced guidance in the form of a document called “No Secrets”. This
has been further developed into the Adult Protection – Safeguard and Protect policy which all
statutory agencies within the Dudley borough are signed up to implementing. The guidance within
the Safeguard and Protect policy gives us advice that:
“Abuse is the violation of an individual’s human and civil rights by another person or persons”
“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”.
Who could be at risk of abuse?
An adult is potentially vulnerable and at risk if, in need of the support of others to meet their basic
human needs, and therefore:
“Is or may be in need to community care services by reason of mental or other disability,
age or illness; and who is or may be unable to protect him or herself against significant
harm or serious exploitation.”
(“Who Decides?” – Lord Chancellor’s Department 1997)
What Types of Abuse are there?
Physical: To hit, slap, push, kick, and misuse medication, use inappropriate restraint methods or
sanctions.
Sexual: Rape, sexual assault or sexual attacks to which the vulnerable adult has not consented,
could not consent, or has been put under pressure to consent.
Psychological Emotional: 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: Theft, fraud, exploitation or pressure in connection with wills, property, inheritance, or
financial transactions. To misuse or misappropriate the property of a person, or their possessions
or benefits.
Neglect: To ignore medical or physical care needs. A 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.
Discriminatory: Racist or sexist abuse based on a person’s disability, and other forms of
harassment, slurs, or similar treatment.
Institutional: Mistreatment or abuse of a person or persons by a regime, or individual staff within
an institution. This usually occurs when the routines, system and norms of an institution compel
individuals to sacrifice their own preferred lifestyle and cultural diversity to the needs of the
institution.
3
Responding to an Adult Protection Referral (Guidance for Healthcare Professionals)
Is adult protection the most appropriate procedure?
Yes – If the adult is vulnerable and unable to protect themselves
An adult is potentially vulnerable if they need the support of others to meet their basic
human needs, and therefore;
“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 protect him or herself
against significant harm or serious exploitation.”
“Who Decides” Lord Chancellor’s Department 1997
This description can include people with learning disabilities, older people and those with
physical disability or impairment. The need for additional support for protection may be
increased when complicated by additional factors such as physical frailty or chronic illness,
sensory impairment, challenging behaviour, drug or alcohol problems, social or emotional
problems, communication difficulties, poverty or homelessness.
Vulnerability is not a rigid concept, and there may be conflicting views about an individual’s
capacity and situation.
In considering whether adult protection procedures should be used, staff should assume
they are relevant until and unless information suggests that this is not the case.
Yes – If the adult is at risk of significant harm
When making an assessment of the seriousness of abusive behaviour, it is important to
take into account the vulnerability of the individual, nature and extent of the abuse, length
of time it has been occurring and its impact upon the adult.
The seriousness or extent of abuse may not always be clear, when concerns are first
expressed. It is important therefore, when considering the appropriateness of intervention,
to approach reports of incidents or allegations with an open mind.
4
What do I do now?
As a healthcare professional with either your own concerns or in receipt of a
concern relating to suspected abuse, you will be responsible for taking action on
this issue. You will need to report the information received to the Social Care Duty
Team for Adults at Dudley Council if you think a case of abuse may be occurring
and then record your actions.
Central Access Team:
Adult Protection Manager:
Central Access Admin:
0300 5550055
01384 813249
01384 818543
Staff with concerns regarding a vulnerable adult situation must:
Contact Social Care Duty Team or The Adult Protection Manager at Social Services
and alert your manager
Complete a body chart if necessary
Complete a safeguarding concerns form
Input the basic information into the Trust Incident recording System
Make sure your concerns and actions are recorded on the Cause for Concern form and
Body Chart where appropriate. This information should where possible provide what you
know about:
Vulnerability of, and risk of harm to, the adult
Any need for urgent intervention
Specific concerns of the referrer
Type of abuse suspected
Disabilities and special needs of the adult
Information about the alleged perpetrator
Other people who are significantly involved
Key agencies already involved with the vulnerable person
Key agencies to be contacted
Any further information available
5
Storage of records
Where do you file your Cause for Concern form?
Please store these forms in a secure file system at your team base and ensure that you
document that the incident form has been completed and keep a note of the incident
reference number.
What happens next?
Once you have passed on the initial information to the Social Care Duty Team you may
continue to be involved in the following ways:
Reassurance to those involved
Attendance at the Planning Meeting which may be called by the Social Care
Team Manager
Ensuring the information collected is held in accordance with the guidance in the
Safeguard and Protect document and in accordance with Health Service
procedures and using the appropriate record forms within this pack
Involvement with the subsequent investigation if and when appropriate
Attendance at subsequent meetings relating to the case.
A worker from the responsible Adult Care team will contact you or your manager. The
information you gave will be shared on a “need to know” basis with other appropriate Care
Organisations such as the Police or the Quality Commission, so that a decision can be
made as to how best to investigate the concerns you have raised.
You will be kept informed, and if a Case Conference is required, you and your manager
will be invited, and will be involved in contributing to any Protections Plan that is produced.
Adult Protection Manager
Care Quality Commission:
West Midlands Police
01384 818543
03000 616161
0845 113500
6
Dudley Community Services
Safeguard & protect- Vulnerable Adults
Operational Guidelines
Flowchart
Initial action to be taken by health care professionals in cases of suspected
vulnerable adult abuse
The health care professional should inform the client of proposed
action if appropriate and the necessity of informing social care
Where client or personal safety is at risk. Do not disclose proposed
action
Health care worker discusses with team leader/senior team member
and completes Incident Form and Cause for Concern Form
Concerns remain and
Incident Form completed
Concerns no longer
remain
May refer to own or other agencies to
access services required
Document on Cause for Concern
paperwork kept on file
Telephone contact with Duty Social Worker
Adult team covering the area in which the client
lives
Follow up in writing the Cause for Concern paperwork
Health care profession attends interagency
planning meeting
7
Dudley Community Services
Safeguarding Vulnerable Adults Concerns Form
Name of Client
D.O.B
NHS No.
Address
Key Agencies Involved (Please Specify)
Community Healthcare Professional
(please state)
General Practitioner
Social Services
Other (please state)
Date Problem Occurred:
Where problem occurred:
Please outline the brief summary of the concern:
Describe immediate action taken:
Action taken following discussion with Line Manager:
Concerns Raised by: Name
Position
Base
Tel No
Any Further Action Taken
8
Body Charts
Name
NHS Number
DOB
9
Name
NHS Number
DOB
10
Index of Injuries/Concerns
Date
Name
NHS Number
Injuries/Concerns
Action
DOB
11