Rochdale Borough Safeguarding Adults Board
Professional decision-making tool in response to a
Safeguarding alert
Author: Jane Timson
April 2014
Date for Review: April 2015
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Professional decision-making tool in response to a Safeguarding alert
Introduction
All adults have the right to live in a safe environment free from abuse and harm. The focus of work must be on the outcomes that people wish to
achieve in order to enable them to remain in control of their lives.
This guidance is for practitioners and partner agencies and explains the processes involved in making a decision about whether an “alert” received
regarding an adult who appears to be at risk of harm or is being harmed, is processed through the safeguarding adults’ procedures. Such “threshold
decisions” are crucial in ensuring that members of the population who meet the definition of “Adult at Risk” (No Secrets 2000) are able to receive the
assistance they need. Once an alert has been accepted and further information is gathered there may be situations where the threshold needs to be
reconsidered. It is important to recognise that this document is a tool to help safeguarding professionals determine an appropriate and
proportionate response to alerts. It is not to be used to determine whether or not an alert is raised.
The priority should always be to ensure the safety and protection of adults at risk.
If a decision is made not to follow Rochdale Borough Safeguarding Adults Board (RBSAB) Multi Agency Adults at Risk policy and procedures, the
reasons and rationale should be recorded in a strategy meeting (if this does not breach their confidentiality).
The RBSAB Adults at Risk procedures should not be used in cases of self-neglect. These cases should be brought to the attention of the relevant
adult care team / team manager, and should then be considered under community care arrangements. Further advice/information is in the Self
Neglect Guidelines which can be found on the Rochdale Council’s website on the Safeguarding Adults webpage
(www.rochdale.gov.uk/safeguardingadults).
This threshold framework has been designed to consider examples of abuse which sit outside of Adults at Risk procedures and also those that sit
inside the procedures and require significant further investigation.
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Regular small concerns can amount to a far higher level of concern which then requires a safeguarding alert.
The following list will assist the decision making process but should not be seen as exhaustive and professional judgement should be exercised.
The key areas for decision making are:
The harm – always take account of the individual’s perception. What impact has it had on the person or others around them? Are others at risk?
Has a crime been committed?
How vulnerable is the individual? What is the setting / environment for the adult at risk and the person who may be causing harm? What are the
personal and social factors that may contribute to that vulnerability? Can the person seek help / remove themselves from the environment if
needed?
Does the person have the mental capacity to make a specific decision? What are the views of the adult at risk? Are they aware of the alert?
Have they consented to information sharing?
Whether duress or coercion or intimidation is an influence.
The relationship between the adult at risk and the person causing the harm. Does it involve a person in a position of trust?
What other support mechanisms are in place? How robust are they? Will the person use them?
Is the child under 18 years or a young person at risk?If so, refer them to the relevant children’s team.
How likely is it that the abuse may reoccur?
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The following are factors that may assist you to determine vulnerability (not exhaustive)
Personal characteristics of the adult at risk that increase
vulnerability may include:
Personal characteristics of the adult at risk that decrease
vulnerability may include:
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Not having mental capacity to make decisions about their own
safety including fluctuating mental capacity. Experience of mental
distress which may include self-harm
Communication difficulties
Physical dependency – being dependent on others for personal
care and activities of daily life
Low self esteem
Childhood experience of abuse
History of being a looked after child
Transition
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Having mental capacity to make decisions about their own safety
Good physical and mental health
Having no communication difficulties or if so, having the right
equipment / support to communicate
No physical dependency or, if needing help, able to self-direct
Positive former life experiences
Self-confidence and high self-esteem
Having knowledge and information to make informed choices
Social / Situational factors that increase the risk of abuse may
include:
Social / Situational factors that decrease the risk of abuse may
include:
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Being dependant on others for their care.
Not receiving the right amount of care they need
Isolation and social exclusion
Stigma and discrimination
Lack of access to information and support
Being the focus of anti-social behaviour
Good family relationships
Active social life and a circle of friends
Able to participate in the wider community
Good knowledge and access to a range of community facilities
Remaining independent and active
Access to sources of relevant information
Threshold decision making can be complex. The incident may constitute several types of abuse types for, example, medication errors could be an
indicator of institutional abuse but could also fall within physical abuse,, psychological abuse or neglect. Forced marriages are also likely to
encompass more than one type of abuse.
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The table below is a non-exhaustive list of examples, to support practitioners to make informed, defensible decisions using professional judgement.
If in doubt, practitioners should discuss this with their line manager or Rochdale Adult Care Safeguarding Team on 0845 602 4998.
Lower Level Concern
Types of Abuse
Level
Physical
Significant Harm
Could be addressed via agency internal
process/procedures e.g. management action,
disciplinary procedures or community care
assessment
Commissioning teams should be notified of all lower
level concerns involving commissioned service, to
enable quality monitoring.
Very Significant Harm
Addressed under Safeguarding Procedures. If
potentially a criminal matter, Police or other
Emergency Services may be required.
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2
3
4
Staff error on one occasion
causing little or no harm, e.g.
skin friction mark due to ill-fitting
hoist sling.
Isolated incident involving
vulnerable adult on vulnerable
adult not resulting in harm.
Inexplicable marking or lesions,
cuts or grip marks on a number of
occasions.
Inappropriate restraint
Withholding of food, drinks or aids
to independence.
Adult at risk does not receive
recommended mobility
assistance on one occasion not
resulting in harm.
Inexplicable very light marking
found on one occasion.
Vulnerable adult on vulnerable
adult incident where there is a
power imbalance being used to
cause harm / exploitation.
Inexplicable fractures/injuries.
Appropriate moving and
handling procedures not
followed on one occasion not
resulting in harm.
Adult at risk attends casualty,
minor injury unit, GP surgery with
minor injury and doubtful
explanation, wants treatment but
no other action. Health
professional checks previous
history but no previous concern
has been recorded.
Adult at risk is injured through
common flouting of procedures.
Assault
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Types of Abuse
Level
Physical (continued)
Lower Level Concern
1
2
Isolated incident of carer falling
asleep at night on duty remains
a management issue.
Adult at risk in pain or otherwise
in need of medical care such as
dental, optical, audiology
assessment, foot care, therapy
does not on one occasion receive
required timely medical attention.
Environmental hazards
including maintenance.
Medication
Sexual
Adult does not receive
prescribed medication
(missed/wrong dose) on one
occasion - no harm occurs
Medication administration
records are inaccurate.
One off incident of sexualised
nature that has caused no
distress.
Significant Harm
3
Very Significant Harm
4
Predictable and preventable
incident between two vulnerable
adults where injuries have been
sustained or emotional distress
caused – the staff fails to prevent.
Grievous bodily harm/assault
leading to permanent or
substantial injury or death
including Female Genital
Mutilation.
One medication error where
significant harm occurs
Deliberate misadministration of
medications
Recurring missed medication or
administration errors that cause
no harm
Covert administration without
medical authorisation.
Missed medication or errors that
affect more than one adult which
may or may not result in harm
Pattern of recurring errors or an
incident of deliberate
misadministration that results in ill
health or death.
Directed by one vulnerable adult
to another.
Attempted penetration by any
means (whether or not it occurs
within a relationship) without valid
consent.
Verbal sexualised teasing or
harassment.
Being made to look at
pornographic material against will
/ where valid consent cannot be
given.
Recurring sexualised touch or
masturbation without valid
consent.
Being subject to indecent
exposure.
Contact or non-contact sexualised
behaviour which causes distress
to the person at risk.
Voyeurism
Female Genital Mutilation.
Sex in a relationship
characterised by authority,
inequality or exploitation, e.g. staff
and service user.
Sex without valid consent (rape).
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Types of Abuse
Level
Psychological
Lower Level Concern
1
Isolated incident where adult is
spoken to in a rude or
inappropriate way – respect is
undermined but little or no
distress caused.
2
Resident in a warden complex
reports that s/he finds the warden
overbearing and intrusive.
Significant Harm
3
Very Significant Harm
4
Isolated taunts or verbal outbursts
which cause distress.
Emotional blackmail e.g. threats
of abandonment / harm.
The withholding of information to
dis-empower.
Frequent and frightening verbal
outbursts.
Treatment that undermines dignity
and damages esteem.
Denial of basic human rights/civil
liberties, over-riding advanced
directive, forced marriage.
Denying or failing to recognise an
adult’s choice or opinion.
Prolonged intimidation /
victimisation.
Frequent verbal outbursts.
Humiliation
Adult at risk is intimidated and
bullied and they are frightened to
talk about why
Money is not recorded safely or
properly.
Financial
Failure to meet agreed
contribution to care by
family/attorney but resident still
has personal allowance and the
placement is not at risk.
7
Vicious / personalised consistent
verbal attacks.
Adult not routinely involved in
decisions about how their money
is spent or kept safe -capacity in
this respect is not properly
considered.
Misuse/misappropriation of
property, possessions or benefits
by a person in a position of trust
or control. To include misusing
loyalty cards.
Adult’s monies kept in a joint bank
account – unclear arrangements
for equity of interest.
Personal finances removed from
adult’s control.
Adult denied access to his/her
own funds or possessions.
Fraud/exploitation relating to
benefits, income, property, last
will and testament.
Failure to meet agreed
contribution to care by
family/attorney results in failure to
provide personal allowance
and/or jeopardises the placement.
Theft of money or property.
Types of Abuse
Level
Lower Level Concern
1
2
Significant Harm
3
Missed home care visit on one
occasion - no harm occurs.
Inadequacies in care provision
leading to discomfort - no
significant harm e.g. left wet on
one occasion.
Recurrent missed home care
visits where risk of harm
escalates, or one miss where
harm occurs.
Adult is not assisted with a
meal/drink on one occasion
and no harm occurs.
No access to aids for
independence on one occasion
and no harm occurs.
Vulnerable adult who is
susceptible to pressure ulcers is
not formally assessed.
Neglect
Care plan does not address
assessed needs / or is not
followed on one occasion and
no harm occurs.
Care plan not followed and no
harm occurs.
Very Significant Harm
4
Ongoing lack of care to extent
that health and well-being
deteriorate significantly e.g.
pressure wounds, malnutrition,
loss of independence /
confidence.
Adult at risk is discharged from
hospital without adequate
planning, procedures not followed
and experiences harm as a
consequence.
Hospital discharge, no adequate
planning and harm occurs.
Adult at risk is known to mental
health services and assessed as
high risk of suicide – timely
response not made to report of
possible suicide and harm or
emotional distress occurs.
Failure to specify in a plan of care
how a significant need must be
met. Inappropriate action or
inaction related to this result in
harm such as injury or choking.
Failure to arrange access to life
saving services or medical care.
Care plan does not address risk
of harm i.e.
i) Management of behaviour to
protect self or other.
ii) Liquid diet because of
swallowing difficulties.
Discriminatory
Incident of teasing, rude,
insulting, or belittling manner
on one occasion, motivated by
prejudicial attitudes towards an
adult’s individual differences
and little or no distress is
caused.
Isolated incident of care planning
that fails to address an adult’s
specific diversity associated needs
for a short period.
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Failure to intervene in dangerous
situations where the adult lacks
the capacity to assess risk.
Recurring taunts. (Hate Crime)
Being refused access to essential
services.
Inequitable access to service
provision as a result of diversity
issue.
Denial of civil liberties e.g. voting,
making a complaint.
Recurring failure to meet specific
care/support needs associated
with diversity.
Humiliation or threats on a regular
basis. (Hate Crime)
Types of Abuse
Level
Lower Level Concern
1
Significant Harm
3
2
Very Significant Harm
4
Being the focus of anti-social
behaviour.
Adult at risk is repetitively not
supported to attend church or
receive pastoral visits which
causes distress leading to
psychological harm.
Discriminatory
(continued)
Female Genital Mutilation.
Hate Crime resulting in
injury/emergency medical treatment
or fear for life.
Hate crime resulting in serious
injury/attempted murder/honour based
violence.
Lack of stimulation/
opportunities to engage in
social and leisure activities
over a short period of time and
no harm occurs.
Institutional
Service user not enabled to be
involved in the running of
service.
Care-planning documentation
not person-centred.
Denial of individuality and
opportunities to make informed
choices and take responsible risk.
Bad practice not being reported and
going unchecked.
Adult at risk is discharged from
hospital without adequate
discharge planning but no
harm occurs - needs to be
addressed as a quality issue.
Continual lack of stimulation /
opportunities to engage in social /
leisure activities resulting in
emotional or physical distress.
Unsafe and unhygienic living
environments.
Rigid/inflexible routines.
Restraint / possible deprivation of
liberty is occurring and no application
for DOLS authorisation has been
received although it has been
recommended. Best interest has been
ignored or presumed.
Adult at risk subject to a
Deprivation of Liberty
Safeguards (DOLS) has their
escorted visit cancelled at
short notice with no
explanation on one occasion.
Adult at risk whose personal
plan of care stipulates that they
should have two staff
supporting them is supported
by one member of staff on one
occasion and no harm occurs.
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Adult at risk dignity is undermined
e.g. lack of privacy during support
with intimate care needs.
Staff misusing a position of power
over service users.
Evidence of staff colluding to cover up
incidents.
Types of Abuse
Level
Lower Level Concern
1
2
Institutional
(continued)
Professional
Significant Harm
3
Very Significant Harm
4
Adult at risk lacks capacity and
steps to protect are not least
restrictive.
Over medication and/or the use of
inappropriate restraint in the
management of behaviour.
Adult at risk is discharged from
hospital without adequate
discharge planning and harm
occurs.
Widespread consistent ill treatment.
Adult at risk whose personal plan
of care stipulates that they should
have two staff supporting them is
supported by one member of staff
on several occasions or one
occasion and harm occurs.
Adult at risk fearful to report concerns
because of fear of repercussions.
Denying Adult at risk access to
professional support and services
such as advocacy.
Failure to support adult at risk to
access health, care, treatments.
Failure to whistle blow on serious
issues when internal procedures
to highlight issues are exhausted.
Failure to refer disclosure of
abuse.
Poor, ill-informed or outmoded
care practice and harm occurs to
service users.
Service design where groups
of service users living together
are incompatible and no harm
occurs.
Service design where groups of
service users living together are
incompatible and harm occurs.
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Punitive responses to challenging
behaviours.
Professionals entering into a sexual
relationship adult at risk.