10.6 Working with Adults with Learning Disabilities

RELATED CHAPTERS

RELEVANT INFORMATION

Ask Listen Do – Feedback, Concerns and Complaints (NHS England)

Learning Disability – Applying All Our Health (gov.uk)

Core Capabilities Framework for Supporting People with a Learning Disability (Skills for Health)

Improving Healthcare Access for People with Learning Disabilities (gov.uk)

Reasonable Adjustments for People with a Learning Disability (gov.uk)

Tackling Inequalities in Care for People with Learning Disabilities and Autistic People (SCIE)

April 2025: This new chapter contains best practice for working with adults with learning disabilities, including how to empower people so they can recognise and understand any risks they may face and know what to do if they have concerns or are frightened about someone else.

1. Introduction

Adults with learning disabilities may have a greater need for protection if they are unable to keep themselves safe. They can experience abuse and neglect from people they know such as family, friends, neighbours, support staff and other practitioners, but also from complete strangers. It is important, therefore, that staff understand the issues, are able to recognise signs of potential abuse and can empower adults with learning disabilities, where possible, to recognise and understand the risks they may face and know what to do if they have concerns or are frightened about someone.

1.1 Findings from LeDeR

Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) reviews all deaths of people with a learning disability or autism and aims to identify learning to help prevent similar deaths in the future.

LeDeR reviews have found that people with learning disabilities die younger than those without learning disabilities; six out of 10 people with a learning disability die before they reach the age of 65, compared to one in 10 in the general population. The programme also found that people with learning disabilities are twice as likely to die from avoidable causes than the general population, with almost half of all deaths being classified as avoidable.

Some of the most common concerns found during LeDeR reviews relate to:

delays in the diagnosis and treatment of illness;
poor care coordination and communication between agencies;
omissions in care and the provision of substandard care;
poor application of the Mental Capacity Act 2005;
a lack of timely referral to specialists, including learning disability services and neurologists.

2. What is a Learning Disability?

Mencap defines learning disability as:

‘a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life. People with a learning disability tend to take longer to learn and may need support to develop new skills, understand complicated information and interact with other people.’

However, with personalised support, many adults with learning disabilities can lead fulfilling and independent lives.

2.1 Causes of learning disabilities

Before birth, damage to a baby’s brain and spinal cord (called the central nervous system) can cause a learning disability. This may include if the mother has an accident, illness, infection or is exposed to environmental toxins while pregnant, or if the parents pass certain genes or an inherited condition to the unborn baby. A baby can also be born with a learning disability if they do not get enough oxygen during childbirth, have a traumatic head injury, or are born too early (premature birth). A learning disability can also be caused by early childhood illnesses (such as meningitis or measles), seizures, accidents or abuse or neglect, which result in injury or trauma to the brain. Sometimes the cause of a learning disability is not known.

2.2 Types of learning disabilities

There are nearly 1.2 million adults in the UK with a learning disability (Mencap), which can be mild, moderate, severe or profound. In all cases, a learning disability is a lifelong condition.

Mild learning disabilities can be difficult to diagnose as the adult will often socialise well with other people, can manage most daily tasks and require only limited support. However, they may need support in some areas, such as completing forms or finding a job.

Adults with a severe learning disability or a profound and multiple learning disability (PMLD) will have greater needs for care and support, including mobility, personal care and communication, especially if they also have a physical disability or disabilities. People with a moderate learning disability may also need support in these areas, but that is not always the case.

2.3 Related conditions

Some adults with learning disabilities may also have other conditions, including:

autism – approximately half of autistic people may also have a learning disability (see What is Autism? Mencap);
cerebral palsy, which is a physical condition that affects movement, posture and coordination– (see Cerebral Palsy, Mencap);
challenging behaviour, also known as behaviour of concern, is not a learning disability but adults with learning disabilities are more likely to show it (see Challenging behaviour, Mencap);
Down syndrome (also called Down’s syndrome) is a genetic condition that usually causes some level of learning disability (see, Down Syndrome, Mencap).

For further information, see Learning Disability and Conditions (Mencap).

2.4 Learning difficulties

A learning disability is different from a learning difficulty, as a learning difficulty does not affect general intellect. A learning disability affects somebody across all areas of their life. Specific learning difficulties, such as dyslexia, only affect a subset of skills and are not the same as a learning disability.

The main types of learning difficulty are dyslexia (which mainly affects reading and writing skills and sometimes information processing), dyspraxia (which affects physical co-ordination and can cause people to perform less well than expected in daily activities) and dyscalculia (which is persistent difficulty in understanding numbers which can lead to a range of difficulties with maths). It is possible for a person to have both a learning disability and a learning difficulty. Sometimes neurodevelopment and neurological conditions like ADHD are confused with a learning difficulty or a learning disability, but they are not the same.

3. Abuse and Neglect of Adults with Learning Disabilities

The Care and Support Statutory Guidance (Department of Health and Social Care) identifies the following types of abuse and neglect, all of which can affect adults with learning disabilities;

physical abuse;
domestic violence;
sexual abuse;
psychological abuse;
financial or material abuse;
modern slavery;
discriminatory abuse;
organisational / institutional abuse;
neglect and acts of omission; and
self-neglect.

If an adult with a learning disability has communication needs, this may make them more vulnerable to abuse and exploitation.

3.1 Hate crime

Disability hate crime is a criminal offence motivated by hatred or prejudice towards a person because of their actual or perceived disability.

The Crown Prosecution Service define disability hate crime as:

‘Any incident / crime which is perceived by the victim or any other person, to be motivated by a hostility or prejudice based on a person’s disability or perceived disability’. Disability Hate Crime and other Crimes against Disabled People – Prosecution Guidance (Crown Prosecution Service).

Hate crime can include:

verbal and physical abuse;
threatening behaviour;
damage to property;
online abuse;
stalking and harassment.

Hate crime directed at adults with learning disabilities should be reported to the police, or online at Stop Hate UK.

3.2 Befriending crime or mate crime

Whilst not a category of abuse within the Care and Support Statutory Guidance, befriending crime (or mate crime) is another type of abuse often experienced by adults with learning disabilities. It occurs when someone pretends to be the friend of an adult simply to take advantage of them. It can include:

grooming or forcing an adult to commit a crime;
taking an adult’s money;
forcing an adult to work for little or no pay (see also Modern Slavery chapter);
preventing an adult’s access to food or basic needs;
harassment or emotional abuse;
sexual assault / abuse or physical abuse.

3.3 Cuckooing

Adults with learning disabilities may also be victims of ‘cuckooing’. This is when a person or group of people befriend an adult who is in some way vulnerable and then move into their property and use it to deal drugs and / or as a base for sex work or other criminal activities. Adults with learning disabilities, particularly those who are living on their own, are at increased risk of being targeted by such criminals as they may not fully understand risks and dangers or know how to ask for help, so they can be easily manipulated or frightened. They may also be receiving higher rates of benefits from the Department of Work and Pensions due to their disability, which can result in them being an additionally attractive target of financial fraud.

Concerns that an adult with learning disabilities is experiencing, or at risk, of any type of abuse of neglect should be shared with the local authority safeguarding adults team. Wherever possible, practitioners should speak to the adult first to discuss their concerns and ask their views and what they would like to happen. However, practitioners can still share safeguarding concerns with the local authority even if they are not able to speak to the adult first, or if the adult does not give their consent.

3.4 Organisational abuse

Organisational abuse (also called institutional abuse) includes neglect and physical and / or psychological abuse or poor care practices within a residential or other specific care setting; including care provided to an adult in their own home. This could be a one-off incident or involve ongoing, long term or recurring poor treatment of an adult.

Organisational abuse can involve neglect or poor professional practices linked to the structure, policies, processes and practices in place in an organisation. In some organisations, poor practices can result in a ‘closed culture’ where not many people visit the care setting (if the care setting is located away from towns and cities and is not easily accessible by transport, for example) and adults are at risk of harm, including human rights breaches and abuse. See also Closed Cultures (Care Quality Commission).

4. Ask, Listen, Do – Practice Guidance Information for Working with Adults with Learning Disabilities

The information in this section is taken from The Oliver McGowan Mandatory Training on Learning Disability and Autism – (NHS)

4.1 Ask

Always communicate with the adult first, even if you’re not sure they are able to understand you.
Ask what the adult’s preferred methods of communication are.
Ask if the adult has a communication passport, hospital passport, care plan or other document that you could see. This could help you understand the adult’s needs and how best to support them.
Begin with open questions. If the adult struggles, then provide more support and move on to yes and no questions, if needed.
You may need to repeat or rephrase things.
Ask:

- “what would you like to happen?”
- “how would you like to be supported?”
- “what is the best way I can help you?”

Ask if there is anyone else it would be helpful to talk to.
Always consider the adult’s mental capacity to make decisions about sharing information with others. Only share information, or talk to other people, with the adult’s consent or (if they lack mental capacity) where it is in their best interests.
If the adult is struggling, do not ask, “what is wrong with you?” but instead, “what has happened to you?”

4.2 Listen

Listen to all the ways that the adult might communicate their thoughts, feelings and preferences. This includes body language, tone, behaviour and any other method they use to communicate.
Don’t jump in when an adult is taking time to think. Allow time and listen carefully to their views and choices.
Adults many need more processing time. Be patient and persevere.
Listen to the adult’s own language and understanding; use their words where it is helpful.
In listening, check that the adult has understood what you have said; get them to summarise in their own words.
Check that the adult is not simply repeating what you have said or just agreeing with you. If you notice any response patterns, try asking questions in a different way to see if you get the same answers.
Avoid making judgements or assumptions, which can be barriers to good listening.
Consider involving an advocate if the adult needs support in order for their voice to be heard.

4.3 Do

Empower adult. Support to them to have choice and control in their own life. Make sure that you keep them at the centre of decision making.
Encourage adult e to ask questions and to tell you if they don’t understand something. Never talk about the adult as if they weren’t there.
Treat the adult in an age-appropriate way, respecting their roles and experiences.
Be respectful and take time to find out about the adult’s preferences and cultural needs.
Don’t assume that because the adult has a learning disability they don’t understand. Instead, make sure that things are explained in more simple language. This means avoiding jargon and long, complex sentences.
Break things down into chunks or smaller steps.
Make use of existing reports and care plans, which help you to understand the adult’s areas of strength and needs and how best to adapt your approach.
Think holistically about the adult and their life. Consider their broader needs, such as good supportive relationships, meaningful occupation, the right environment and meeting their mental and physical health needs, and the impact these may have.
Promote independence and skills development in a way that is meaningful and accessible for the adult.

4.4 Things to remember

Communication includes both giving and receiving information.

It is important to take responsibility for meeting an adult’s unique communication and information needs.

Even when an adult is unable to communicate verbally, it is important to involve and include them by using communication methods which are suited to their needs. It is your responsibility to make that possible.

You may get incomplete or incorrect information from, or about, an adult if they are stressed and finding it difficult to process.

They may be able to understand more than they can express at that moment, because they may be overwhelmed and need space and time to process and understand.

The sensory environment is important for many as it can be overwhelming or frightening. Remember to consider this when choosing a venue.

5. Using the Care Act Principles to Safeguard Adults with Learning Disabilities

To reduce the likelihood of adults with mild or moderate learning disabilities experiencing or being at risk of abuse or neglect, practitioners should provide support and information tailored to their individual needs and level of understanding. The six key principles for safeguarding adults contained in the Care Act 2014 should guide all work to safeguard adults with learning disabilities.

Prevention: Where possible, adults should be provided with appropriate level information and education about what safeguarding is, the signs of harm and abuse and what to do if they believe they, or someone they know, are at risk of or are experiencing abuse or neglect. Providing a sound knowledge base in this way can help to reduce the likelihood of abuse being recognised and reported. Taking preventive measures will help reduce the overall risk to the adult and empower them to take control of their own lives. Organisations such as Mencap or local learning disability teams provide easy read guides which can be used to support adults with learning disabilities (see Easy Reads and Easy Read Library, Mencap). Positive risk management plans can also be used to help the adult live the life they want to live while seeking to minimise any risks they may face.
Empowerment: It is essential to involve adults in decisions about their lives and seek their views on what they want to happen (see Section 4, Ask, Listen, Do – Practice Guidance Information for Working with Adults with Learning Disabilities). Too often, when working with adults with learning disabilities, practitioners and medical professionals make decisions on their behalf and without consulting them This may be because the adult lacks the mental capacity to make the decision themselves (see Mental Capacity chapter) or because practitioners do not realise that making decisions for adults may not be in their best interests or reflect their wishes. Even if the adult lacks mental capacity to make a decision, their views still need to be sought. Seeking the adult’s views should start when a safeguarding concern is first raised; practitioners should ask them the adult what they want to happen and what outcome they want to achieve at the end of the safeguarding process (see Making Safeguarding Personal chapter). By putting the adult at the centre of the process, it ensures their voice is heard and that they are kept informed about what is happening, what will happen next and if the outcome they want can be achieved. The adult’s preferred outcomes should guide the safeguarding process as much as possible. Under section 42 of the Care Act, the adult is not required to give consent for a safeguarding enquiry to take place, as the local authority has a duty to investigate a safeguarding concern if all the relevant criteria is met (see Safeguarding Enquiries Process). However, once the safeguarding enquiry is underway, the local authority will need to decide what action it is going to take following the investigation. The adult, who is the subject of the safeguarding process, does need to be involved in this, unless there are exceptional circumstances where the risk to the adult would increase.
Proportionality: Practitioners should not rush to make decisions, without considering the least intrusive response to any safeguarding concern. Failing to consider the most appropriate response can have a negative impact on adults with learning disabilities, especially if they are protective of the alleged abuser who could be a partner, family member, friend or a long-time carer. They may not want to feel they have got the person in trouble with adult social care or, potentially, the police. Therefore, when a concern is raised, practitioners need to make sure they take a proportionate response by assessing the situation and taking the least restrictive approach to reducing the risk, while always keeping the adult at the centre of the safeguarding process.
Protection: Practitioners need to make sure that they provide support to those at most risk of harm and that they have a key support network around them, which can help them feel able to tell a trusted person what is happening to them. This can be done by ensuring the adult has access to advocacy (see Independent Advocacy chapter), key workers, and regular visits from practitioners from other agencies as applicable, including provider services. It is also important that if a safeguarding referral is received, the relevant practitioner regularly checks in with the adult to see how much they want to be involved in the process and what this could look like for them. For example, one adult may want to attend the safeguarding meetings whilst someone else may want an advocate to go on their behalf. Practitioners need to ensure that accessible information is provided to assist with explaining the process such as easy reads, pictorial support, sign language or any other form of communication that will meet their needs (see Interpreting, Signing and Communication Needs chapter).
Partnership: Working in partnership with other agencies and local communities is key to keeping adults with learning disabilities safer. This ensures the adult themself to know who they can go to for support and also provides information and knowledge to the community about their role in safeguarding adults. It also enables the adult to maximise their independence, knowing that they are safer. One of the ways this has been done is the introduction of ‘safe places’, where shops and community centres sign up to provide a safe place for vulnerable people to access support and assistance if they are scared or need a place of safety. Safe places can be identified by a yellow sticker in the window – see Keep Safe with Safe Places).
Accountability: Practitioners need to make sure they are accountable for their actions and are transparent with the adult they are supporting. The adult must be kept informed, in a way which is appropriate to their particular needs, so that they understand what everyone’s role is and what they can expect to happen.

These six key principles underpin the making safeguarding personal agenda, which focuses on what the adult wants to happen as an outcome of the safeguarding process. Working this way supports adults with learning disabilities to feel more confident as they know their views, wishes and feelings will be heard. Making Safeguarding Personal is a significant move away from the previous approach where adults with learning disabilities would often have things ‘done to them’ to keep them safe, without involving them in the decision-making process.

As Lord Justice Mumby stated:

“What good is it making someone safer if it merely makes them miserable?” (see Local Authority X v MM & Anor (No. 1) (2007))

Practitioners need to ensure they promote the views and needs of the adult themselves.

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2.21 Stalking

RELEVANT CHAPTER

Domestic Abuse

SUPPORTING INFORMATION

Statutory Guidance – Stalking Protection Orders: Statutory Guidance for the Police (Home Office) – what police need to do under the Stalking Protection Act, which introduced stalking protection orders

Report a Stalker (gov.uk)

Stalking and Harassment (Northumbria Police)

April 2025 – This new chapter provides an overview of stalking behaviours and the Stalking Protection Orders Statutory guidance (the guidance states: Stalking Protection Orders should be considered as part of local safeguarding adults procedures).

1. Introduction – what is stalking?

The police and CPS have adopted the following description of stalking:

‘a pattern of unwanted, fixated and obsessive behaviour which is intrusive. It can include harassment that amounts to stalking or stalking that causes fear of violence or serious alarm or distress in the victim’. Statutory Guidance – Stalking Protection Orders: Statutory Guidance for the Police, Annex A: Understanding Stalking (Home Office)

There is no such thing as a ‘typical’ stalking perpetrator or a ‘typical’ stalking victim, but stalkers may often target people who are particularly vulnerable, including adults with care and support needs. Stalking disproportionately affects women and girls, but men and boys can be victims too. Stalking affects people of all ages and from all backgrounds, and it can have a devastating impact on victims.

Stalking behaviours often have the same characteristics as other forms of abuse, including domestic abuse, rape and other sexual offences, harassment, and so-called ‘honour-based’ abuse. Stalking behaviours can be an extension of coercive control, when an abusive intimate partner relationship has ended and / or the perpetrator and the victim are no longer living together (see Domestic Abuse chapter).

Different perpetrators will engage in different types of behaviour depending on their motive and what they hope to achieve from pursuing their victim. The relationship between the perpetrator and the victim, as well as the context in which the stalking behaviour takes place, can also vary. In many cases the victim and perpetrator will be known to each other.
Fear of serious harm or death does not have to be present for the perpetrator’s behaviour to amount to stalking, or for the victim to feel they have to make significant changes to their daily activities.

There may be a combination of online and offline stalking behaviours committed by the perpetrator.

The perpetrator’s behaviours may appear to others as ‘harmless’ and within the law, particularly if considered as isolated incidents rather than as part of a pattern of behaviour. However, behaviours may amount to stalking depending on:

the context of the behaviour;
the motivations driving the behaviour; and
the impact on the victim.

Stalking perpetrators can manipulate practitioners, agencies and systems, using a range of tactics to continue their contact with, and control over the victim, including:

deliberately targeting adults who might be vulnerable;
manipulating an adult’s mental health (for example, making them think that they are ‘going mad’);
using the system against the victim by making counter-allegations against them, or making false reports to organisations or claiming to be the victim of the stalking behaviour themselves;
attempting to frustrate or interfere with a police investigation into their behaviour;
using threats in order to manipulate the victim. For example, by telling the victim that they will make a counter-allegation against them; that the victim will not be believed by the police or other agencies; that they will inform social services; or contact immigration officials where the victim does not have permission to be in the UK.

2. Identifying Stalking Behaviours and Supporting Victims

Prevention and early support are key principles of adult safeguarding, therefore adults with care and support needs should receive clear and simple information from practitioners about what stalking is, know how to recognise the signs and what to do if they need help.
Stalking can include:

following someone;
going uninvited to their home;
hanging around somewhere they know the person often visits;
watching or spying on someone;
sending unwanted gifts, flowers, cards, emails or texts;
becoming friends on social media and then repeatedly mentioning the adult in posts or leaving comments on posts they have commented on.

2.1 Action to take

Adults who are being stalked should be supported to:

report it and tell others;
collect evidence and keep a diary (e.g. keep any messages or unwanted gifts, write down details of when the stalker was seen nearby);
complete a risk assessment using the Risk Screening Checklist;
contact a specialist agency for support and advice:
- Suzy Lamplugh Trust / national stalking helpline ;
- Paladin National Stalking Advocacy Service.

All adults have the right to feel safe in their own homes. Stalking is a criminal offence and should, therefore. be reported to the police.

3. Criminal Offences

3.1 Stalking

The Sentencing Council defines stalking as persistently following someone. It does not necessarily mean following them in person, and can include watching, spying or forcing contact with the victim through any means, including social media.

If a person is convicted of stalking under the Protection from Harassment Act 1997 the maximum sentence is six months’ custody. If the stalking is racially or religiously aggravated, the maximum sentence increases to two years’ custody.

3.2 Stalking involving fear of violence or serious alarm or distress

Stalking involving fear of violence or serious alarm or distress is a more serious offence. It involves two or more occasions that have caused the victim to fear violence will be used against them or had a substantial adverse effect on their day-to-day activities, even where the fear is not explicitly of violence. Evidence that the stalking has caused this level of fear could include the victim:

changing their route to work, the hours or days they work or their employment to avoid contact with the stalker;
putting additional home security measures in place;
moving home;
suffering physical or mental ill-health.

The maximum sentence is 10 years’ custody. If racially or religiously aggravated, the maximum sentence is 14 years’ custody.

4. Stalking Protection Orders

4.1 Overview

Stalking Protection Orders are civil orders which can be requested by the police. The threshold for starting criminal proceedings does not need to be met for a Stalking Protection Order to be made – providing a way for early police intervention in stalking cases. No previous conviction for stalking offences is needed to apply for an order.

The use of Stalking Protection Orders should be considered as part of local adult and / or child safeguarding and public protection procedures.

When the threshold to start criminal proceedings has already been met, a Stalking Protection Order is not an alternative to criminal prosecution for stalking offences but can be used alongside prosecution for such an offence. This allows for protection to be put in place for the victim even if the criminal case results in an acquittal, or where a criminal prosecution is not pursued.

Stalking Protection Orders may be used in a domestic abuse context where appropriate.

The police should consider applying for an order where it appears to them that:

the alleged perpetrator has committed acts associated with stalking;
the alleged perpetrator poses a risk of stalking to a person; and
there is reason to believe the proposed order is necessary to protect the other person from that risk. (The person to be protected does not have to have been the victim of the acts mentioned above.)

The ‘risk of stalking’ may relate to committing physical or psychological harm to the other person and / or physical damage to their property. This includes acts which the alleged perpetrator knows, or ought to know, would not be welcomed by the other person even if, in other circumstances, the acts would appear harmless in themselves.

Interim Stalking Protection Orders are intended to make it quicker to obtain an order when there is an immediate risk of harm, for example in cases where there are concerns about suicide or serious violence, including murder, but where further information or investigation is required to meet the criteria to obtain a full Stalking Protection Order or when the court is unable to provide the full order in time.

4.2 Conditions of an Order

The conditions of an Order could include banning the alleged perpetrator from:

entering certain locations or defined areas where the victim lives or frequently visits;
contacting the victim by any means, including by telephone, post, email, text message or social media;
contacting or interacting with the victim through other people, for example friends or family;
making reference to the victim on social media either directly or indirectly;
making vexatious (upsetting) applications to the civil court (including the Family Court) which reference the victim;
recording images of the victim;
using any device capable of accessing the internet;
physically approaching the victim (at all, within an area agreed as part of the Order, as outlined on a map); and / or
being involved in any kind of surveillance of the victim.

The conditions of the order could also include positive requirements for the perpetrator to:

attend an assessment as to whether they are suitable for treatment;
attend an appropriate perpetrator intervention programme;
attend a mental health assessment;
attend a drugs and alcohol programme;
give their devices to the police (for example, phones, laptops and mobile phones);
provide the police with access to their social media accounts, mobile phones, computers, tablets and passwords / codes; and / or
sign on at a police station.

4.3 Breach of an Order

A person who, without a reasonable excuse, breaches a Stalking Protection Order or an Interim Stalking Protection Order commits a criminal offence.

If the name used by or the address of a person, who is subject to a Stalking Protection Order / Interim Stalking Protection, changes during the duration of the Order, they must notify the police of that within three days; failing to do so is a criminal offence.

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8.5 Executive Function

SUPPORTING INFORMATION

Executive dysfunction and the MCA (SCIE)

Executive Functioning and the MCA – Webinar (SCIE)

Decision-making and mental capacity (NICE)

Executive functioning and the Mental Capacity Act 2005: points for practice (Community Care)

Mental Capacity Resource Centre (39 Essex Chambers)

February 2025 – This new guidance provides an overview of executive function and how it can impact mental capacity assessments. It also includes practice points to help support adults who have impaired executive function.

1. What is Executive Function and Impaired Executive Function?

Executive function is a term used to describe a set of cognitive skills that are controlled by the frontal lobes of the brain, and which help us function in day-to-day life. This includes normally automatic abilities such as decision making, emotional control, flexibility in thinking, being able to multi-task, motivation, inhibition, self-control, planning and organisation. When executive function is impaired (also known as executive dysfunction or executive impairment), it can impact on these areas. This, in turn, can mean adults find it more difficult to make appropriate decisions and solve problems, and may struggle with aspects of their lives if they do not receive support. Often people with impaired executive functioning may say one thing but then find it difficult to put it into practice.

2. Executive Functioning and Mental Capacity

Carrying out mental capacity assessments can be challenging when an adult has impaired executive functioning, as their actions will often be different to what they are saying. If the presence of impaired executive functioning is overlooked it can lead to inaccurate conclusions and leave adults at risk of harm, with no services, or the wrong services, in place to support them. However, it must be emphasised that impaired executive functioning is not, by itself, evidence of a lack of mental capacity (see Mental Capacity chapter, Section 3 Assessing Capacity).

Adults with impaired executive function can often present well in a mental capacity assessment, as they may be able to mask their shortcomings. They may often be unaware they are doing this or, having undergone previous assessments, may know what answers to give. Despite this, there will often be signs that they struggle in their day-to-day lives. This is known as the ‘frontal lobe paradox’, which is when they can ‘talk the talk’ but ‘not walk the walk’ (Executive Functioning and the Mental Capacity Act, Community Care).

Case example:

During an assessment of capacity in relation to managing finances, Lesley explains how they manage their money, where they bank and can give an overview of their income and outgoings. They clearly recognise bank notes and coins, can add them up and describe will happen if they do not pay their bills. On the basis of this information, they appear to have mental capacity. However, care staff in their supported accommodation then explain that Lesley does not pay their bills, spends all their money on computer games, is building up large debts and not purchasing essential items, such as food or personal care items. This highlights the importance of gathering evidence to confirm whether an adult can implement in practice what they say they can do.

Similar situations have been highlighted in court judgments, including AW (A Local Authority v AW [2020] EWCOP 24). In this case, AW had a learning disability and autism. Concerns had been raised regarding his mental capacity in relation to sexual relationships, contact with others, social media, accommodation and care and support needs. Mental capacity assessments had been completed and AW was found to have mental capacity in relation to his accommodation and support needs. But further concerns were raised regarding this outcome as it was believed that AW did not understand the risks to himself as a result, as what he said did not reflect his later actions. The judge found AW lacked mental capacity and noted:

“Although the written material may have suggested otherwise, having heard the oral evidence and submissions I have reached the conclusion that this is not a case in which AW fluctuates in his capacity to decide on the issues under consideration. I accept that there is a basic and profound lack of understanding, and that, by reason of the deficits in his executive functioning, he has a pervasive inability to use or weigh the information.” The judge also raised that “the ability to think, act, and solve problems, including the functions of the brain which help us learn new information, remember and retrieve the information we’ve learned in the past, and use this information to solve problems of everyday life”.

The Second National Analysis of Safeguarding Adult Reviews, Final report: Stage 2 Analysis (LGA) also highlighted the implications of not recognising impaired executive function, which can mean practitioners do not carry out thorough mental capacity assessments. This appears to be a particular issue in cases of drug or alcohol dependency, when practitioners may conclude that the adult is making decisions because of a ‘lifestyle choice’ and therefore does not require a mental capacity assessment. This can expose the adult to substantial risk, because the practitioner has not taken a holistic view of their life and considered whether they are actually able to make their own decisions.

3. Signs of Impaired Executive Functioning

Impaired executive functioning is more common in certain situations including self-neglect and hoarding (see Self-Neglect Guidance) and among adults who are autistic, (see Working with Autistic Adults chapter), have an acquired brain injury, eating disorder, learning disability or who misuse drugs or alcohol.

Some of the key signs that an adult has impaired executive function include:

being able to say but not do – they tell practitioners the ‘right thing’, but there is no evidence they are putting this into practice;
making lots of promises and being very plausible in their reasonings;
acting as if there is no reason for practitioners to be concerned, even when provided with evidence to the contrary;
struggling to initiate, plan and order their activities;
struggling with new situations, new places and / or changes in routine;
behaviour which is aimless, impulsive and fragmented;
being unable to see the impact of their actions or able to reflect on these;
being unable to think flexibly or see any nuances;
thinking which is quite black and white in style;
lacking a filter in social situations – they may say what they think or see and not be concerned or think about any potential impact of this;
acting impulsively.

Where an adult may have impaired executive functioning, a full mental capacity assessment will be required to explore if they can make the decision in question and, if not, if they have an impairment of their mind or brain. Once this is established, it is important to check there is a connection (also called the ‘causative nexus’) between any impairment and their decision-making difficulties. The adult should also be provided with support so they can develop skills to help them overcome these difficulties and make as many of their own decisions as possible.

4. Key Areas to Consider when Assessing Mental Capacity with an Adult who has or may have Impaired Executive Functioning

Mental capacity assessments can be challenging for practitioners where there are concerns about an adult’s executive functioning. Key points for practice include:

4.1 Material time

The Mental Capacity Act Code of Practice states:

“For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.”

Cameron and Codling have highlighted that practitioners often misinterpret the meaning of ‘material time’ (which generally refers to a person’s ability to make a specific decision at the time it needs to be made) and only consider evidence that is presented to them on the day of the mental capacity assessment. With adults who have impaired executive functioning, this can mean that the incorrect outcome is reached, with them either being deemed to have mental capacity or that they are solely making an ‘unwise decision’. When it comes to executive functioning, it is particularly important to remember that the material time may not be the time when the person was assessed, and that ‘real world’ evidence from other practitioners, family, friends and carers should also be taken into account to ensure that a fuller picture of their capacity to make decisions is gained.

4.1 Problem-solving skills

Problem solving can be difficult for an adult with impaired executive functioning as they can struggle to weigh up different situations and manage the unexpected. It is important to explore how the adult came to the conclusion they have reached. They should be asked questions around their ability to problem-solve, for example – Can you tell me why it’s a good thing that…? Can you tell me the bad things about ……? What would happen without…..?

4.2 Impulsiveness

Being impulsive can affect an adult’s decision making and is often observed in those with impaired executive function. Deciding when an impulsive decision indicates a lack of mental capacity can pose a challenge to the assessor (as all adults can be impulsive to a degree). It is important to look for a link (or causative nexus) between the impulsive decision making and any underlying impairment of the adult’s mind or brain.

People with executive functioning difficulties may find it hard to explain why they changed their mind in the moment.

4.3 Unwise decision

Distinguishing between unwise decision making (which, on its own, does not indicate that a person lacks mental capacity) and decisions affected by impaired executive functioning can be a challenge.

What may appear to be ‘unwise decision’ in line with principle 3 of the Mental Capacity Act could, if there are repeated examples, be evidence of impaired executive functioning. When assessing ‘unwise decisions’, the functional test of mental capacity is important as this involves looking at the process of how the adult reached their decision. In unwise decision making, the adult is fully aware of the facts / risks involved but consciously chooses to ignore or give less weight to certain facts relevant to the decision. When an adult has impaired executive functioning, they cannot pull together the correct pieces of information and use or weigh them in a meaningful way to make the decision.

For more information see, see Assessing Capacity, Mental Capacity chapter.

Scaling questions (where adults are asked to rate their observations, impressions or predictions on a scale from 0 to 10), can be useful in these situations, to see where the adult benchmarks themselves in risk-taking, and if they have any awareness of their impulsive decision making.

4.4 Professional curiosity

4.5 Holistic approach

It is essential to gather information from those involved in the adult’s life, to ensure you have a sound evidence base to support decision-making. An adult with impaired executive functioning can say the right thing, but will often struggle to put this into practice, so assessments must also seek evidence from other sources. This means it is particularly important to speak to family, carers and other practitioners to ensure that what the adult is telling you matches with their actions. It can be helpful to see the adult in different settings at different times, as it is only by understanding how difficulties with executive function are impacting on the adult and their life, that support can be put in place to help them to do what they want to do.

It is good practice to regularly re-assess the adult’s mental capacity in as, with support and practical strategies in place, they may be able to make decisions. It can also assist with gathering further evidence, as any repeated mismatch between the adult’s words and actions should be documented.

5. Further Reading

Mental Capacity Act (2005) Code of Practice

Second National Analysis of Safeguarding Adult Reviews, Final report: Stage 2 analysis (LGA)

When Mental Capacity Assessments must delve beneath what People say to what they do – Dr Emma Cameron and James Codling (Community Care)

Capacity guide – Website containing guidance for clinicians and social care professionals on the assessment of capacity

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2.15 Hypothermia: Recognition and Prevention

OVERVIEW

Hypothermia is a serious medical condition in which a person’s body temperature falls below the usual level (>35ºC) as a result of being in severe cold for a long time. This briefing note providers guidance for practitioners on:

Signs and symptoms;
Safeguarding considerations;
Immediate treatment; and
Tips for safety and prevention.

For full details, see:

Hypothermia Recognition and Prevention – Briefing Note (opens as a PDF).

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6.9 Serious Violence Duty

RELATED INFORMATION

Statutory Guidance: Serious Violence Duty (Home Office)

Serious Violence Response Strategy (Northumbria PCC)

August 2024: This new chapter provides an overview of the Serious Violence Duty and links to the Northumbria Serious Violence Response Strategy.

1. Serious Violence

Serious violence covers specific types of crime, such as homicide, knife crime, and gun crime, and areas of criminality where serious violence or its threat is inherent, such as in gangs and county lines drug dealing. It also includes crime threats faced in some areas of the country such as the use of corrosive substances as a weapon.

For the purposes of the Serious Violence Duty (section 13 of the Police, Crime, Sentencing and Courts Act 2022), serious violence in the local area is violence that is serious in that area, taking account of: the maximum penalty which could be imposed for the offence (if any) involved in the violence, the impact of the violence on any victim, the prevalence of the violence in the area and the impact of the violence on the community in the area.

2. Serious Violence Duty

The Serious Violence Duty was introduced as part of the Police, Crime, Sentencing and Courts Act 2022 and requires specified authorities – police, Justice (probation and YOTs), Fire and Rescue Service, Health (ICBs) in England and Local Health Boards in Wales, local authorities – to work together to prevent and reduce serious violence. This includes identifying the kinds of serious violence (so far as it is possible to do so) and to prepare and implement a strategy for preventing and reducing serious violence in the area.

The duty also requires the specified authorities to consult relevant authorities, namely educational, prison and youth custody authorities for the area in the preparation of their strategy. The duty takes a multi-agency approach to understand the causes and consequences of serious violence, focusing on prevention and early intervention, and informed by evidence. It does not require new multi-agency structures and encourages the use of existing local structures and partnerships to prevent and reduce serious violence and ultimately improve community safety and safeguarding.

Local partners have to publish their serious violence strategy and review it as appropriate.

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5.1.8 Inherent Jurisdiction of the High Court

August 2024: This new chapter, explains the inherent jurisdiction and how it can be used to safeguard adults who the Courts describe as ‘capacitous but vulnerable’.

1. Introduction

The term ‘inherent jurisdiction’ refers to the High Court’s ability to make declarations, orders and grant injunctions in situations where there is no statutory power to intervene to protect an adult. It has been described by courts as a ‘safety net’ as it allows them to intervene where there is no other legal avenue available. It can be used in situations not covered by existing legislation, such as the Mental Capacity Act 2005 (MCA), Mental Health Act 1983 or legislation in relation to domestic abuse, coercive and controlling behaviour or forced marriage.

However, it cannot be used in a way that would directly contradict any legislation.

It can be used to fill a gap where there is no existing applicable legislation, but not as a way of getting around or circumventing existing legislation.

In all cases, it is necessary to first consider what, if any, other legislative mechanisms exist. It is only after considering whether any existing legislation covers the position. that it can be clear whether there is a gap to be filled, and whether recourse to the inherent jurisdiction is necessary.

Any legal professions or organisation with legal standing can bring an application to the High Court. This includes local authorities, NHS trusts and Integrated Care Boards.

2. Scope of the Inherent Jurisdiction

The inherent jurisdiction can be used to fill a legal ‘gap’ and so can cover a variety of scenarios. By its very nature, there is no legislation setting out the precise remit of the inherent jurisdiction, and it is instead developed on an ongoing basis by way of case law. For this reason, legal advice must be obtained as soon as possible in circumstances where it is thought that an application to the High Court may be required.

One of the main areas where the inherent jurisdiction has been used in recent cases is in situations where an adult is not able to freely make their own decisions, but this is not as a result of mental incapacity. In these situations, the courts have used the term ‘capacitous but vulnerable’ which means the person has mental capacity but is vulnerable in some other way.

For example, an adult may be subject to external influences, such as coercion or undue influence from another person, which limits their ability to make their own decisions freely. The adult’s decision-making is therefore impaired, and they are unable to make their own choice freely, but this is because of coercion or undue influence, rather than because of a disturbance or impairment in the functioning of their mind or brain, as required by the MCA (see Mental Capacity chapter).

Case law has established that a person may have physical or cognitive impairments but those will not necessarily, on their own, mean that they are ‘at risk’ so as to make use of the inherent jurisdiction necessary. On the other hand, a person may have no physical or cognitive impairment but is still ‘at risk’ as a direct result of the coercion or abuse from another person, and so may come within the remit of the inherent jurisdiction. A family member may use influence over another family member, but for the situation to come within the inherent jurisdiction, the influence must be ‘undue’ or ‘coercive’ so the adult is incapable of making their own decisions.

The inherent jurisdiction may also be used in situations where action is required to safeguard an adult from risks from themselves, such as self-neglect, where the adult has mental capacity and so action under legislation is not an option, but the risks they cause to themselves are so great that court intervention is necessary (see Self Neglect Guidance).

It may also be used where an adult lacks capacity but the situation is not covered by the Mental Capacity Act, for example where the adult falls into a legislative ‘gap’ between the Mental Health Act 1983 and the Mental Capacity Act 2005.

3. Types of Order

Before making any order, the court must be satisfied that it is necessary and proportionate to do so. The order must be reasonable and proportionate to the circumstances and not go beyond the minimum necessary to safeguard the adult.

Orders may or may not be time-limited.

Orders may require someone to take specified actions (such as to allow access to an adult) or may set out what someone must not do (such as to threaten or assault an adult).

Types of orders which may be made under the inherent jurisdiction include (but are not limited to) orders:

allowing social care professionals to gain access to adults where there are safeguarding concerns but where, for example, another person is denying or restricting access to the person about whom there are concerns and there are no grounds for an order under existing legislation;
freezing assets to prevent the adult’s money or property being wrongly transferred or spent;
recovering money and / or property belonging to the adult which has already been disposed of;
overturning a decision about the transfer of money belonging to the adult which has already been made.

Orders made under the inherent jurisdiction can be directed either at the adult or at the person who is coercing them.

For example, orders have been made against the person coercing the adult preventing them from:

refusing access to the adult by health and social care professionals;
not allowing the adult to have contact with family and / or friends;
behaving in an aggressive and / or confrontational manner to health and social care staff;
interfering in the provision of care and support to the adult;
assaulting or threatening the adult;
seeking to persuade or coerce the adult into transferring ownership of property (such as money or their home);
trying to persuade or coerce the adult into moving into a care home or nursing home;
behaving in a way towards the adult which is degrading or coercive, such as having unreasonable restrictions on which rooms in the house the adult is allowed in, or punishing the adult, particularly if those punishments are degrading or otherwise humiliating.

Case law has established that, in general, it is better for orders to be made in relation to the person coercing the adult, rather than directed at the adult themself. This is because such an order is likely to be less of a restriction for the adult, and so more proportionate and more likely to promote their independence and empowerment.

Where an order is requested which is directed at the adult, the High Court* has stated that, in order to satisfy the requirements for the order to be both necessary and proportionate, the applicant should be able to demonstrate (with supporting evidence) that they have considered:

whether the adult will be informed about the order;
whether the adult is likely to understand the purpose of the order;
whether the adult will appreciate the impact if the order is breached or broken.

*Redcar & Cleveland Borough Council v PR [2019] EWHC 2305 (para. 46)

See Appendix 1: Case Law Regarding Mental Health and Inherent Jurisdiction and Appendix 2: Deprivation of Liberty safeguards and inherent jurisdiction.

4. Legal Summary of the Inherent Jurisdiction

The inherent jurisdiction is the High Court’s jurisdiction or power to protect ‘incompetent’ and also ‘vulnerable’ adults. Usually this is where a person has mental capacity, and therefore the MCA cannot be used. It is a jurisdiction that can only be used by the High Court, not the Court of Protection (CoP).

The legal standard is set out by Munby J, Re SA (Vulnerable Adult with Capacity: Marriage) [2005] EWHC 2942 (Fam), at 76-83

McFarlane LJ in A Local Authority v DL & Ors [2012] EWCA Civ 253 at paras 54, 62 described it as:

“The High Court has jurisdiction over those who, if not incapacitated, are reasonably believed to be i) under constraint, or ii) subject to coercion or undue influence, or iii) other disabling circumstance: “some other reason deprived of capacity to make relevant decision, disabled from making a free choice, or incapacitated or disabled from giving or expressing a real and genuine consent”:

4.1 Basic principles

To be able to use the inherent jurisdiction, the proposed intervention must be necessary and proportionate.

The Court will first attempt to use inherent jurisdiction to assist creative decision-making, rather than taking a decision for the adult: LBL v RYJ and VJ [2010] EWHC 2665 (COP) “facilitative, rather than dictatorial, approach of the court”;

A Local Authority v DL & Ors [2012] EWCA Civ 253 at para 68 per McFarlane LJ noted that inherent jurisdiction is not limited solely to affording a vulnerable adult a temporary safe space’ within which to make a decision free from any alleged source of undue influence. The Court may, in appropriate cases, impose long-term injunctive relief to protect the vulnerable adult.

5. Practice Guidance for using the Inherent Jurisdiction

5.1 Documents required

The relevant legal team will make the application to the High Court using a Part 8 claim form and will include:

draft order;
witness statement;
source documents.

5.2 Grounds / what to show

Explanation of how the court has jurisdiction; for example coercion; undue influence; other disabling influences.
That the proposed intervention is necessary.
That the proposed intervention is proportionate; this should include the alternative options which have been considered.

5.3 Legal process

The application is filed in the Family Division of the High Court.

Points to consider / discuss include:

Does the application need to be lodged without notice being given to those who are alleged to be controlling the person?
Is it urgent?
If it is not urgent, should the application be started with a request for directions (which is when the court gives instructions to the parties on how they are to prepare the case) ?
Are there any interim measures required?
Does there need to be any fact-finding hearing?

5.4 Where a person has borderline mental capacity

If mental capacity is uncertain at the start of the proceedings, there are two options:

Commence in High Court and explain why;
Commence in the CoP and transfer to the High Court if required.

If urgent action is required, it is best to start proceedings in the High Court.

6.Further Reading

6.1 Relevant chapters

Mental Capacity

6.2 Relevant information

Guidance Note: Using the Inherent Jurisdiction in Relation to Adults (39 Essex Chambers)

Gaining access to an adult suspected to be at risk of neglect or abuse (SCIE)

Appendix 1: Case Law Regarding Mental Health and Inherent Jurisdiction

Redcar & Cleveland Borough Council v PR [2019] EWHC 2305 (para. 46)

The facts centred around a capacitous (person with mental capacity) but vulnerable 32-year-old woman who was living with her parents. Her mental health deteriorated, and she was admitted to hospital. While she was in hospital, she made allegations about her father. The woman’s mental health improved, and when she was well enough to be discharged from hospital, the local authority became concerned that she was planning to return home to live with her parents. The authority issued an application under the inherent jurisdiction for protective orders.

In its judgment at paragraph 46, Cobb J observed that “before a local authority made an application under the court’s inherent jurisdiction, which was designed to regulate the conduct of a subject by way of injunction, particularly where mental illness or vulnerability was an issue, it should be able to demonstrate (and support with evidence) that it had appropriately considered:

whether the person was likely to understand the purpose of the injunction;
(ii) would receive knowledge of the injunction; and
(iii) would appreciate the effect of breach of that injunction. If the answer to any of these questions was in the negative, the injunction was likely to be ineffectual and should not be applied for or granted since no consequences could flow from the breach”.

There is not yet clear case-law as to the extent to which orders may be made under the inherent jurisdiction which would have the effect of depriving the adult of their liberty.

Appendix 2: Deprivation of Liberty Safeguards and Inherent Jurisdiction

The use of the inherent jurisdiction to authorise a deprivation of liberty must comply with article 5 of the European Convention on Human Rights and is illustrated in the case of NHS Trust v Dr A [2013] COPLR 605.

The facts involved an Iranian doctor, Dr A, who went on hunger strike to recover his passport that had been confiscated by the UK Borders Agency following his failed claims for asylum. He suffered from a delusional disorder which impaired the functioning of his brain by affecting his ability to use or weigh up information relevant to his decision whether to accept nourishment. It was in his best interests for the court to make an order permitting the forcible administration of artificial nutrition and hydration. This treatment would involve deprivation of liberty, but Dr A was ineligible to be deprived of his liberty under the MCA because he was already detained under the MHA. A legislative gap had occurred; as he could not be given the treatment under the MHA because it was not for a mental disorder, but a physical disorder.

2.1 Issues and judgement

The legal question was whether the High Court had power to make order under inherent jurisdiction to authorise forcible feeding of an incapacitated adult where a deprivation of liberty could not be authorised under MCA 2005 section16(A)(1): “If a person is in ineligible to be deprived of liberty by this Act, the court may not include in a welfare order provision which authorises the person to be deprived of his liberty”. It was not disputed that subjecting Dr A to forcible feeding amounted to a deprivation of liberty, but the difficulty was identifying how that deprivation was to be authorised in law.

The solution to the problem was to authorise treatment under the High Court’s inherent jurisdiction as being in Dr A’s best interests (paragraphs 94 & 96) In NHS Trust v Dr A, the Courts firmly established that the inherent jurisdiction was available to provide a remedy particularly, when none was available under the comprehensive MCA 2005 legislation that would meet the care of such a mentally incapacitated adult.

“[96] In all the circumstances, I hold that this court has the power under its inherent jurisdiction to make a declaration and order authorising the treatment of an incapacitated adult that includes the provision for the deprivation of his liberty provided that the order complies with Art 5. Unless and until this court or another court clarifies the interpretation of s 16A of the MCA, it will therefore be necessary, in any case in which a hospital wishes to give treatment to a patient who is ineligible under s 16A, for the hospital to apply for an order under the inherent jurisdiction where the treatment (a) is outside the meaning of medical treatment of the MHA and (b) involves the deprivation of a patient’s liberty.”

This decision illustrates how the inherent jurisdiction is a flexible legal tool to plug legislative gaps. It can not only protect adults who fall outside the scope of the MCA but can also be raised for those persons who need to be deprived of liberty and fall between the provisions of the MHA and MCA.

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8.4 Working with People who have Lasting Power of Attorney

Key points for practitioners

Do not take the person’s word that they have a lasting power of attorney (LPA) in place. Practitioners should be sure they have the evidence.
A quick way to check with the Office of the Public Guardian (OPG) is for the attorney to provide the practitioner with a code, which enables an immediate online check.
If an LPA / deputyship is in place, the practitioner should check that the LPA / deputy has the legal authority to make the decision in question.
If an LPA / Deputyship is not in place, the practitioner must still involve the relevant people in any decisions they are making.

If the practitioner believes the LPA / deputy is not acting in the person’s best interests, they may need to make a referral to their safeguarding adult’s team and the OPG. The Court of Protection has power to remove an attorney, for example if the attorney does not act in the best interests of the donor.

August 2024: This new guidance covers why it is important to find out if there is a ‘lasting power of attorney’ (LPA) or ‘deputyship’ when working with an adult who does not have mental capacity.

1. Working with Adults who Cannot Make Decisions Themselves

When working with an adult who lacks mental capacity, it is important to be clear about who the decision maker is.

When practitioners are supporting an adult who lacks the mental capacity to make decisions regarding health and welfare or property and finance, it is important to find out if there is a ‘lasting power of attorney’ (LPA) or ‘deputyship’ in place. The Office of the Public Guardian (OPG) can provide information on whether a person has an LPA, enduring power of attorney or court appointed deputy (see Find Someone’s Attorney, Deputy or Guardian).

An LPA is a legal document that enables a donor (that is the person who wants to have the LPA) to select an attorney (the person the donor has chosen) to act on their behalf in relation to two types of decisions: 1) health and welfare and / or 2) property and finance. A donor can have a number of attorneys and replacement attorneys (these are attorneys who will step into the role of attorney if the current named attorney/s can no longer act). When there are a number of attorneys, the donor needs to choose if they will act ‘jointly’ (which means all attorneys need to make a decision together), or ‘jointly and severally’ (which means attorneys can make decisions together or separately) for specific decisions.

For health and welfare matters, the donor must lack the mental capacity to make the decision in question before the attorney/s can take over this role (this can be different for property and finance (see Section 1.1). The reason someone may lack mental capacity is usually either because of a lifelong disability that affects their cognition, such as a severe learning disability or a progressive condition such as dementia. However, it is important to remember that just because someone has an impairment of, or a disturbance in the functioning of the mind or brain it does not automatically mean that they cannot make a decision. A mental capacity assessment will need to be carried out to evidence why the person cannot make a particular decision. The mental capacity assessment will look at the person’s diagnosis, how they present and how this is impacting them (causative nexus). For more information, see Metal Capacity chapter.

There are two options for LPAs: property and finance or health and welfare. The donor can apply for both or just one.

1.1 Property and finance

Property and finance cover matters such as selling a property, paying bills, withdrawing money, paying care fees, accessing bank accounts and investments, pensions and benefits.

When a person has mental capacity, they can legally appoint someone as their attorney with LPA for property and finance. A difference between property and finance and health and welfare LPAs is that for property and welfare, the donor can select that they are happy for the attorney to act on their behalf even while they have the mental capacity. Alternatively, the donor can set up the LPA so that the attorney can only act on their behalf if they lack mental capacity. The donor also has the option to set instructions on what the attorney can and cannot do. This means it is important that practitioners check the specific details in the LPA document whenever they are working with someone who has an LPA.

1.2 Health and welfare

Health and welfare covers, for example, decisions around medical care, care needs, moving into a care home or staying at home and how support needs will be met (see also Lasting Power of Attorney: Acting as an Attorney: Health and Welfare Attorneys (gov.uk).

Health and welfare LPAs only become valid when the donor lacks mental capacity to make the specific decision for themself. When completing the application, the donor has the option of selecting if they also want the person they appoint as attorney to make decisions about life-sustaining treatment on their behalf. It is important to remember that life-sustaining treatment can also cover things such as antibiotics due to having pneumonia or being put on a ventilator.

When healthcare or social care staff are involved in preparing a care plan for someone who has appointed a health and welfare attorney, they must first assess whether the donor has the mental capacity to agree to the care plan or parts of it. If the donor lacks mental capacity, practitioners must consult the attorney and seek their agreement to the care plan. They will also need to consult the attorney when considering what action is in the person’s best interests.

In practice, if the person is paying for their own care, there may be more choice about, for example, the choice of a care home than if the local authority or NHS is paying. If the local authority or trust is paying, the person choosing the home should still have a choice of care home. However, the list will be limited to the homes that the local authority or trust will fund. In either situation, the legal decision-maker is the attorney acting in accordance with the LPA.

2. What Happens when an Adult Lacks Mental Capacity – Can someone be Appointed as their LPA?

No, at the time of applying for LPA the donor must have mental capacity. If an adult lacks the mental capacity for this decision, the person wanting to act on their behalf would need to apply for a deputyship. Deputyship is put in place by the Court of Protection; the person wanting to be the deputy has to make the application to the court.

The application to the Court will include a mental capacity assessment (which will be completed by a medical professional or a social worker) to evidence that the person lacks the mental capacity to make decisions as to how to manage their property and finances or health and welfare. The Court will decide if the applicant can act on the person’s behalf. There are a few differences between deputyship and LPA, for example with health and welfare, the life-sustaining treatment option is not applied to deputies. This is due to this being such a significant decision the courts believe that this should be made following consultation with all those involved.

3. How to Check if there is Valid LPA in Place

The Office of the Public Guardian (OPG) holds the records of all registered and valid LPAs (this includes enduring power of attorney and deputyship).

If someone says they have LPA for property and finance and / or health and welfare, the practitioner must ask the attorney to provide the original document which has the OPG reference number. The information is in page 1 in Section 1: The donor; the registration date and reference number are at the bottom marked for ‘OPG office use only’.

If the paperwork is not available, the OPG can carry out a check to see if there is a valid the LPA. This can take some time, therefore if an urgent response is required (for example as part of a safeguarding enquiry), this can be requested online using a template. The OPG normally responds within 48 hours to urgent requests.

Alternatively, the donor or attorney named on the LPA can provide an LPA access code. Practitioners can use the code online to:

view a summary of an LPA;
check whether an LPA is valid;
check who the attorneys are on an LPA.

See View a Lasting Power of Attorney (gov.uk)

4. Other Types of Legal Authority that can Support the Adult when Making Certain Decisions

There are a number of other types of legal authority that can support adults when making particular decisions. These are:

enduring power of attorney: This was in place before LPA was introduced in 2007. It only covered finance and property. Enduring power of attorney could only be registered when a person lacks mental capacity. This is no longer appointed and there are not many remaining in place;
advance decision: This can only be used to refuse medical treatment. To be valid the person must be 18 or over, have the mental capacity to have made an advance decision, which is witnessed, and signed (and therefore is legally binding). Practitioners may come across advance decisions for finances and property; these should not be ignored but instead would need to be considered under ‘wishes and feelings’ (which is a formal term used as part of best interests decisions).
best placed professional: If none of the above are in place, the most relevant professional becomes the decision maker for the specific decision in question, for example medical decisions would be the responsible doctor; care and support needs it would be the social worker; for managing finances it would be the social worker;
Court of Protection: At times the decision may be made by the Court of Protection. This includes when a decision is in dispute, or it is an ‘excluded decision’, which a practitioner has no legal authority over, such as if the person lacking mental capacity wants to get married (see Mental Capacity chapter).

4.1 Other important considerations

Advance statement: This contains the person’s wishes and feelings for example how they want to be cared for, where they want to live etc. It is not legally binding, but the person’s views need to be considered and the decision will be heavily weighted by this.

Next of kin: The person’s next of kin has no legal decision-making authority to make decisions about the person. They would need to have LPA or a deputyship in place. However, practitioners still need to take into consideration their wishes and feelings.

5. Consulting with Others

The attorney has a duty to make decisions subject to the provisions of the Mental Capacity Act (MCA) 2005 (as amended) (including acting in accordance with the principles in section 1 of the MCA and the provisions relating to acting in the donor’s best interests in section 4 of the MCA) and to any specific conditions or restrictions imposed by the LPA.

When deciding what is in the donor’s best interests, attorneys should consider the donor’s past and present wishes and feelings, beliefs and values. Where practical and appropriate, they should also consult with:

anyone involved in caring for the donor;
close relatives and anyone else with an interest in their welfare;
other attorneys appointed by the donor.

An attorney can only consent to or refuse life-sustaining treatment on behalf of the donor if, when making the LPA, the donor has specifically stated in the LPA document that they want the attorney to have this authority. As with all decisions, an attorney must act in the donor’s best interests when making decisions about such treatment. This will involve applying the best interests checklist and consulting with carers, family members and others interested in the donor’s welfare. In particular, the attorney must not be motivated in any way by the desire to bring about the donor’s death. Anyone who has concerns that the attorney is not acting in the donor’s best interests can apply to the Court of Protection for a decision (see Best Interests chapter).

6. What if the LPA or Deputy Refuses to Make the Decision?

Attorneys have a duty not to delegate their decision-making responsibilities to others and must carry out their duties personally, unless authorised by the donor to delegate specific decision-making responsibilities. The attorney may seek professional or expert advice (for example, investment advice from a financial adviser or advice on medical treatment from a doctor). But they cannot, as a general rule, allow someone else to make a decision that they have been appointed to make, unless this has been specifically authorised by the donor in the LPA.

In certain circumstances, attorneys may have limited powers to delegate (for example, through necessity or unforeseen circumstances, or for specific tasks which the donor would not have expected the attorney to attend to personally). But attorneys cannot usually delegate any decisions that rely on their discretion.

Where an attorney refuses to comply with their responsibilities, application may need to be made to the Court of Protection for a decision to be made.

7. What if there are Concerns about the Attorney / Deputy

At times practitioners may have concerns with the LPA or deputy that is in place. This can include things such as the appointed person not acting in the person’s best interests, suspected financial abuse by the appointed person, the appointed person selling the individual’s property when this is not in their best interests, etc. If a practitioner has any concerns about an LPA or deputyship that is in place, it may be appropriate to first work with the attorney to come to a resolution, for example via mediation. However, the practitioner should contact their local safeguarding adults team if they are concerned the attorney is financially abusing or has harmed the donor. Where there are potential criminal offences, the police should be informed. The practitioner will also need to contact the OPG. The OPG can apply to the Court of Protection to remove an attorney if there are concerns about their behaviour.

8. Ending a Lasting Power of Attorney / Deputyship

The donor can end the LPA at any point as long as they have the mental capacity to make such a decision. The attorneys themselves can also remove themselves from the role. The attorney will be asked to return any legal documents to the OPG.

The attorney’s role will also be ended if the donor passes away, the attorney passes away or loses mental capacity and a replacement attorney was not named, or the donor did not state that they must act jointly if the donor’s marriage to the attorney ends and if the attorney of property and finance becomes bankrupt.

With some LPAs there may be a named replacement attorney who would be able to pick up this role if the current attorney is unable to act anymore.

9. Case Examples

9.1 Case example for an adult who self-funds their care and support

Mary has dementia and has been cared for at home with a package of care funded by the family. However, there have been several incidents that have led to Mary assaulting her husband meaning her needs can no longer be met at home. The husband holds an LPA for Property and Financial Affairs and Health and Welfare. The husband has requested a Care Act assessment and following a financial assessment, Mary has been assessed as self-funding her care. The husband has spoken to the social worker who has advised that a care home would be most suitable for Mary. The husband spoke to the GP and the district nurse about this decision as he wanted to seek their views. The social worker advised the husband that it was his decision to choose the care home and provided some information on care homes that were potentially suitable to meet his wife’s needs. As Mary was self-funding her care and LPA was in place, the decision maker was her husband. Her husband informed the social worker that his wife loved living in the countryside, and it would be important to her that the care home be somewhere quiet, with not too many residents, and had lots of space for his wife to wander the grounds.

The MCA is underpinned by five key principles. In line with these, the LPA or deputy must consult with others who are relevant to the decision being made and must act in the person’s best interests. In the example above, Mary’s husband has consulted with relevant professionals and has followed Mary’s views and wishes when it comes to finding a suitable placement for her.

If in this example, the local authority was funding the care and support, the person choosing the home on Mary’s behalf (her husband) should still have a choice of care home, but the choice will be limited to the homes that the local authority will fund. In either situation, the legal decision-maker remains the attorney (Mary’s husband) acting in accordance with the LPA.

9.2 Case example for an adult who needs medical treatment

Tom has a severe learning disability and has been admitted to hospital due to having eating and drinking difficulties. After further investigations, the consultant has recommended that Tom requires a PEG (percutaneous endoscopic gastrostomy). Tom’s parents try to refuse this treatment stating they have an LPA ‘for everything’ and that they want Tom to be able to eat ‘normally’ and not via a tube. However, upon the social worker submitting an urgent request with the OPG, the OPG confirm that Tom’s parents have LPA for property and finance only. Therefore, the decision maker will be the consultant.

If there is no LPA / deputy in place, the relevant practitioner is the decision maker, depending on the decision that needs to be made.

However, in such cases just because family are not the decision maker does not mean they do not have a voice. With any decision, the family’s views are important and hold weight towards the decision. If a unanimous decision cannot be reached, a court application may be required to make the decision.

9.3 Case example for an adult who is Continuing Health Care funded

Helen is fully health-funded and is currently in a nursing home that is closing down. The Continuing Health Care (CHC) nurse has checked their system which states there is no LPA / deputy in place. However, there is also no evidence of how this was checked. The CHC nurse ensures that they complete a check with the OPG who confirms there is no LPA / deputy in place. The nurse saves this email confirmation to the person’s record. The CHC nurse is the decision maker regarding the move to a new placement, they ensure they speak to all involved in the person’s care to gain their views including family. All interested parties agree one of the placements is in Helen’s best interests to move to.

With CHC cases it is important to make sure they are funding 100% of the care, if a split funding agreement is in place, then the local authority is the decision maker.

10. Further Reading

Find out if Someone has a Registered Attorney or Deputy (Office of the Public Guardian)

Urgent Enquiries: Check if Someone has an Attorney or Deputy (Office of the Public Guardian)

View Lasting Power of Attorney (gov.uk)

Use a Lasting Power of Attorney Service (Office of the Public Guardian)

Using a Lasting Power of Attorney (gov.uk)

LPAs – the Duties on the Certificate Provider (Mental Capacity Law and Policy)

Best Interests Decision-Making for Adults who Lack Capacity: A Toolkit for Doctors Working in England and Wales (BMA)

Mental Capacity Code of Practice (Office of the Public Guardian)

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4.2 Complex Adult Risk Management (CARM) Practice Guidance

RELATED CHAPTERS

Complex Adult Risk Management (CARM) Policy

Self Neglect Guidance

South Tyneside Multi Agency Information Sharing Guidance

SUPPORTING DOCUMENTS

Templates and other supporting documents for use throughout the CARM process can be found in Safeguarding Adults Forms, Leaflets and Posters.

June 2024: The CARM Process has been developed to help safeguarding adults partners manage complex risks. Such risks may arise within specific circumstances when working with adults who have the mental capacity to make decisions for themselves, but who are at risk of serious harm or death.

This practice guidance contains detailed information on the process for making a CARM Referral and the format which will be used during a CARM meeting, including how the meetings will be held and the way risk will be discussed, assessed and managed.

1. Criteria for a Complex Adult Risk Management (CARM)

See Safeguarding Adults Forms, Leaflets and Posters where the CARM Referral and Risk Assessment Form can be downloaded.

As agreed by the South Tyneside Safeguarding Adults Board, the agency identifying a risk(s) to the adult will refer to the CARM. The referral will be considered to determine that the CARM criteria is met. Where there is a decision to progress to a CARM meeting, the CARM Administrator will inform the Chair and will coordinate the CARM. In South Tyneside this will be the administrator from the MASH.

Consent for holding a CARM should be obtained from the adult whenever possible, and they should be encouraged to participate in the CARM process. However, a lack of consent does not prevent a CARM from taking place. Under common law, a person may act to prevent serious harm from occurring if there is a necessity to do so.

Referring to CARM is not dependent on gaining consent to share information. The Memorandum of Understanding sets out the legal framework for partners to share information where they believe that an adult is at risk of death or serious injury, or where sharing information is in the public interest. The adult’s views should be sought throughout all interactions as part of a Making Safeguarding Personal Approach (see Making Safeguarding Personal chapter).

In order to consider a person for a CARM meeting, one or more the following conditions must apply:

a. the adult has the mental capacity to make decisions and choices about their life;

b. There is a risk of serious harm (physical or psychological) which is life-threatening and/or traumatic, and which is viewed to be imminent or very likely to occur, or risk of death due to non-engagement with services, and they do not meet the criteria for a safeguarding referral; OR

c. There is the potential of death and or life changing injuries and/or a potential risk to the health and safety of others.

d. There is a high level of concern from partner agencies.

CARM referrals should be sent via email to [email protected]

All referrals will be triaged upon receipt to ensure they meet the CARM criteria. Should a CARM referral not meet the criteria, the referrer will be informed by the CARM Administrator via email. There may be other options available to support the adult and the referrer will be advised of these, where applicable, in the CARM Referral Notification (see Safeguarding Adults Forms, Leaflets and Posters for the Referral Notification Form).

The CARM, ‘What to Expect’ Leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) should, whenever possible, be completed with the adult or their Advocate.

The report templates for Complex Adult Risk Management (CARM) Meeting contains 4 forms, each with a specific use within the CARM process (see Safeguarding Adults Forms, Leaflets and Posters to download a copy).

2. Chairing a CARM Meeting

The purpose of the CARM meeting is to formulate a multi-agency risk assessment and identify actions to reduce the risk.

The Chair of the CARM meeting will always be one of the Safeguarding Adults Board statutory partners (ICB, Police, local authority Adult Safeguarding).

It is the responsibility of the CARM Chair to ensure the correct forms are completed and are used appropriately to record risks, actions outcomes and reviews for the whole process.

The CARM Administrator will be responsible for arranging the minute taker at CARM meetings.

3. Referral and Invitation to Attend a CARM Meeting

The Referring Agency will complete the CARM Referral and Risk Assessment form (see Safeguarding Adults Forms, Leaflets and Posters to download a copy), paying close attention to appropriate and meaningful information regarding professional concerns, the views of the adult (where known), and the initial risk(s) identified. The record should include:

the adult’s history and current situation;
the adult’s views and expectations;
work that has already been undertaken to reach this point/ reduce the risk;
agencies which need to be invited / form part of the CARM process;
the identified risk of serious harm or death;
how the views of the adult can be included. The adult, or an appropriate Advocate, may attend.

Once the referring agency has completed the CARM Referral and Risk Assessment Form, they will email it to [email protected]

The CARM Administrator will arrange the CARM meeting and any subsequent review meetings. It is essential that attempts are made to include full participation of the adult’s views, whether these are given directly or through an Advocate.

Form 1 of the CARM Report Templates is used by the CARM Administrator to inform and invite partner agencies to a CARM Meeting along with clear instructions for agencies to complete sections 2 to 6 of the form (see Safeguarding Adults Forms, Leaflets and Posters to download a copy).

CARM meetings will be held via MS Teams unless requested. Consideration should be given by all agencies involved about any barriers that may impact on the adult’s ability to attend the meeting, for example:

venue accessibility;
how the adult can be included in the meeting process;
are there any risks / concerns to consider?

The ‘What to Expect’ Leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) acts as the invite for the adult and/or their Advocate to attend the CARM meeting and provides an opportunity for them to give their views. It can be discussed with the adult either at a face to face or remote meeting prior to the CARM Meeting or posted to the adult with a stamped addressed envelope for them to return their comments.

The CARM Chair should allow time to seek the adult’s views and ascertain whether the adult will be attending the CARM meeting. It is important to make reasonable adjustments to support the individual to be able to attend their own CARM meeting (see also Equality, Diversity and Human Rights in a Safeguarding Context).

4. Receiving an Invitation to Attend a CARM Meeting

The CARM Administrator will circulate the CARM Agency Report (Form 1) to inform and invite the referrer and relevant agencies to a CARM Meeting. Clear instructions for agencies to complete Sections 2 to 6 of the CARM Agency Report (Form 1) will also be provided (see Safeguarding Adults Forms, Leaflets and Posters to download a copy of the Report Template) .

It is recommended that 10 working days are allowed for partner agencies to prepare information and assess any risks prior to the CARM meeting.

Agencies receiving an invitation to attend a CARM meeting must complete Sections 2 to 6 of the CARM Agency Report (Form 1) in order to:

gather information held within their organisation about the adult;
take reasonable steps to gather further information if required;
liaise with the CARM Administrator to confirm attendance or submit a detailed information report to support the CARM process if required.

Please note: the adult may attend the meeting, but consideration should be given to whether their full or partial attendance is necessary, It is recognised that there may be some circumstances where it is not appropriate for the adult to attend. For example, there may be occasions where full disclosure by professionals may increase the risks or impact on the adult’s ability to engage with the process, or where the adult’s presence may impede candid discussion between professionals. In such circumstances, a pre-meeting might be helpful, prior to the arrival of the adult.

Each agency should consider professional representation; ideally from someone with the appropriate knowledge and expertise in their field and the authority to make decisions on behalf of their agency.

5. The CARM Meetings

The CARM approach involves a series of meetings, and the nominated Chair is responsible for chairing and coordinating these.

The CARM process includes the follow steps:

Step 1 – CARM criteria met

Step 2 – Management meeting held

Step 3 – Review (the review nay be omitted or held multiple times as required)

Step 4 – Closure

The CARM Meeting Agenda (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) provides an aide memoir for the Chair as to what needs to be covered in the CARM meetings. The Chair is also responsible for ensuring the completion of all relevant forms within the CARM Report Templates.

Meeting format

Introductions: (All Meetings) – The Chair will ask all attendees to introduce themselves, clarifying roles and the agencies represented. The Chair will also ask the adult or their Advocate (if they are in attendance) to introduce themselves.
The Chair will read out the CARM Information Sharing Confidentially Statement, which makes specific reference to the legal basis for the information sharing in relation to CARM. The Chair will confirm any apologies received and that Form 1 CARM Agency Reports have been submitted. These details will be recorded in Section 3 of Form 2 CARM Meeting, within the CARM Report Templates.
Is the adult present? Whilst efforts should be made to have the adult present at meetings, at times this may not be achievable or appropriate. The details of a representative/Advocate should be recorded, including the nature of the relationship to the adult.
The Chair should ensure consideration is given to the appropriateness of the representative/Advocate in attending meetings. The representative/Advocate should be appointed or permitted attendance on the basis of ‘best interests’. (Remember, the CARM meeting may highlight or raise sensitive, confidential information which may not ordinarily be accessible)
The Chair and those in attendance should consider the value of information sharing on a case-by-case basis, having careful regard to the context of the risk or cause for concern. For example, matters of fire risk may not require disclosure of the adult’s health needs or specific diagnoses. However, factors affecting the adult’s ability to escape fire (e.g. their mobility) may be relevant when considering risk reduction.
Does the adult understand the purpose of the meeting? All reasonable efforts should be made to explain the reasons for the meeting (i.e. professional concerns) to the adult. This may be explained in writing; however, an additional verbal discussion might be helpful.
What is important to the adult at risk/What is important for the adult at risk? This is Section 4 of CARM Management Meeting (Form 2) within the CARM Report Templates, and requires the Chair (and those attending) to provide a distinction between what is important to the adult and factors which professionals feel contribute to the identified risks. It provides an opportunity for everyone present to indicate what they think it is important for the CARM process to achieve. This may reflect actions raised in the Risk Management Plan (contained in the Report Templates, see Safeguarding Adults Forms, Leaflets and Posters to download a copy). It also provides an opening to explore different, and potentially conflicting, points of view. Effort should be made to negotiate outcomes, but not at the expense of hazard/harm mitigation. For example, in the case of a person who hoards, the adult may want to keep belongings in their home that present a fire hazard. However, the objective of professionals might be to encourage de-cluttering (by regulatory intervention or otherwise).
Description of risks (including a risk rating): Set out the risks known to the group. It may be necessary to write a short explanation of the risk.
Rating the risk: Each specific risk should be rated using the Risk Matrix (Appendix 1 CARM Report Template, see Safeguarding Adults Forms, Leaflets and Posters to download a copy) by the most appropriately qualified attendee. The rating does not require complex calculation but should broadly reflect the likelihood of harm given the circumstances of the adult, for example low, medium, high or very high.
Actions to reduce the risk: The Risk Management Plan (CARM Management Meeting Form 2, Section 5) is a list of actions agreed during the meeting which may reduce the adult’s exposure to harm. The extent to which risk is reduced will initially depend on the predictions (and professional expertise) of those attending the meeting, and whether the agreed actions are successfully achieved. For this reason, the impact of the actions listed must be evaluated by agencies present, and the need for any CARM Review Meeting considered.
The plan may include a diverse list of actions, some which directly reduce risk and others that may seem less tangible.
The CARM Management Meeting record (Form 2) should specify the individual/agency that has been tasked with an action and any anticipated completion or review dates.
Description of any conflicts identified: Conflict of opinion may arise for any number of reasons. This is an opportunity to describe the nature of the conflict and the persons/agencies involved. For example, a Fire Officer or Environmental Health Officer may demand the removal of materials from a hoarded property for the purpose of fire prevention and/or vermin management, but another attendee may feel that this is a violation of the lifestyle choices of the adult.
Legal Powers and Duties considered: Those in attendance should consider any legislation, policies or codes of practice which might be relevant to the case. Duties, with associated powers, should be identified and statutory interventions specified within Form 2 .
Agencies may have discretionary powers which could be applied, and these should be recorded, where appropriate, even if not enacted. In all cases, any impact on the provisions of the Human Rights Act 1998 (e.g. Article 8 – the right to respect for private and family life) must be considered. This includes where a third party is affected directly or indirectly by the behaviour or life choices of the adult.
Outcome of the Meeting: The Chair should verbally summarise the recorded risks and agency actions identified and record these in Section 6 of Form 2. It is the responsibility of the individual agency to ensure agreed actions are completed within the timescale identified, and the impact on the identified risk is evaluated.
The Chair may task an action to an agency if they are absent or unable to attend. It remains the responsibility of the individual agency appointed, rather than the Chair, to complete such actions.
A decision may be made during the CARM that another pathway is more appropriate to manage the risks. For example, those present may identify that the adult meets the criteria for safeguarding procedures. In these cases, it may be necessary to close the CARM and conduct a meeting under Safeguarding procedures (see Safeguarding Enquiries Process).
Where it is identified that the risks have been reduced or removed, a decision will be made that the CARM can be closed. This needs to be recorded in Form 4 CARM Closure Meeting.
Review Meeting Required: The Chair will decide in consultation with the agencies involved in the CARM process whether a further meeting is required, and the timeframe for this to happen. It is more than likely that a Review Meeting will be required to record actions taken and evaluate the impact of these on the identified risks. The Chair will need to consider whether any other agencies could usefully contribute to a Review Meeting and invite them accordingly. The CARM Review Meeting (Form 3) template of the CARM Report Templates should be completed for Review Meetings.
The Review Meeting may decide that the adult no longer meets CARM criteria. In such cases, the CARM process should close, and the decisions should be recorded appropriately in Form 4 CARM Closure Meeting.
Following the CARM Management Meeting: It is the Chair’s responsibility to ensure that all relevant forms are completed accurately and circulated to invited agencies (whether in attendance or not), using secure email. Where a minute taker has formally recorded the meeting, the minutes should be included where relevant . The Chair must agree with the agencies involved how information from the CARM will be shared with the adult and should communicate details of any review meetings to the adult or their Advocate using the guidance detailed in this document.

6. CARM Review Meeting

The Chair should complete CARM Review Meeting (Form 4) record (see CARM Report Template, Safeguarding Adults Forms, Leaflets and Posters to download a copy).

Agency Update: Each agency will provide an update on the impact of agreed actions taken and details of any outstanding actions. It is the responsibility of each of the attendees, and not the Chair, to follow up and complete actions assigned to them.

Additional actions: CARM attendees may identify appropriate actions in addition to those specified in previous meetings. Any additional actions that may be required should be recorded in this section, with details of the individual / agency responsible for the action and the agreed time scales. This section of the record should not include outstanding actions.

The Chair will decide whether a further Review Meeting is required and make the necessary arrangements (if applicable). See Section 7, Closure of CARM.

The CARM Administrator will circulate the updated CARM Forms following the meeting.

7. Closure of CARM

The Chair should complete the CARM Closure Meeting (Form 4) of the Report Templates when it has been agreed that the CARM process can be closed.

Information which should be recorded includes:

Date of closure: This identifies the date that the CARM process concludes. This does not prohibit the re-opening of a CARM should it be necessary at a later point.
Reason for closure / update from Chair / Evaluation of Meeting: This gives the Chair the opportunity to summarise and conclude discussions and actions agreed, as well as any legislation applied, in reaching the conclusion of the CARM.

CARM meetings are often complex by nature and any conflicting views, lack of engagement by the adult, or other relevant factors should be detailed by the Chair. The Chair can also comment on shortfalls and triggers for re-referral into the process.

Where an adult chooses to remain in a situation that places them at risk from identified harms this should be noted in Section 3 of the CARM Closure Form. The views of each agency in respect of the CARM closure and details of the risks which remain should be documented. It is recognised that it may not be possible to address all concerns/risks identified, but the role of CARM is to ensure that each agency has taken all reasonable steps to support the adult to recognise and reduce risks of death and serious harm.

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4.1 Complex Adult Risk Management (CARM) Policy

RELATED CHAPTERS

Complex Adult Risk Management (CARM) Practice Guidance

Self Neglect Guidance

South Tyneside Multi Agency Information Sharing Guidance

Templates and other supporting documents for use throughout the CARM process can be found in Safeguarding Adults Forms, Leaflets and Posters.

Self-neglect (Care Act 2014);

Behaviours that place them at risk/chaotic lifestyles; or

Lack of engagement with services.

1. Introduction

The South Tyneside Safeguarding Adults Board (STSAB) have agreed the CARM approach to manage complex risks. Such risks may arise within specific circumstances when working with adults deemed to have the mental capacity to make decisions for themselves, but who are at risk of serious harm or death through:

Self-neglect (Care Act 2014) (see also Self Neglect Guidance);
Behaviours that place them at risk/chaotic lifestyles; or
Lack of engagement with services.

The aim of the CARM policy is to provide professionals with a framework to facilitate effective multi-agency working with adults who are at significant risk.

2. Legal Considerations

All agencies/organisations have a duty to uphold the law, and the CARM framework should not be seen as a substitute for legislation and existing processes.

Agencies should follow existing legislation and their internal processes, including the Human Rights Act 1998, Mental Health Act 1983, Mental Capacity Act 2005, Care Act 2014, Data Protection Act 2018, Multi Agency Public Protection Arrangements (MAPPA), Multi-agency risk assessment conference (MARAC) etc. These processes will be seen as having primacy over the CARM process.

The CARM framework does not replace any current policies and procedures. The CARM is a framework that sits within the multi-agency adult safeguarding procedures and should only be applied if the criteria are met (see Section 4, Criteria for a CARM). The CARM Framework is for concerns that sit outside of the Care Act 2014 Section 42 enquiry decision but within the ‘wellbeing principle’ of the Care Act (see also Promoting Wellbeing chapter).

Information sharing is key to promoting an adult’s rights and protecting then from significant harm. The Care and Support Statutory Guidance explains that if the adult has the mental capacity to make informed decisions about their safety and they do not want any action to be taken, this does not preclude the sharing of information with relevant professional colleagues. This is to enable professionals to assess the risk of harm and to be confident that the adult is not being unduly influenced, coerced or intimidated and is aware of all the options. This will also enable professionals to check the safety and validity of decisions made. It is good practice to inform the adult that this action is being taken unless doing so would increase the risk of harm.

3. Complex Adult Risk Management (CARM) Process

The CARM is a multi-agency adult assessment risk management process to:

Identify the relevant risks for the individual;
Discuss and agree agency responsibilities/actions;
Record, monitor and review progress with an agreed action plan;
Agree when the risks have been managed, and evaluate the outcome.

The CARM will only be called where the adult at risk does not fall within the existing multi-agency processes, or if it is felt that a CARM meeting will help to reduce the risk of serious harm or death. The CARM is not a substitute for:

Formal adult safeguarding procedures;
Multi-Agency Public Protection Arrangements (MAPPA) see Multi-Agency Public Protection Arrangement);
Multi-Agency Risk Assessment Conference (MARAC) see Multi-Agency Risk Assessment Conferences;
Channel (multi-agency meeting within the Prevent programme) see Adults Vulnerable to Radicalisation and Violent Extremism;

Each agency has a responsibility to ensure that their staff are aware of the CARM policy/process and of the need to contact their safeguarding lead/manager if/when the process is required. The agency that identifies the adult at risk who would benefit from a CARM meeting should ensure the criteria in Section 4 are met and familiarise themselves with the CARM processes, including Section 6, Chairing a CARM Meeting.

4. Criteria for a CARM

One or more of the following conditions must apply for a CARM to be called:

the adult has the mental capacity to make decisions and choices about their life;
there is a risk of serious harm (physical or psychological) which is life-threatening and/or traumatic, and which is viewed to be imminent or very likely to occur, or death due to non-engagement with services, and they do not meet the criteria for a safeguarding referral;

here is the potential of death and or life changing injuries and/or a potential risk to the health and safety of others in the community;
There is a high level of concern from partner agencies.

The principles of the Mental Capacity Act (2005) must be followed to establish whether the adult has the mental capacity to make the relevant decisions. Further information and guidance on Mental Capacity assessments and best interests decision-making can be found in the Mental Capacity and Best Interests chapters.

It is essential that every effort is made to engage and involve the adult deemed to be at risk throughout the CARM process, where they will engage.

CARM is an opportunity to ensure all agencies have offered the appropriate support/options to the person. All relevant legislation must be considered throughout the process.

5. Preparation for a CARM Meeting

Consent for holding a CARM meeting should be obtained from the adult wherever possible. The adult should be encouraged to participate in the process and given the ‘What to Expect’ information leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy). However, a lack of consent must not prevent the meeting from taking place.

Referring to CARM is not dependent on gaining consent to share information. Each agency will have their own Memorandum of Understanding that sets out the legal framework for partners to share information where they believe that an adult is at risk of death or serious injury, or where sharing information is in the public interest. The adult’s views should be sought throughout all interactions as part of a Making Safeguarding Personal Approach (see Making Safeguarding Personal chapter).

Where the criteria are met and a CARM meeting is agreed, the nominated Chair will ensure:

The appropriate agencies are invited to the meeting including non-statutory, voluntary sector and local community groups to facilitate the best opportunity to encourage positive engagement with the adult at risk;
Consider whether there are agencies not currently involved with the adult that should be invited to attend;
Where children are part of the household or are linked to the person, ensure Children’s Services are invited to the meeting and a safeguarding children referral has been made (see Safeguarding Children Procedures).
Ensure the views of the adult can be included – the adult, or an appropriate advocate, may attend;
Consider the resources necessary, should the adult wish to attend and have communication/physical needs.

All partner agencies must ensure that an appropriate member of staff, with the required seniority to make decisions on behalf of their organisation, attends the CARM meeting.

6. Chairing a CARM Meeting

See also Safeguarding Adults Forms, Leaflets and Posters where the CARM Meeting Agenda and Reporting Template can be downloaded.

The purpose of the meeting is to formulate a multi-agency risk assessment and identify actions to reduce the risk. The nominated Chair will chair the meeting and ensure completion of the CARM Reporting Template at every meeting (a copy can be downloaded from Safeguarding Adults Forms, Leaflets and Posters).

7. Death of a Person within CARM Process

Where a person dies whilst within the CARM process:

HM Coroner must be informed;
Consider a Safeguarding Adults Review (SAR) referral and discuss with Adult Social Care/ICB Adult Safeguarding Leads.
Consider a Learning Review.

8. Information Sharing

Each agency needs to be aware of the principles of sharing information and be aware of the threshold of sharing information on a ‘need to know basis’. Information can be shared to protect the vital interests of the adult at risk See Data Protection Act.

9. Evaluation of CARM and Quality Assurance

Each agency must maintain records of the CARM meetings in which they are involved. Agencies are responsible for collating and reporting information to the South Tyneside Safeguarding Adults Board as required.

At the closure of every CARM the Chair and members must review the process and complete the evaluation in Section 2 of Form 4 in the CARM Report Template (which can be downloaded from Safeguarding Adults Forms, Leaflets and Posters).

Following closure of the CARM the Adult at Risk, the Chair and members must complete the respective CARM Evaluation.

Audit of the CARM process will be agreed via the Performance Management and Evaluation Sub-Group of the Safeguarding Adults Board.

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10.3 Professional Curiosity

RELATED CHAPTER

Escalation and Challenge Protocol

Supervision

SUPPORTING INFORMATION

Professional Curiosity Resource (SAB Manager Network)

Professional curiosity in safeguarding adults: Strategic Briefing (Research in Practice for Adults)

February 2025: A link to the NEW Professional Curiosity Resource developed by the National SAB Business Manager Network has been added. The resource emphasises that professional curiosity is everyone’s business and includes practical examples of ways in which practitioners can build relationships with adults, by using communication skills, asking questions, listening and focusing on the person and their responses.

1. What is Professional Curiosity

Professional curiosity is about exploring and understanding what is happening in a person’s life, rather than accepting things at face value. It involves observing, listening, asking direct questions and sometimes having difficult conversations with people. It is also known as ‘respectful uncertainty’.

It is about practitioners making sure that – when working with adults and their families / friends and carers– that they keep an open mind, ask questions, dig deeper and challenge their own assumptions as well as those of other practitioners.

Professional curiosity and challenge are essential part of practice, with the aim of keeping adults with care and support needs safe. Safeguarding Adults Reviews have often found that practitioners have not been curious enough, have not asked enough probing questions and have too easily accepted situations as they have been presented to them.

The risks of abuse or neglect that an adult may face are not always immediately obvious, especially if they or their family / friends do not want practitioners to know what is really happening. This may be more likely if an adult is being abused or neglected by someone they know or there are other types of criminality in the home. Being more curious as practitioners and digging deeper into areas of an adult’s life or circumstances, can help inform assessments and empower staff to influence key moments of decision-making and therefore help to keep adults safe and promote their wellbeing (see Promoting Wellbeing chapter).

Professional curiosity can help practitioners:

understand the full picture;
make sure they have all the necessary information;
improve outcomes for adults with whom they are working;
help keep adults safe;
identify disguised compliance (see Section 3, Disguised Compliance);
support other professionals working with the adult, including those from partner agencies.

Whilst this information focuses on practitioners working with adults with care and support needs, it also applies when working with children and families.

2. Professionally Curious Practice

Professional curiosity requires practitioners to:

think ‘outside the box’ and consider an adult’s circumstances as a whole, including other how their life is affected by other family members (see Whole Family Approach chapter);
engage with adults and their families in a way that helps them understand the adult’s lived experiences. This should include taking a person-centred approach and providing culturally appropriate practice to the people with whom they are working (see Making Safeguarding Personal and Safeguarding Adults and Culturally Competent Practice chapters).

Adults may not always disclose information about abuse and / or neglect directly to practitioners, particularly when they first meet. This can make identifying adults who are, or at risk of, being abused or neglected more challenging. Being professionally curious is, therefore, key to being able to identify possible abuse and acting promptly to safeguard the adult and promote their wellbeing.

It can also mean considering issues which may be outside of their usual professional role. In such circumstances, discussions should take place with line managers and staff from other agencies to clarify roles and responsibilities, to ensure all relevant care and support is in place for the adult.

There are different ways of being professionally curious. These include observing, asking, listening and clarifying. Practitioners should spend time engaging with adults and their families / friends on visits, using these approaches as required.

2.1 Observing

Do you see or observe anything, when you meet with the adult / their family / friends, that makes you feel uncomfortable?
Do you observe behaviours which indicate abuse or neglect, including domestic abuse (see Types of Abuse and Neglect and Domestic Abuse chapters)?
Does what you observe either contradict or support what you are being told by the adult, their family or other practitioners who are involved?
How do the adult and family members interact and communicate with each other, and with you?
Do you want to ask further questions as a result of what you have seen?

2.2 Asking

Do not assume you know what is happening in the adult’s home environment – ask questions and seek clarity if you feel you are not sure.
Do not be afraid to ask questions of everyone involved, including any visitors to the home. Be open in the way you ask questions, so that people know it is about being able to achieve the best outcomes for the adult – you are not judging or criticising them.
Be open to accepting new or unexpected information that may not support your initial assumptions about the situation. Incorporate this into your assessment and review care and support plans as necessary

2.3 Listening

Are you being told anything that you think you needs further clarification (see Section 2.4 Clarifying)?
Do you feel the adult, family member or friend is trying to tell you something, either verbally or through non-verbal cues, for example you pick up in their body language or what they are not saying?
Is there anything that concerns you about how family members or friends interact with the adult and what they say?
It is essential that you have the time and space to have a private conversation with the adult, to give them the opportunity to say anything they want without family / friends listening or speaking for them. This should not just be a one-off conversation but as often as possible, as it may take time for the adult to build up a trusting relationship with you.

2.4 Clarifying

Are practitioners from other agencies involved? If so, what information do they have?
Are other practitioners being told the same things by the adult / family /friends as you, or are they being given different accounts of the same situation?
Are other practitioners concerned about the adult, and if so what are their concerns?
Would a multi-disciplinary discussion be useful / required?
What action has been taken so far? Is there anything else which could or should be done by you or someone else to support the adult?

Sharing relevant information with relevant practitioners from other agencies is key to safeguarding adults who are experiencing, or at risk of, abuse and / or neglect and, as well as ensuring better outcomes for all adults who have care and support needs. See South Tyneside Multi Agency Information Sharing Agreement.

3. Disguised Compliance

Some adults, family members or friends may display a behaviour called ‘disguised compliance’. This is when people give the appearance of co-operating with agencies in order to deflect practitioner concerns and avoid raising suspicions.

People will often want to show their ‘best side’ when interacting with practitioners; this can be quite normal behaviour. To a small degree, disguised compliance can be seen in many people. However, there is a difference between this and someone who is being superficially cooperative in order to keep abuse or neglect of the adult hidden and practitioners away. In such cases, the adult, family member or friend plans this compliance, to make it look like they are cooperating, when in reality they are not.

There is a risk that practitioners who are not professionally curious may delay or avoid taking action, due to disguised compliance.

4. Professional Challenge

Practitioners may experience differences of opinion, concerns and issues both with colleagues in their own organisation and with those from other agencies. In such circumstances it is vital these are resolved as effectively and swiftly as possible.

Working with different professional perspectives is a key part of a healthy and well-functioning partnership, and differences of opinion can usually be resolved by discussion and negotiation between the practitioners concerned. It is essential however, that where differences of opinion arise they are resolved in a constructive and timely manner, so they do not adversely affect the outcomes for adults and their families / friends.

If there is a difference of opinion between practitioners, remember:

the process of resolving professional differences and disagreements can help find better ways to improve outcomes for adults and their families / friends;
each practitioner is responsible for their own cases and their actions in relation to individual adults;
differences and disagreements should be resolved as simply and quickly as possible by individual practitioners and /or their line managers;
everyone should respect the views of others, whatever the level of their experience;
discussions about disagreements should always be respectful and courteous and remain professional at all times;
challenging more senior or experienced practitioners can be difficult, so practitioners may need support to do so when necessary;
practitioners should expect to be challenged and not take it personally – working together effectively depends on open and honest relationships between agencies.

The likelihood of professional differences is reduced by everyone being clear about their roles and responsibilities and ensuring that they do what has been agreed as well as the ability to discuss and share problems.

See Escalation and Challenge Protocol.

5. Supervision

Regular supervision helps improve practitioner decision-making, accountability, and supports professional development. It is also an opportunity to question and explore an understanding of a case.

Group supervision and reflective practice can also be effective in promoting professional curiosity, as practitioners can use these spaces to think about their own judgments and observations and discuss them with colleagues in a safe space. It allows practitioners to learn from each other’s experiences, especially as the issues considered may be similar to other cases.

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2.12 Historic (Non Recent) Allegations of Abuse (including Sexual Abuse)

RELEVANT INFORMATION

Napac (National Association for People Abused in Childhood)

November 2023 – This chapter, which contains information for practitioners on the action to take if an adult discloses abuse they experienced in the past, is new. It includes advice on how to support the adult concerned.

1. Introduction

There may be times when an adult makes an allegation of abuse, including sexual abuse, that happened many years ago. This is often called historical or non-recent abuse. Most commonly it is an adult reporting abuse that happened during their childhood, but it could also be an older adult who experienced abuse as a younger adult. The impacts of abuse can last a lifetime and can have an ongoing impact on the adult’s physical and mental health, relationships and wellbeing.

There are a number of reasons why the adult may not have been able to report the abuse at the time it took place. This includes:

a concern that they would not be believed;
not understanding what was happening to them;
a fear of retaliation from the alleged abuser;
the consequences to themselves or others of the impact / fallout of reporting the abuse;
a power imbalance between the abuser and the adult.

Reasons why an adult may later decide to report abuse they experienced as a child include:

media coverage of other successful prosecutions of historical abuse;
being aware of other allegations against the abuser and wanting to stop them abusing others;
having shared their experiences with another person who will support them to report the abuse;
seeking a sense of closure.

2. Action to Take

An adult may disclose non recent abuse to practitioners from any organisation, or may go directly to the Police or social care (children’s or adults).

The adult should be supported to share their story at their own pace and reassured that they will listened to and taken seriously.

It is important to avoid asking leading questions, but the following information will help identify appropriate next steps:

When the abuse occurred (and if possible, over what time period);
Where did the abuse took place and if there were other victims;
Who the perpetrator was (if the adult will not name the perpetrator, try to establish the relationship, e.g. family member, teacher, care worker);
If they know if the alleged perpetrator is still alive, and where they may live.
Whether the alleged abuser is known to still be contact with children, and the identity of any child who may currently be at risk, if known.

It should be explained that information the adult gives may need to be shared – even if the adult does not want to make a formal report to the Police or social care – to protect other children from possible abuse.

If the alleged abuser was in a position of trust with children or vulnerable adults at the time of the offence/s, either children’s social care or adult social care (as relevant) should hold a strategy discussion to determine what is known about the alleged abuser now and whether any further action is required, including whether other children may also have been abused or if they still have contact with children or vulnerable adults now – either professionally or in their home lives. Discussions should involve senior police officers and partner agency managers to ensure there are appropriate resources, as required.

Historical abuse allegations can be more complex to investigate and prosecute due to the passage of time; there may be less evidence available and / or people may have left the area for example. However, evidence including photographs may still be available and people may be willing to give statements. There are however many examples of successful prosecutions of historical abuse.

For further information in relation to children’s safeguarding, see the Safeguarding Children Partnership Procedures.

For action in relation to adult safeguarding, see Safeguarding Enquiries Process.

3. Supporting the Adult

Adults should be offered appropriate support. This could include a referral to mental health services or signposting to local organisations who provide support for victims / survivors of abuse.

Agencies involved should agree who keeps the adult informed of progress with any investigation.

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2.20 Self Neglect Guidance

RELATED CHAPTERS

Escalation and Challenge Protocol

Adult Safeguarding Risk Threshold Tool

RELEVANT INFORMATION

Self-Neglect at a Glance (SCIE)

7 Minute Briefings (Adults AP, AS and AT)

What to do about self neglect – Animation (North East ADASS)

Self Neglect – Don’t walk away, walk alongside (South Tyneside leaflet)

Tissue Viability Service: Referral Criteria and Referral Form (for people of all ages with a wide variety of complex wounds, including pressure ulcers, leg ulcers and surgical wounds).

This section of the APPP contains the accessible formatted version of the Self-Neglect Guidance. You can also view a PDF version: Self Neglect Guidance for Multi Agency Partners

November 2023: This multi agency guidance for staff is new. It explains how to support someone who is self-neglecting or hoarding.

1. Introduction

The purpose of this toolkit is to develop practice guidance for a range of multi-agency professionals to use, when supporting someone who is self-neglecting or hoarding. Through a review of the current self-neglect process, there has been some identified learning that can be applied in the development of this toolkit. This Toolkit can be used by any multi-agency partner.

The Care and Support Statutory Guidance clarified the relationship between self-neglect and safeguarding and has now made self-neglect a category of harm, about which the Local Authority has a duty to make enquiries and to assess need with the promotion of well-being at the heart.

Further clarification received from the Department of Health and Social Care states that self-neglect is the responsibility of safeguarding boards in terms of ensuring that policies and procedures underpin work around people who self-neglect, balancing, self-determination, robust mental capacity assessment, consent and protection. It does not mean that each case of self-neglect must progress to a Section 42 enquiry, but that each case must receive an appropriate response.

Engaging with, assessing and providing support to such people can be complex and frustrating and often requires a clear understanding of the law, to ensure actions taken are defensible. Many dedicated, compassionate practitioners are left struggling with cases, feeling alone and isolated.

In 2011, the Law Commission undertook a series of scoping studies in adult social care. This identified a historic lack of understanding of self-neglect, resulting in inconsistent approaches to support and care. In an effort to address this, the Care and Support Statutory Guidance formally recognises self-neglect as a category of abuse and neglect – and within that category identifies hoarding.

This means that the need locally for a consistent approach is key in ensuring that multi-agency professionals work together, to ensure that people who self-neglect have the right support, which is timely and in a proportionate and preventative way.

2. The Local Picture

Year	Number of Safeguarding Concerns Raised	Number of Section 42 Enquiries	Number Relating to Self-Neglect	No/Outcome of Cases Submitted for SAR
2019/20	952	787	32	3
2020/21	1072	478	26	13
2021/22	1084	361	32	13
2022/23	1312	346	69	6

Self-neglect became a domain of abuse within the Care Act 2014. However, how self-neglect differs from other domains of abuse, is that there is no other person inflicting self-neglect on the individual in an abusive way – therefore there is no alleged perpetrator only the individual themselves.

For social workers, this provides a significant challenge in developing relationships that empower the individual, or safety plans based upon what makes a person feel safe and well cared for, yet respect autonomous decision making, whilst juggling other duties and responsibilities.

It is important to explore the person’s history; listen to the way they talk about their life, difficulties and strategies they have developed for self-protection. By doing this, social workers and health professionals can begin assessing why the person self-neglects and begin to offer support in replacing attachment objects, with interaction and relationships with people and the community. Distress may have led people to seek comfort in having possession; when faced with isolation they may seek proximity to things they’re attached to and when faced with chaos may seek to preserve predictability.

Early relationships can have quite an effect on how a person perceives the world and may not recognise their self-neglect – and may even find comfort in their situation. Deep-seated emotional issues, which have evolved as coping strategies cannot be undone in an instant.

3. What is Self Neglect?

(Click on the image to enlarge it)

Self-neglect manifests itself in different ways. It might be that a person is physically or mentally unwell or has a disorder and cannot meet their own care needs as a result. They may have suffered trauma or loss or be receiving inappropriate support from a carer. The person may not recognise the level of self-neglect. The foundations of self-neglect can begin with trauma and loss, parental attachment and control issues and information processing deficits.

Self-neglect can also occur as a result of cognitive impairment, dementia, brain damage, depression or psychotic disorders. It may be down to substance use, including misuse of prescribed medications.

3.1 Types of Self-Neglect

Lack of self-care to an extent that it threatens personal health and safety;
Neglecting to care for one’s personal hygiene, health or surroundings;
Inability to avoid self-harm;
Failure to seek help or access services to meet health and social needs;
Inability or unwillingness to manage one’s personal affairs.

3.2 Indicators of self-neglect

(Click on the image to enlarge)

3.3 Children and the links to self-neglect

The impact of self-neglect in adults can impact upon children, and present as a form of child abuse that occurs when a child’s basic needs are not met by their caregivers. This can include lack of food, clothing, hygiene, medical care, education, or supervision for children and result in parent(s) being unable to their child’s emotional needs. This can be because of mental health issues, substance or alcohol misuse, self-harm, loss and grief or any form of past and current trauma.

Practitioners should always be aware of the impact of adult self- neglect on any children living within the family home and if they are worried about a child, submit the relevant safeguarding children concerns as per guidance provided in the Safeguarding Children Partnership, Referral Guidance.

Further information can also be found at: Working Together to Safeguarding Children

3.4 Obesity / malnourishment and the links to self-neglect

There is an interface between obesity or malnourishment and self-neglect, which identifies some key issues for practitioners:

In cases of self-neglect where the person is plus size or malnourished, staff should consider any possible underlying causes, or disabilities which may be interfering with the person’s ability and/or choice to engage with care and support.

Cooperation, collaboration and communication between professionals specialised in working with disability and those working in obesity/malnourishment services which can help lead to improved prevention, early detection and treatment for people.

Health and Social Care providers need to identify and understand the barriers that people with disabilities and obesity/malnourishment may face in access to health and preventative services and make efforts to address them before assuming that the person is ‘refusing’.

Health and social care providers need to adjust policies, procedures, staff training and service delivery to ensure that services are easily and effectively accessed by people with disabilities and obesity/malnourishment. This needs to include addressing problems in understanding and communicating health needs, access to transport and buildings, and tackling discriminatory attitudes among health care staff and others, to ensure that people are offered the best possible opportunity of engaging with services.

It may be that the person is able to engage in a conversation about a mental health or physical health problem when they do not feel able to talk about their obesity/ malnourishment. This may be due to concerns about stigma, embarrassment or worries that professionals may seek interventions that they are not ready to access. Engaging the person to work on the issues they see as important is essential to developing a longer-term relationship.

There should be active support for obese/malnourished individuals to live independent and healthy lives. It is important that health promotion initiatives recognise the limits of information giving and the need for whole communities to be included in tackling discrimination, to allow people to have the confidence to accept support and join in with community activities.

4. Roles and Responsibilities

Service	Examples of how agencies can support someone who is self-neglecting
Clinical Psychology	can support people who self-neglect by developing psychological understanding of their situation and helping them find strategies to help manage their situation, including psychological therapy.
Community nurses	provide healthcare to people in their own homes. They will refer to other services, such as the continence or respiratory service, or for specialist equipment such as profiling beds.
Environmental health	…aims to reduce the risk to the self-neglecting person themselves, but also the wider community through practical direct work with the person, invoking any relevant legislation where necessary.
Fire and Rescue Services	can provide fire safety advice, including hoarding, and put practical measures in place to reduce the risk of a fire. They may refer on to other agencies for more support.
General Practitioners (GPs)	can identify people who seem to be self-neglecting, provide support and advice and refer to other agencies such as mental health, to enable people to get support and assistance if required.
Hospital nurses	…will identify patients who seem to be self-neglecting, support the patient and refer to other agencies to enable potential to gain help and support required, within and following their stay in hospital
Housing	can help people practically to support their tenancies to avoid the risk of being evicted, due to problems with self-neglect. Housing will refer to other agencies if required, for example the Fire Service, Assistive Technology etc.
Advocacy	support the person to make their own decisions, ensure their views, wishes, feelings, beliefs and values are listened to, and may challenge decisions that they feel are not in the person’s best interests.
Occupational therapists	work with individuals to identify any difficulties they experience in day to day living activities, finding ways to help individuals resolve them. They support independence where possible and safety within the community, to help build confidence and motivation.
Paramedics	are called by the person or a third party caller due to medical concerns or health deterioration. They will deliver appropriate emergency treatment, assess mental capacity in relation to the health issues presented (particular around refusal to go to hospital) and refer on to other agencies with concerns.
Physiotherapists	can help with treatment of injury, disease or disorders through physical methods and interventions. A Physio helps and guides patients, prescribes treatment and orders equipment. They can refer to other services if required.
Police	can investigate and prosecute if there is a risk of wilful neglect, they can provide safeguarding to families and communities by sharing information, refer to specialist partner agencies and use force to gain entry/access of there are legal grounds to do so.
Probation	will identify problems via home visits and provide regular monitoring. They may refer to social services, mental health, housing and health. They will complete risk assessments and risk management plans, making links to the risk of serious harm.
RSPCA/LA/Animal Welfare Services	investigate complaints of cruelty to and neglect to animals and offer support and advice.
Social workers	…will complete assessments by talking to and getting to know the person. They may establish their mental capacity to make a particular decision about their lives and consider all options available. They may put in support or care or refer to other agencies. They may arrange multi-agency meetings and will rely on sign up from partner agencies regarding this. They can help with relationship building, communication skills and try to develop social networks for the person who is self-neglecting.
Voluntary, Community and Faith Sector organisations	staff and volunteers can provide a whole range of social opportunities and support, to support people to connect with their peers and communities. This includes clubs, support groups, foodbanks and faith led support services. Staff and volunteers from this sector are a vital part of the formal and informal planned care and support for people who self-neglect.
Mental health outreach team	can provide specialist mental health related to support to people who self-neglect in their own homes. This includes practical support, active support and will aim to promote independence and choice, linking in with other services and sharing information.
Red Cross	…can provide short term support in the home for people after a hospital admittance following an accident, illness or during a personal crisis.
Hospital Discharge Social Care	can assess and plan care and support for people who are admitted to hospital, so that when the person is discharged, this is as safe a journey as possible for the person who is self-neglecting. This includes completing capacity and risk assessments, as well as information sharing with the wider MDT.
Welfare rights	…can support the person who is self-neglecting to maximise their income, which may have a positive impact on their ability to self-care and emotional wellbeing.
Drug and alcohol services	can provide support, advice, counselling and ensuring the person who is self-neglect access the appropriate level of health and social care support. This in addition to supporting the person if they have a drug or alcohol problem which may impact on their ability to self care.
Reablement / intermediate care	can support if someone is self-neglecting due to an acute problem, by providing short term support to re-enable and promote independence.

REMEMBER

Safeguarding is Everyone’s Responsibility and all professionals can undertake assessments, informed by multi-agency meetings where appropriate.

See also Local Contacts for information on how to contact safeguarding partners.

5. The Legal Perspective

5.1 Legal options in relation to self-neglect

There are many legislative responsibilities placed on agencies to intervene in or be involved in some way with the care and welfare of adults who are believed to be vulnerable.

It is important that everyone involved thinks proactively and explores all potential options and wherever possible, the least restrictive option e.g. a move of the person permanently to smaller accommodation where they can cope better and retain their independence.

The following outlines a summary of the powers and duties that may be relevant and applicable steps that can be taken in cases of dealing with persons who are self-neglecting and/or living in dirty and unpleasant conditions. The following is not necessarily an exhaustive list of all legislative powers that may be relevant in any particular case. Cases may involve user of a combination of the following exercise of legislative powers.

The tenant is responsible for the behaviour of everyone who is authorised to enter the property.

There may also be circumstances in which a person’s actions amount to anti-social behaviour under the Anti-Social Behaviour, Crime and Policing Act 2014. Section 2(1)(c) of the Act introduced the concept of “housing related nuisance”, so that a direct or indirect interference with housing management functions of a provider or local authority, such as preventing gas inspections, will be considered as anti-social behaviour. Injunctions which compel someone to do or not do specific activities, may be obtained under Section 1 of the Act. They can be used to get the tenant to clear the property or provide access for contractors. To gain an injunction, the landlord must show that, on the balance of probabilities, the person is engaged or threatens to engage in antisocial behaviour, and that it is just and convenient to grant the injunction for the purpose of preventing an engagement in such behaviour. There are also powers which can be used to require a tenant to cooperate with a support service to address the underlying issues related to their behaviour.

Environmental Health

Environmental Health Officers in the Local Authority have wide powers/duties to deal with waste and hazards. They will be key contributors to cross departmental meetings and planning and in some cases, e.g. where there are no mental health issues, no issues regarding the mental capacity of the person concerned, and no other social care needs, then they may be the lead agency and act to address the physical environment.

Remedies available under the Environmental Protection Act 1990 include:

Litter clearing notice where land open to air is defaced by refuse (section 92a);
Abatement notice where any premise is in such a state as to be prejudicial to health or a nuisance (sections 79/80)

Other duties and powers exist as follows:

Town and Country Planning Act 1990 provides the power to seek orders for repairs to privately owned dwellings and where necessary compulsory purchase orders. The Housing Act 2004 allows enforcement actions where either a category 1 or category 2 hazard exists in any building or land posing a risk of harm to the health or safety of any actual or potential occupier or any dwelling or house in multiple occupation (HMO). Those powers range from serving an improvement notice, taking emergency remedial action, to the making of a demolition order. Local Authorities have a duty to take action against occupiers of premises where there is evidence of rats or mice, under the Prevention of Damage by Pests Act 1949;
The Public Health (Control of Disease) Act 1984 Section 46, sets out restrictions in order to control the spread of disease, including use of infected premises, articles and actions that can be taken regarding infectious persons.

Landlords

These powers could apply in Extra Care Sheltered Schemes, Independent Supported Living, private-rented or supported housing tenancies. It is likely that the housing provider will need to prove the tenant has mental capacity, in relation to understanding their actions before legal action will be possible. If the tenant lacks capacity, the Mental Capacity Act 2005 should be used.

In extreme cases, a landlord can take action for possession of the property for breach of a person’s tenancy agreement, where a tenant fails to comply with the obligation to maintain the property and its environment to a reasonable standard. This would be under either Ground 1, Schedule 2 of the Housing Act 1985 (secure tenancies) or Ground 12, Schedule 2 of the Housing Act 1988 (assured tenancies).

The tenant is responsible for the behaviour of everyone who is authorised to enter the property.

Mental Health Act 1983

Sections 2 and 3 Mental Health Act 1983: Where a person is suffering from a mental disorder (as defined under the Act) of such a degree, and it is considered necessary for the patient’s health and safety or for the protection of others, they may be compulsorily admitted to hospital and detained there under Section 2 for assessment for 28 days. Section 3 enables such a patient to be compulsorily admitted for treatment.

Section 7 Mental Health Act 1983: A Guardianship Order may be applied for where a person suffers from a mental disorder, the nature or degree of which warrants their reception into Guardianship (and it is necessary in the interests of the welfare of the patient or for the protection of other persons). The person named as the Guardian may be either a local social services authority or any applicant.

A Guardianship Order confers upon the named Guardian the power to require the patient to reside at a place specified by them; the power to require the patient to attend at places and times so specified for the purpose of medical treatment, occupation, education or training; and the power to require access to the patient to be given, at any place where the patient is residing, to any registered medical practitioner, approved mental health professional or other person so specified.

In all three cases outlined above (i.e. Schedule 2, 3 and 7), there is a requirement that any application is made upon the recommendations of two registered medical practitioners.

Section 135 Mental Health Act 1983: Under Section 135, a Magistrate may issue a warrant where there may be reasonable cause to suspect that a person believed to be suffering from mental disorder, has or is being ill-treated, neglected or kept otherwise than under proper control; or is living alone unable to care for themselves. The warrant, if made, authorises any constable to enter, if need be by force, any premises specified in the warrant in which that person is believed to be, and, if thought fit, to remove them to a place of safety.

Section 135 lasts up to 36 hours (it’s usually 24 hours and in certain circumstances a Doctor can extend by 12 hours) and is for the purpose of removing a person to a place of safety with a view to the making of an assessment regarding whether or not Section 2, 3 or 7 of the Mental Health Act should be applied.

Section 136 Mental Health Act 1983 allows Police Officers to remove adults who are believed to be “suffering from mental disorder and in immediate need of care and control” from a public place of safety for up to 24 hours for the specified purposes, with the option to extend for 12 hours. The place of safety could be a police station or hospital.

Mental Capacity Act 2005

The powers to provide care to those who lack capacity are contained in the Mental Capacity Act 2005. Professionals must act in accordance with guidance given under the Mental Capacity Act Code of Practice when dealing with those who lack capacity and the overriding principle is that every action must be carried out in the best interests of the person concerned.

Where a person who is self-neglecting and/or living in squalor and does not have the capacity to understand the likely consequences of refusing to cooperate with others and allow care to be given to them and/or clearing and cleaning of their property, a best interest decision can be made to put in place arrangements for such matters to be addressed. A best interest decision should be taken formally with professionals involved and anyone with an interest in the person’s welfare, such as members of the family.

The Mental Capacity Act 2005 provides that the taking of those steps needed to remove the risks and provide care will not be unlawful, provided that the taking of them does not involve using any methods of restriction that would deprive that person of their liberty. However, where the action requires the removal of the person from their home, then care needs to be taken to ensure that all steps taken are compliant with the requirements of the Mental Capacity Act. Consideration needs to be given to whether or not any steps to be taken require a Deprivation of Liberty Safeguards application (see Deprivation of Liberty Safeguards chapter). In addition consideration needs to be given to S47 of the Care Act whereby the Local Authority needs to have taken reasonable steps to mitigate/prevent the loss or damage of a person’s property and/or belongings.

Where an individual resolutely refuses to any intervention, will not accept any amount of persuasion, and the use of restrictive methods not permitted under the Act are anticipated, it will be necessary to apply to the Court of Protection for an order authorising such protective measures. Any such applications would be made by the person’s care manager who would need to seek legal advice and representation to make the application.

Section 44 Mental Capacity Act 2005 created an offence of ill-treating or wilfully neglecting a person who lacks capacity, or whom the offender reasonably believes to lack capacity. The offence may only be committed by certain persons who have a caring or other specified responsibility for the person who lacks capacity. The penalties are, on summary, conviction up to 12 months imprisonment, a fine not exceeding the statutory maximum, or both, or on conviction on indictment of up to 5 years imprisonment or a fine or both.

Article 8 of the Human Rights Act 1998 states that the right to private life protects people’s well-being and autonomy, including: people living free from abuse or neglect (including self-neglect).

Court of Protection

You can apply to the Court of Protection to get an urgent or emergency court order in certain circumstances, e.g. a very serious situation when someone’s life or welfare is at risk and a decision has to be made without delay. You won’t get a court order unless the court decides it’s a serious matter with an unavoidable time limit. Where an emergency application is considered to be required, relevant legal advice must be sought.

Power of Entry

The Police can gain entry to a property if they have information that a person inside the property was ill or injured with the purpose of saving life and limb. This is a power under Section 17 of the Police and Criminal Evidence Act 1984.

Inherent Jurisdiction

There have been cases where the Courts have exercised what is called the ‘inherent jurisdiction’ to provide a remedy where it has been persuaded that is necessary, just and proportionate to do so, even though the person concerned has mental capacity. See also Mental Capacity chapter

In some cases of self-neglect, there may be evidence of some undue influence from others who are preventing public authorities and agencies from engaging with the person concerned and thus preventing the person from addressing issues around self-neglect and their environment in a positive way.

Where there is evidence that someone who has capacity is not necessarily in a position to exercise their free will due to undue influence, then it may be possible to obtain orders by way of injunctive relief that can remove those barriers to effective working. Where the person concerned has permitted another reside with them and that person is causing or contributing to the failure of the person to care for themselves or their environment, it may be possible to obtain an Order for their removal or restriction of their behaviours towards the person concerned.

In all such cases legal advice should be sought.

Animal welfare

The Animal Welfare Act 2006 can be used in cases of animal mistreatment or neglect. The Act makes it against the law to be cruel to an animal and the owner must ensure the welfare needs of the animal are met. Powers range from providing education to the owner, improvement notices, and fines through to imprisonment. The powers are usually enforced by the RSPA, Environmental Health or DEFRA.

Fire

The Fire and Rescue Service pathway states that if 3 or more of these factors are present a request / referral for a safe and well check should be made.

Age

Behaviours

Vulnerabilities

Occupiers over 65

· Smoking

· Smokes where sleeps

· Clutter/Hoarding level 4 and over

· Previous fires/burn marks

· Alcohol and Substance Misuse

· Emollients and paraffin based creams

· Lives Alone

· Restricted Mobility

· Immobile

· Sensory Impairments

6. Mental Capacity and Self Neglect

The Mental Capacity Act 2005 provides a statutory framework for people who lack capacity to make decisions for themselves. The Act has 5 statutory principles and these are the values which underpin the legal requirements of the act. They are:

A person must be assumed to have capacity unless it is established that they lack capacity;
A person is not to be treated as unable to decide unless all practical steps have been taken without success;
A person is not to be treated as unable to decide merely because they make an unwise decision;
An act done or decision made, under the Act on behalf of a person who lacks capacity must be done, or made, in their best interests;
Before the act is done or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

Where a person’s self-neglecting behaviour poses a serious risk to their health and safety, intervention will be required. With the exception of statutory requirements, any intervention or action proposed must be with the person’s consent. In extreme cases of self-neglecting behaviour the very nature of the environment should lead professionals to question with the person has capacity to consent to the proposed action or intervention and trigger a capacity assessment.

This is confirmed by the Mental Capacity Act Code of Practice, which states that one of the reasons why people may question a person’s capacity to make a specific decision is “the person’s behaviour or circumstances cause doubt as to whether they have capacity to make a decision” (4.35 MCA Code of Practice). Consideration must be given where there is dialogue or situations that suggest a person’s capacity to make decision with regard to their place of residence or care provision may be in doubt.

Any capacity assessment carried out in relation to self-neglecting behaviour must be time specific and relate to a specific intervention or action. The professional responsible for undertaking the capacity assessment will be the person who is proposing the specific intervention or action and is referred to as the ‘decision-maker’. Although the decision maker may need to seek support from other professionals in the multi-disciplinary team, they are responsible for making the final decision about a person’s capacity.

If the person lacks capacity to consent to the specific action or intervention, then the decision maker must demonstrate that they have met the requirements of the best-interests “checklist”. Due to the complexity of such cases, multi-agency meetings to coordinate assessments may be required. Where the person denies access to professionals the person who has developed a rapport with the person self-neglecting will need to be supported by the relevant agencies to conduct capacity assessments.

In particularly challenging and complex cases, it may be necessary for the local authority to refer to the Court of Protection to make the best interests decision. Any referral to the Court of Protection should be discussed with legal services and the relevant service manager.

6.1 What is the difference between competency and capacity and why is this important when working with people who self-neglect?

Competency: To be competent means that the overall function of the brain is working effectively to enable a person to make choices, decisions and carry out functions. Often the mini mental state test is used to assess competency. In many people who have, for example, Dementia, Parkinson’s Disease or Huntington’s Disease, the first aspect of brain function affected is the executive function and unfortunately this is not tested very effectively using the mini mental state test.

Effective Function: The executive function of the brain is a set of cognitive or understanding/processing skills that are needed to plan, order, construct and monitor information to set goals or tasks. Executive function deficits can lead to problems in safety, routine behaviours. The executive functions are in the first to be affected when someone has, for example, dementia. See also Executive Functioning Grab Sheet.

Capacity: Capacity is decision making ability and a person may have quite a lack of competency but be able to make a specific decision. The decision making ability means that a person must be able to link the functional demands, the ability to undertake tasks, the ability to weigh up the risks and the ability to process the information and maintain the information to make the decision. In some way, shape or form, the person has to be able to let the person assessing them know that they are doing this. Many competent people make what others would consider to be bad decisions but are not prevented from taking risks and making bad decisions. This is not a sign that a person lacks capacity to make the decision, just that they have weighed everything up, considered the factors and determined that for them this would be what they wanted. The main issue in the evaluation of decision-making capacity is the process of making the decision, and not the decision itself.

This is important because the mental capacity assessment uses two tests. The first is called the functional test and this involves looking at whether the adult can make the decision in question. Adults should be provided with practical support to help them make decisions. If you are concerned about an adults’ ability to make decisions because either they cannot:

understand information about the decision to be made; or
retain that information in their mind;
or weigh up that information as part of the decision making process:
or communicate their decision by talking, using sign language or any other means)

Then they will be considered not able to make a decision. There only needs to be evidence in one of these areas, not all of them. If the assessment finds that the adult cannot make the decision in question, even with support, then Stage 2 should be considered.

The second part of a mental capacity assessment requires evidence to show that the person’s inability to make a decision is because of an impairment of their mind or brain. Examples include, conditions associated with some types of mental illness, dementia, significant learning difficulties, long term brain damage and the effects of drugs and alcohol. If the adult does not have such an impairment or disturbance of the mind or brain, they will not lack capacity under the Mental Capacity Act.

Decisions should not be broad decisions about care, services or treatment, they should be specific to a course of action. If a practitioner requires the consent, agreement, signature or understanding of the individual, then they should determine the capacity of the person to consent to that action using the assessment process defined in the Mental Capacity Act 2005. This may be for tenancy, individual treatment options, aspects of care offered, equipment required, access to services, information sharing or any intervention. If you understand the course of action being proposed and offered to the person, then you will be the person required to assess the individual’s the person, all agencies are responsible for developing questions for that agency to ask to determine their capacity as well as is practicably possible.

For more information, and a mental capacity assessment template, see Mental Capacity.

6.2 Practice examples

Housing: The Housing Officer will need to conduct and record a capacity assessment, where there is doubt about the person’s ability to provide consent. If the person is deemed to lack capacity to make that decision a ‘Best Interest’ decision must be made. A third party cannot sign a tenancy agreement on behalf of another person unless they have a Court Appointed Deputyship or a Lasting Power of Attorney that specified such actions under ‘finance’.

Health: If a health professional is proposing a course of treatment, medication or intervention, they understand the intervention proposed, therefore, they are the person to determine whether the person self-neglecting understands the intervention. If the health professional doubts the person’s ability to understand they must conduct (and record) a capacity assessment. If the person is deemed to lack capacity to make that decision a ‘Best Interest’ decision must be made. A third party cannot give consent on behalf of another person unless they have Court Appointed Deputyship or a Lasting Power of Attorney that specifies such actions under ‘welfare’.

Occupational Therapy: The Occupational Therapist (OT) understands the rehabilitative process/equipment required by the person to meet their needs. If the person does not appear to understand then the OT must assess the person’s capacity to decide about the proposed equipment.

6.4 Examples of what to ask when assessing capacity

6.4.1 The legal test

Section 2(1) Mental Capacity Act 2005 “A person lacks capacity in relation to a matter if, at the material time, he is unable to make a decision for himself in relation to that matter because of an impairment of, or disturbance in the functioning of, the mind or brain”.

6.4.2 Applying the test

To apply the test if can be broken down into 3 questions:

Is the person able to decide about where to live?
Is there an impairment or disturbance in the functioning of the person’s mind or brain? If so,
Is the person’s inability to make the decision because of the identified impairment or disturbance?

Think about:

What areas does the person need support with?
What sort of support do they need?
Who will be providing the support?
What would happen if they did not have any support or refused it?
That carers might not treat them properly and that they can complain if they are not happy about their care.

A person is unable to decide on residence if they are unable to:

Understand the information relevant to the decision; or
Retain that information; or
Use or weight that information as part of the process of making the decision; or
Communicate their decision (by any means).

7. Pathway for Self Neglect

View the Pathway for Self Neglect

8. When does a Section 42 (Safeguarding) Enquiry Occur?

In most safeguarding issues, the Care Act 2014 (Section 42) requires that each local authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. This enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom.

Cases of self-neglect may not prompt a Section 42 enquiry. We invariably judge these on a case by case basis. Whether or not a response is required will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.

It is key to establish a trusting relationship with a person who is engaging in self-neglect because restricting their autonomy can be harmful.

What professionals think an adult who self-neglects might hope and fear when they arrive in their lives:

I Hope that…
“They will listen to me”	“They will provide support”		“They will be respectful”		“They will leave me alone”		“They will help me”
“They will sort my problems out”		“They will be sensitive and understanding”				“They will see me as a person”
“They won’t disappear or change too frequently if I’ve got to know them”				“They will manage my health and care needs”

I Fear That …
“I will lose my independence”	“They will make me do things”	“They will take my things away”	“They will put me in a home”	“There will be repercussions which I will not like”
“I will lose control of my life”	“I will lose my identity”	“I will be arrested or prosecuted”	“I will lose my home”	“They will judge me”
“They will make me feel distressed, upset and anxious”		“They will evict me and I will be homeless”

Safeguarding duties apply to:

Any adult who has care and support needs (whether or not the local authority is meeting any of those needs); and
Is experiencing, or at risk of abuse and neglect (including self-neglect); and
As a result of those care and support needs is unable to protect themselves from either the risk or, or the experience of, abuse and neglect

The duties apply equally whether a person lacks mental capacity or not. So, while an individual’s wishes and feelings are central to their care and support, agencies must share information with the local authority for initial enquiries to take place.

Enquiries may take place even when the person has mental capacity and does not wish information to be shared, to ensure abuse and neglect is not affecting others, that a crime has not been committed, or that the person is making an autonomous decision and is not being coerced or harassed into that decision. Safeguarding duties have a legal effect in relation to many organisations and the local authority may request organisations to make further enquiries on their behalf.

Better Safe Than Sorry

The Care and Support Statutory Guidance identified that not all cases of self-neglect need to go to Section 42 enquiry – perhaps the situation is not impacting on the person’s wellbeing, does not impact on others, or is not a result of abuse or neglect.

It could be argued that someone self-neglecting is not going to share intimate details of themselves straight away. It can take time to develop trust and unless further enquiries are made (often requiring a multi-agency response to information gathering and capacity assessments) we may be leaving someone vulnerable, and making assumptions that cannot be justified later.

The purpose of a safeguarding enquiry (Section 42) is initially for the local authority to clarify matters and then decide on the course of action to:

Prevent abuse and neglect from occurring
Reduce the risk of abuse and neglect
Safeguard in a way that promotes physical and mental wellbeing
Promote choice, autonomy and control of decision making
Consider the individual’s wishes, expectations, values and outcomes
Consider the risk to others
Consider any potential crime
Consider any issues of public interest
Provide information, support and guidance to individual and organisations
Ensure the people can recognise abuse and neglect and then raise a concern
Prevent abuse/neglect from reoccurring
Fill in the gaps in knowledge
Coordinate approaches
Ensure that preventative measures are in place
Coordinate multi-agency assessments and responses

These responsibilities apply to people who hoard/self-neglect and whose health and wellbeing are at risk as a result. People may not engage with professionals or be aware of the extent of their self-neglect.

For social workers and health professionals, this provides a significant challenge in developing relationships that empower the individual, or safety plans based upon what makes a person feel safe and well cared for, yet respect autonomous decision making, while juggling other duties and responsibilities.

It is important to explore with the person their history; listen to the way they talk about their life, difficulties and strategies for self-protection.

By doing this social workers can begin assessing why the person self-neglects and offer support in replacing attachment to objects with interaction and relationships with people and the community. Distress may lead people to seek comfort in having possessions; when faced with isolation they may seek proximity to things they’re attached to and when faced with chaos may seek to preserve predictability.Early relationships can have quite an effect on how a person perceives the world and may not recognise their self-neglect and may even find comfort in the situation. Deep-seated emotional issues, which have evolved as coping strategies cannot be undone in an instant.

Trauma Informed Practice should be considered.

9. Top Tips

9.1 Myth busting

Myth	Fact
Self-neglect is about hoarders	Self-neglect includes lots of other factors, such as not managing personal care or medication, not paying bills or eating properly. Many people who hoard don’t self-neglect at all.
We (social worker, nurse, psychologist, occupational therapist, mental health team etc) can wave a magic wand.	We can help but the person needs to engage with what is offered.
Medication and therapy can provide a quick solution.	Improving wellbeing, quality of life or neglectful behaviour can take a long time.
Safeguarding will sort everything out (an easy referral can keep this person safe).	It’s a team effort. It requires a multi-agency approach to work with complex cases.
If a safeguarding referral is made, the social worker can enter a person’s home and remove self-neglecting people from their property.	Social workers are unable to remove someone from their property without consent or a court order or legally prescribed process.
People can be forced to engage in personal care tasks and have support from care agencies. Staff can ‘just do it’ for the person and fix the problem.	A person has to consent to personal care being undertaken. If someone has mental capacity they have the right to make unwise decisions.
f a person refuses help, such as with de-cluttering or cleaning, we can force them to accept it.	It is all about negotiation and understanding why they are saying no, and an attempt to reach a shared goal so some support can be delivered and the risk reduced.
Social workers can over-ride someone’s decision when they have mental capacity.	They cannot, nobody can.
Social workers have powers of surveillance.	They don’t.
Only doctors can assess mental capacity.	A range of people can assess capacity, depending on how well they know the person and what the decision is that needs to be made.
Self-neglecting people are lazy and it’s a ‘lifestyle choice’.	Situations can be very complex, and it may be choice in some elements of the adult situation, but not all.

9.2 Effective engagement

Ask the person to tell you a story about them or their past

Take note of objects around them, such as photographs and jewellery and engage in conversations about specific items

Ask them what helps when things get difficult

Find out information about the person’s past, and how this may trigger their behaviour in the present

Have an open and honest conversation and ensure their response has been acknowledged

Body language – don’t look shocked or uncomfortable, be open and positive, be mindful of your facial expression

Ask what their current concerns are

Ensure you display empathy

Consider how you would speak to the person if they were your friend

Look into the person’s support networks, including friends and family. Find out about any interests they have, or have had previously

Ask them what they would like to accomplish in the future

Go at the person’s own pace

Find out what the individual wants help with, this may not be related to their self-neglect

Be clear about what can happen

Encourage a deeper conversation, for example ‘what are the things working well in your life?’

Ask them what you can work on together to achieve what they want from their life

Set milestones, keeping them small and timely, for example ‘what hopes do you have for the coming week?’

Ensure you are in a location where the person feels comfortable to talk, which may not always be at home initially

Offer an understanding statement, for example ‘I understand that the problem with your neighbours is really affecting you’

Write down some key points before entering the conversation

Identify the strengths in the person that you might highlight in your conversation and how some ideas on how they might draw on those strengths

Appreciate their circumstances and tell them you want to learn about them, such as asking about their strengths, abilities and preferences.

9.3 Professional curiosity

Offer to make a cup of tea, whilst doing so, see if there is enough food in the cupboards and fridge.
Ask to see where they sleep; is it easy to access? Are the sleeping arrangements appropriate for that person?
Ask if they feel safe living where they are. If they say ‘no’, explore why.
Find out how they keep themselves warm. Discuss heating arrangements.
Give the person time to answer the question. Allowing for silence when they are thinking.
Never make assumptions without talking to the individual or fully exploring the case.
Use your communication skills, review records, record accurately, check facts and feedback to the people you are working with and for.
Focus on the need, voice and the lived experience of the person.
Listen to people who speak on behalf of the person and who have important knowledge about them.
Speak your observations such as ‘I’ve noticed you’ve lost weight, have you been feeling unwell’?
Pay as much attention to how people look and behave as to what they say.
Build the foundation with the person before asking more personal and difficult questions.
Ask ‘How are you coping at the moment?’ ‘What helps when you are not feeling your best?’
Explore the person’s concerns. Don’t be afraid of asking why they feel a certain way.
Put together the information you receive and weigh up details from a range of sources and/or practitioners.
Ask yourself ‘How confident am I that I have sufficient information to base my judgements on?’
Question smoking habits, and consider fire risk at the same time, such as ‘Where in the property do you smoke the most?’ ‘Is it in bed or the living room?
Speak to the person about medications. Ask if they are taking medication and how they find it. Do they have side effects, are they taking it consistently?
Ask who visits and how long it has been since they had a visitor.
Ask if they are in any pain, and what they are doing to manage the pain?
Ensure the person feels listened to and valued. When ending the conversation, thank them for sharing with you.

10. Further Resources

Care Act 2014 Section 42 – Enquiry by Local Authority

Care Act 2014 Section 47 – Protecting Property of Adults

Ten Top Tips when Working with Adults who Hoard (Community Care)

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1.8 Safeguarding Adults and Culturally Competent Practice

RELEVANT CHAPTERS

Equality, Diversity and Human Rights in a Safeguarding Context

RELEVANT INFORMATION

Culturally Appropriate Care (Care Quality Commission)

Examples of culturally appropriate care (Care Quality Commission)

Developing Cultural Competence (Research in Practice and partners)

Human rights in health and social care (Equality and Human Rights Commission)

November 2023: This chapter, which is new, highlights the importance of recognising and trying to understand people’s cultural identities when working to safeguard them and promote their needs.

1. Introduction – What is Culturally Competent Practice

To practice in a way which is culturally competent (also called ‘culturally appropriate’ practice), staff and services need to understand and be respectful of the beliefs, practices and cultures of diverse communities. This is very important when working with people whose cultures do not reflect those of mainstream services.

Cultural identity covers many different things. For example, it might be based on a person’s ethnicity, country of birth or religion, or it might be about their sexuality or gender identity. Lesbian, gay, bisexual and transgender people have their own cultures, as do Deaf people who use British Sign Language. Cultural identity is an important part of a person’s wellbeing.

Practitioners need to be able to recognise, and respond to, issues linked to the cultural identity of people they are working with. A failure to do this can mean that opportunities to identify issues which are important to the person or understand why they are acting in a certain way are lost. The importance of this approach has been highlighted by Safeguarding Adults Reviews (SARs) nationally.

2. Why is Culturally Competent Practice Important?

Actions taken in response to safeguarding adults’ concerns (including referrals, safeguarding enquiries, assessments and safeguarding plans) must always take account of issues relating to cultural identity within the lives of the adult and their family.

When adults are treated in a way which is sensitive to their cultural identity, they are more likely to engage well with staff and services and achieve better outcomes, which will keep them, their families and communities safer.

When adults are not supported in a way which recognises their cultural identity, they can:

feel marginalised and discriminated against;
suffer low self-esteem and low self-confidence;
miss out on opportunities to stay safe;
have their actions misunderstood;
feel stressed and anxious; and
experience a loss of rights.

3. Cultural Competence and Safeguarding

Understanding and communicating well with people from different cultures is an important part of providing person-centred care, including safeguarding adults (see Making Safeguarding Personal chapter). Everyone is part of one or more cultures and people can identify with more than one culture.

As also noted in Section 2, people are more likely to have their needs identified, receive appropriate support and experience positive outcomes (including being protected from harm) if their culture is recognised and taken into account by practitioners.

A person’s cultural identity can sometimes make it hard for them to ask for help from services or to protect themselves. This can be because they:

are worried they will not be believed;
do not know how to ask for help;
are worried about possible repercussions for them and / or their family;
have a lack of trust in statutory services or people in positions of authority;
fail to realise that their experience amounts to abuse or neglect.

Also, if practitioners do not directly ask the adult about possible abuse and neglect it can mean they do not have the opportunity to ask for help.

Factors linked to culture can also increase or reduce the level of risk the adult is likely to experience. A failure to consider this can lead to an inaccurate assessment of risk, and safeguarding issues may not be recognised.

Issues of culture and faith can never be used to justify behaviour which constitutes the abuse of an adult or child (see for example the chapters on Honour Based Abuse, Female Genital Mutilation (FGM) and Forced Marriage).

Practice Examples

Examples of culturally appropriate care (Care Quality Commission)

If the adult’s first language is not English, learn a few useful phrases or terms from that language. They may also like to teach you a few phrases. In safeguarding meetings for example, the adult and their family may appreciate being welcomed or thanked in their first language.

All cultures have rules about politeness that affect the way people communicate. Be curious and ask questions, sensitively. For example, it is important to address people in the way they prefer. For example, elderly people may prefer to be addressed as Mrs Smith or Mr Patel until they are happy for staff to use their first name. They may always want to be addressed more formally, however.

4. Role of Practitioners

In providing culturally appropriate care, practitioners should have a respectful and sensitive approach which aims to understand how culture can affect different aspects of people’s lives, including the way they feel, behave and are responded to by other people and organisations.

Practitioners do not need to share the same cultural values as the adult to be able to practice in a culturally competent way, nor do they need to be experts on different cultures. However, they do need to be aware of their own cultural values and how these might sometimes be different from the people they are supporting and how that might impact on the adult and their family. This will help them understand people better and provide a more appropriate response.

It is important that practitioners do not make assumptions that all adults from the same ethnic background or same religion will share the same cultural identity or values.

Practitioners should also think about how their actions – and those of the organisation they work for – could affect people from different cultures, including making it harder for them to seek help or engage with support.

When assessing if someone lacks mental capacity or giving information to support someone to make a decision, you should also take cultural factors into account. Using the Mental Capacity Act to make a ‘best interests’ decision must include considering the person’s beliefs and values.

5. Providing Culturally Appropriate Care – Practice Guidance

Often, small changes make a big difference to people. The most important things which practitioners can do include:

listening to the adult, spend time getting to know them and their families (where appropriate), ask questions about their lives and beliefs;
asking about what is important to the person, and what being safe means to them;
trying to understand and meet people’s preferences, and remember that the adult is the expert in their own life;
do not make assumptions, be aware of your own cultural values and beliefs and how that may impact on the adult and their family;
look at the adult’s life and experiences as a whole, including their cultural needs, and protect them from discrimination.

Remember that some people may be put off reporting abuse or neglect or engaging with services because of concerns about their cultural differences. It is also important to remember factors which can make it hard for some adults to keep themselves safe or ask for help: These include:

not being able to read or write;
not being able to hear;
not speaking English as a first language;
fear of authority;
limited social networks;
poor quality / temporary housing / frequent house moves which means their access to services is disrupted;
poverty;
living in a closed or close-knit community – which can make adults worry about bringing shame on their family.

Examples of culturally appropriate care (Care Quality Commission)

Cultural competence training should be available for staff in all organisations. It is also important to have an open staff culture, so staff can raise any issues with managers and work out solutions together.

It can sometimes be helpful to match staff with adults from the same culture, for example as a keyworker. However, it is important to ask the adult first and not assume it is what they want. You should discuss it both with them and also the staff member. Be aware that some people may not want to share information with someone from their own cultural background, particularly if there are difficult issues for them, as with safeguarding concerns for example.

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Deaf

A person who identifies as being Deaf with an uppercase D is that they are culturally Deaf and belong to the Deaf community. Most Deaf people are sign language users who have been deaf all of their lives. For most Deaf people, English is a second language and as such they may have a limited ability to read, write or speak English.

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7.8 Health and Wellbeing of Staff

RELEVANT CHAPTER

Supervision

RELEVANT INFORMATION

Health and Wellbeing of the Adult Social Care Workforce (Department of Health and Social Care)

Looking After Yourself (Skills for Care)

Taking Care of your Staff’s Mental Health (Mind)

May 2023 – This new chapter is based on Health and Wellbeing of the Adult Social Care Workforce published by the Department of Health and Social Care. It includes advice and links to other information that employers and managers can use to help build the resilience of their team and address any concerns their staff may have.

1. Introduction

With increasing pressure on services, it is vital that all those providing care and support to adults – both employers and employees – are able to take time to think about their health and wellbeing, as well as that of their colleagues and the people and families they support.

The information in this chapter is taken from Health and Wellbeing of the Adult Social Care Workforce (Department of Health and Social Care). Whilst the guidance was written during the COVID pandemic, it includes relevant advice and links to other information that employers and managers can use to help support the resilience of their teams and address any concerns their staff may have.

2. Mental Wellbeing

The following steps can be useful when promoting the mental wellbeing of staff:

have a structure to the day, and try to develop a daily routine; writing a plan for the day or week may be helpful. It is also important that staff keep doing things they enjoy as this can give relief from anxious thoughts and feelings and can boost mood;
physical health has a significant impact on mental wellbeing. As the body releases endorphins when exercising, this can relieve stress relief and also boost mood;
maintaining relationships with family and / or friends is important for mental wellbeing. Staying in touch with people on the phone or via video or social media is particularly if people are feeling anxious;
avoid continually checking the news – via 24-hour channels and social media – as this can make people feel more worried and anxious. It may more helpful to only check the news at set times in the day;
good-quality sleep can have a positive impact on how people feel mentally and physically. Every Mind Matters gives advice on how to get a good night’s sleep;
people should be asked if they are ‘ok’, and always encouraged to seek help if they are struggling. Services available include:
- sending a message with the word FRONTLINE to 85258 to start a conversation with the Shout messaging support service;
- Samaritans offer support NHS and social care workers in England. They can be contact for free, day or night, on 116 123;
- Every Mind Matters which provides comprehensive support, tips and ideas on mental health and wellbeing.

2.1 How managers can help

During supervision, managers should check in with their staff and ask about their wellbeing (although staff should be clear they can ask for help in between supervision sessions if they are struggling). Mind recommend developing Wellness Action Plans with staff as a practical well of supporting their mental health and wellbeing.

3. Building Resilience and Managing Stress and Anxiety

It is important that staff are helped to find ways of coping with increased pressure. Skills for Care has a guide on how to build personal resilience which includes tasks for staff to complete that help to recognise pressure and stress. It provides advice on developing resilience through emotional intelligence, accurate thinking and realistic optimism.

MindEd provides free educational resources on mental health.

The Every Mind Matters page on managing anxiety provides advice on managing worries that people may have.

Other information and support includes:

Mental Health Foundation– less stressful workplaces;
Mind– how to be mentally healthy at work;
NHS- Be Kind to your Mind.

4. Physical Wellbeing

Staff should try to keep active, where and when possible. This can include walking outside or running or riding a bike once a day, as fresh air is extremely beneficial for mental health.

For those who are not able to exercise outdoors, there are several online workouts that can be done at home. The NHS provides free, easy 10-minute workouts and the NHS Fitness Studio has a collection of accessible exercise videos.

Staff should ensure they get rest and respite during work or between shifts, eat healthily, engage in physical activity and stay in contact with family and friends. People should avoid unhelpful coping strategies such as tobacco, alcohol or other drugs. In the long term, these can worsen mental and physical health.

Advice on what to do if a person has Covid-19 can be found on the NHS website.

5. Financial Wellbeing

Financial wellbeing is about people having a sense of security and having enough money to meet their needs; it is about being in control of day-to-day finances and having the financial freedom to make choices that allow people to enjoy their life.

There are a number of organisations to help staff with financial problems they may have:

Mind– money and mental health;
Citizens Advice– help for people who are struggling to pay their bills. It is important that bills are not ignored as this can make the situation worse;
National Debtline provides free, confidential and independent advice on dealing with debt problems.

The Money Advice Service works to improve people’s financial wellbeing. It gives free, impartial money advice. It also includes a number of useful tools and calculators.

There is also information on:

6. Concerns about Work

It is important that people’s rights as workers are protected, especially during times of increased pressure. Similarly, staff have a professional duty to act if they are concerned that the safety of those they care for is at risk. If any member of staff has any concerns about employment practices, it is important that they feel able to raise them.

Any concerns should be raised with the senior management team in the first instance. There will be internal procedures in the workplace about what to do.

Staff can also contact their union or professional body, if they have one, for advice about what to do if they have concerns. They can play a helpful role in trying to resolve any problems staff may be facing and improve workplace practice.

Finally, if staff want to report a serious case of bad practice or have been unsuccessful in resolving any issues with their organisation, they can contact CQC and / or the safeguard adults team in the local authority.

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1.9 Co-production

RELATED CHAPTERS

The Care Act 2014

RELEVANT INFORMATION

Think Local Act Personal – What is Co-production?

Think Local Act Personal – Ladder of Co-production

Think Local Act Personal – Ten Top Tips for Co-production

November 2022 – This chapter, which describes what is meant by co-production and how it can when making decisions and designing services, was added to the procedures site.

1. Introduction

Adults who use care and support services, and those of partner agencies, are at the centre of the personalisation agenda and the Care Act 2014. Feedback from adults and carers about their service experience and outcomes – that were either achieved or not achieved – are vital to providing effective and appropriate services.

2. Co-production

Co-production is a way of working whereby everybody – adults who use services, carers and staff – works together on an equal basis to create a service or come to a decision which works for them all.

However, the definition of co-production does change in different settings (see What is Co-production? TLAP).

The Care Act states:

Co-production is when you as an individual influence the support and services you receive, or when groups of people get together to influence the way that services are designed, commissioned and delivered.

The TLAP National Co-production Advisory Group says:

Co-production is not just a word, it is not just a concept, it is a meeting of minds coming together to find shared solutions. In practice, co-production involves people who use services being consulted, included and working together from the start to the end of any project that affects them. When co-production works best, people who use services and carers are valued by organisations as equal partners, can share power and have influence over decisions made.

The New Economics Foundation notes six main aspects of co-production:

Recognising people as assets: People are seen as equal partners in designing and delivering services, rather than as passive beneficiaries or burdens on the system.

Building on people’s capabilities:Everyone recognizes that each person has abilities and people are supported to develop these. People are supported to use what they are able to do to benefit their community themselves and other people.

Developing two-way reciprocal relationships: All co-production involves some mutuality, both between individuals, carers and public service professionals and between the individuals who are involved.

Encouraging peer support networks: Peer and personal networks are often not valued enough and not supported. Co-production builds these networks alongside support from professionals.

Blurring boundaries between delivering and receiving services:The usual line between those people who design and deliver services and those who use them is blurred with more people involved in getting things done.

Facilitating not delivering to:Public sector organisations (like the government, local councils and health authorities) enable things to happen, rather than provide services themselves. An example of this is when a council supports people who use services to develop a peer support network.

3. Involving Adults who use Services

Adults who use services should be involved at each level of development, delivery, and review of care and support services in order to:

ensure that services are developed to meet the care and support needs of adults;
ensure that the services which are provided are of good quality;
ensure positive outcomes for those who use the service.

Service commissioners should ensure that adults who use services can:

have their views considered in the development of new strategies and services;
contribute to the review and performance management of existing strategies and services;
receive information on planning and delivering of new services in an accessible and jargon-free format;
contribute to meetings and decision making where practicable. This may include practical support (for example, reimbursement of expenses; considering the time and venue for meetings) and other assistance (for example help to deal with jargon – see TLAP Care and Support Jargon Buster, stress, power imbalances);
access appropriate training and mentoring support to enable them to contribute to planning arenas.

Social workers and service providers should ensure adults:

have easy access to a charter on their rights and responsibilities within the service;
have easy access to clear information on all the services available (see Information and Advice chapter);
have access to information on their care and support options (see Care and Support Planning chapter);
are fully involved in the assessment process and development and review of their individual care plan and have their needs, wishes and goals incorporated into their plan;
receive information on how to make comments, complaints and compliments about the service they receive;
contribute to the evaluation of the service.

User led organisations (ULOs) are one approach to facilitating user involvement as referenced in the Care and Support Statutory Guidance. ULOs are organisations that are run by and controlled by people who use care and support services, including disabled people of any impairment, older people, and families and carers. See also A Commissioner’s Guide to Developing and Sustaining Local User-Led Organisations (SCIE).

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11.5 CQC Emerging Concerns Protocol

RELEVANT CHAPTERS

Whistleblowing

RELEVANT INFORMATION

Emerging Concerns Protocol (Care Quality Commission and partners)

1. Introduction

This chapter summarises the Emerging Concerns Protocol which can be used by organisations who have signed up to the protocol to act early and share information with regulators where there are concerns about risks to people using services, their carers, families or professionals.

Partners to the protocol share a common objective of making sure that health and social care professionals and systems across the UK serve to protect the public, whilst maintaining the health, safety and wellbeing of professionals, people using services and also their families and carers.

The aim of the protocol is to strengthen and encourage good practice by enabling the sharing of information about emerging quality concerns in a timely fashion.

Each of the organisations signed up to the protocol has a responsibility for responding to concerns about care provision and a role in ensuring that those who use services, their carers and families receive high-quality services from professional staff and registered health and social care organisations.

2. Purpose of the Protocol

The Protocol states:

‘The purpose of the Protocol is to provide a clear mechanism for signatories to share information that may indicate risk. This could include risks to people who use services, their carers, families, learners or professionals. Primarily it is a mechanism to triangulate information to support decision making. It aims to enable:

safe and timely sharing of information, which individually might seem small or insignificant, but when joined together can tell us a problem is emerging

consideration of any collaborative support, decisions or regulatory activity to address concerns in a proactive way.

This will allow signatories to fulfil our collective role better, as well as improve our ability to fulfil our individual roles. We also believe that working together more effectively can reduce unnecessary burden. For example, we can do this by encouraging our organisations to develop joint plans when we share similar concerns, or by taking assurance from each other’s actions.

3. Principles

The following principles – which underpin the Protocol – have been agreed across all organisations acting as signatories.

The Protocol is:

open to use irrespective of how small an issue may appear to be
flexible and empowering, supporting signatories to understand how they can share information
developed through a collaborative, partnership approach between organisations
linked to other governance arrangements and tools in the system, such as the National Quality Board’s quality governance and oversight guidance
not a replacement of existing responsibilities and arrangements for taking emergency action, including arrangements for whistleblowing and responsibilities under Duty of Candour and Fit and Proper Persons Regulations.

Organisations that have signed up to the Protocol commit to:

promoting the use of the Protocol and considering its use for relevant issues no matter how small
considering how issues may have implications for system and professional regulators, including in relation to learning environments
modelling an open culture and encouraging others to openly share information
being transparent about how the Protocol is used, while maintaining confidentiality of content (in all directions, including the National Quality Board, providers, public, registrants)
being explicit about confidentiality agreements and parameters (including working with information shared by third parties)
using the Protocol within the law, including any restrictions on information sharing that are included in each signatory’s statutory role
respecting the executive autonomy of each individual signatory
acting in support of good working relationships and existing formal and informal mechanisms that already exist, for example, signatories will continue to use specific Memoranda of Understanding they may share.

4. The Process for Responding to Concerns

4.1 Categories of concern

Concerns may come into three categories:

concerns about individual or groups of professionals;
concerns about healthcare systems and the healthcare environment (including the learning environments of professionals);
concerns that might have an impact on trust and confidence in professionals or the professions overall.

4.2 How to use the protocol

This is a summary of the process. See the Annexes for more detailed information about each stage.

4.2.1 A concern is identified

Evaluate information and source;
Does the protocol need to be triggered?

REMEMBER: no piece of information is too small to invoke the protocol.

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.2 Consider the interests of partner organisations

Who do we need to share with?
Who do we need information from? (See Annex A: Organisations Involved).

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.3 Contact Organisations B, C & D to share (and request) information

All organisations store information in their own systems;
Organisation A responsible for formal recording of the use of the protocol.

See Section 6, Recording Requirements and Section 7, Sharing Personal Data

4.2.4 Hold regulatory review panel (RRP)

RRP convened, coordinated, chaired and minuted by Organisation A;
Use the template agenda for a regulatory review panel.

4.2.5 Share outcomes

RRP record shared with all partners and Health and Social Care Regulators Forum secretariat for monitoring and report at next Forum (including if there is no further action);
Use of protocol reviewed for learning every time.

5. Safeguarding

Any organisation may receive information that indicates that abuse, harm or neglect has taken place. Any form of abuse, avoidable harm or neglect is unacceptable. Each organisation will have procedures for managing these types of concerns and they must be followed. Each organisation remains responsible for ensuring they follow their own internal safeguarding procedures. Nobody should wait to activate the protocol instead of acting on safeguarding concerns – immediate action should always be taken where necessary (see Safeguarding Enquiries Process section).

6. Recording Requirements

7. Sharing Personal Data

When using the protocol, mostly there should not be a need to share personal data about individuals. Organisations convening an RRP must ensure however that only those who need to know the information should attend if personal information is to be shared in the panel.

Any processing of personal data is subject to the requirements of the Data Protection Act 2018 and the UK General Data Protection Regulation (see Data Protection Act chapter).

Annexes

Annex A: Organisations Involved

Annex B: An Example of Protocol Use

Annex C: Sharing Data

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2.17 Modern Slavery

Audio & Quick Read Summary

SOUTH TYNESIDE SPECIFIC INFORMATION

Modern Slavery, Trafficking and Exploitation (MSTE) Response Plan (2023-26) (opens in Word)

Modern Slavery Statement (South Tyneside Council)

Modern Slavery Exploitation – Hidden in plain sight (leaflet)

RELEVANT INFORMATION

Modern Slavery and Exploitation Helpline: Free Confidential Advice in over 200 Languages

Modern Slavery Statutory Guidance (Home Office) – How to Identify and Support Victims

Modern Slavery Resources (Home Office)

Modern Slavery Training Resource Page (Home Office)

April 2024: The updated Modern Slavery, Trafficking and Exploitation (MSTE) Response Plan (2023-26) has been added. The response plan aims to provide a framework that provides a multi-agency approach to supporting people who have been subject to slavery, trafficking and exploitation.

1. Introduction – What is Modern Slavery?

Modern slavery is a serious and often hidden crime where people are exploited by criminals, usually for profit. It includes trafficking, slavery / servitude and forced labour.

In all types of modern slavery a victim is, or is intended to be, used or exploited for someone else’s gain, with no respect for their human rights. Criminals involved in modern slavery can be people who are working alone, those running small businesses or part of a wider organised crime network.

Adult victims are usually coerced or forced into modern slavery by use of threats, force, deception or by someone abusing their position of power over the victim. However, vulnerable adults (and children) cannot give their informed consent to be in such a position and therefore exploitation, even without any type of coercion, could still be modern slavery.

The scale of modern slavery in the UK is significant. Modern slavery crimes are being committed throughout the country and there have been increases in the numbers of victims identified every year. In 2023, the Home Office received 8,622 reports of adult potential victims via the Duty to Refer process; a further 4,929 reports of adult potential victims were reported through the Duty to Refer (DtN) process (see Section 5, National Referral Mechanism and the Duty to Refer). Adults who consented to a referral for support through the Duty to Refer process were most commonly from Albania, Vietnam or Eritrea.

Modern slavery can be difficult to spot and often goes unreported. Staff working in social care, health, local authorities and any other role which comes into contact with the public could potentially see signs of modern slavery. Staff should be trained to:

understand the signs and indicators of modern slavery;
know how to take appropriate action; and
provide victims with protection and support, based upon their individual needs. It is essential that professionals recognise that those who were previously victims of survivors of modern slavery (known as survivors) may be at risk of re-trafficking and further harm and take action to prevent this. This is because they may be found by their previous exploiters or coerced by new exploiters.

Multi-agency working is vital to ensure that victims are identified, protected and safeguarded.

Modern slavery is an adult safeguarding concern, and the local authority has legal duties to provide support to suspected or known victims. Under the Modern Slavery Act 2015, all modern slavery offences are punishable by a maximum sentence of life imprisonment. For modern slavery concerns regarding children please see the Safeguarding Children Procedures.

2. Types of Modern Slavery

Modern slavery includes the following:

human trafficking;
slavery / servitude and forced or compulsory labour.

2.1 Human trafficking

Human trafficking is where a victim is forced or deceived into a situation where they are then exploited. It involves the movement of people for exploitation, and can occur across international borders or within in a country.

The Council of Europe Convention on Action against Trafficking in Human Beings defines ‘human trafficking’ as:

“the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.”

Human trafficking involves three basic elements;

action;
means; and
purpose of exploitation.

It should be seen as involving a number of actions which are all connected, rather than a single act at a particular point, as shown in the table below:

Elements of human trafficking in adults	What this means
Action	recruitment, transportation, transfer, harbouring or receipt, which includes an element of movement whether national or cross-border;
Means	threat or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability;
Exploitation	for example, sexual exploitation, forced labour or domestic servitude, slavery, financial exploitation, removal of organs.

(taken from Modern slavery statutory guidance: how to identify and support victims, Home Office)

To be considered as human trafficking, a victim must be trafficked for purposes of exploitation. This can be:

sexual exploitation: in most cases of human trafficking for sexual exploitation purposes, victims will be female, but there are also male victims. Rape and violence are common, and victims are often tricked and given false promises of good jobs and economic opportunities.
forced or compulsory labour: victims have to work for little or no pay, and their employers will not let them leave or find another job. If they are foreign nationals, their passports may be taken by their exploiters so they cannot return home. They may also be forced to live in terrible conditions. Forced labour can take place in any sector of the labour market, including manufacturing, food preparation and processing, agriculture, nail bars and hand car washes.
forced criminality / criminal exploitation: victims are forced to commit illegal activities, including pick pocketing, shoplifting, begging, growing and cultivating cannabis, being exploited across different areas of the country known as ‘county lines’, benefit fraud, sham marriage and other crimes. The Modern Slavery Act states that victims who have been forced into criminality should not be prosecuted.
removal of organs: victims are trafficked for their internal organs (typically kidneys or the liver) to be taken (‘harvested’) to be transplanted in other people (who usually pay for the new organs).
domestic servitude: victims work in a household where they may be ill-treated, humiliated, made to work long and tiring hours, forced to work and live in very difficult conditions or forced to work for little or no pay. Victims of forced marriage can also be victims of domestic servitude.

2.2 Slavery, servitude and forced or compulsory labour

As well as trafficking, modern slavery also covers cases of slavery, servitude and forced or compulsory labour. Some people may not be victims of human trafficking (because they are not moved from one area to the other for the purposes of exploitation) but they can still be victims of modern slavery.

Slavery, servitude and forced labour are illegal in the UK.

For a person to be a victim of slavery, servitude or forced labour there must have been?

the means (being held, either physically or through threat – for example, threat or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability);
a service (a person has to have provided a service for the benefit of others – for example, begging, sexual services, manual labour, domestic service).

3. Identifying Victims

It can be difficult to identify victims of modern slavery; they are often reluctant to come forward, may not recognise themselves as victims or, because they are scared, they may tell their stories with obvious mistakes or leave some information out.

Some adults are more vulnerable to becoming victims of modern slavery, including:

young men and women;
pregnant women;
former victims of modern slavery (including people who do not consent to the National Referral System (see Section 5) who may be at risk of being re-trafficked;
people who are homeless or who are at risk of becoming homeless;
people with drug and alcohol issues;
people who have learning difficulties, disabilities, communication difficulties, chronic developmental or mental health disorders or other health issues;
people who have experienced abuse before;
people in deprived / poor areas where there are few job opportunities are more likely to be recruited by traffickers, pretending to be recruitment agencies / genuine employers;
people struggling with debt;
people who have lost family or suffered family breakdown or have limited support networks;
people with criminal records who employers may not want to take on;
illegal immigrants who are not allowed to work and therefore do not have an income;
older people who are lonely and do not have much money;
people who speak no or very little English and / or cannot read or write in their own language;
overseas domestic workers.

3.1 Signs to look out for

Victims of modern slavery can be found anywhere. However, there are certain industries where they are more likely to be found such as nail bars, hand car washes, food preparation / processing factories, domestic service, farming and fishing, building sites and the sex industry.

The Modern Slavery statutory guidance (Home Office) provides the following indicators:

3.1.1 General Indicators

Victims may:
Believe that they must work against their will	Have false identity or travel documents for example a passport (or none at all)
Be unable to leave their work or home environment	Be found in or connected to a type of location or venue likely to be used for exploiting people
Show signs that their movements are being controlled / feel that they cannot leave	Be unfamiliar with the local language
Be subjected to violence or threats of violence against themselves or against their family members and loved ones	Not know their home or work address
Show fear or anxiety	Allow others to speak for them when addressed directly
Have injuries that appear to be the result of an assault	Be forced, threatened or deceived into working in poor conditions
Not be allowed to have the money they have earned	Be disciplined / controlled through punishment
Be distrustful of the authorities	Receive little or no payment
Be afraid of telling anyone their immigration status	Work very long hours over long periods
Come from a place where human trafficking victims are known to come from	Live in poor or substandard accommodations
Have had the fees for their transport to the country of destination paid for by organisers of human trafficking, who they must pay back by working or providing services	Have no access to medical care
Have no or not much contact with other people	Only be allowed to have limited contact with their families or with people outside of their immediate environment
Be unable to speak freely with others	Believe that they must work until they have paid off the debt they are told they owe
Be dependent on their ‘bosses’ / facilitators	Have believe the false promises of their bosses / facilitators.

3.1.2 Physical indicators

Physical injuries – with no clear explanation as to how or when they got the injuries or which are either not treated or only partly treated, or there may be lots of / unusual scars or broken bones which have healed.
Work related injuries – often through having poor or no personal protective equipment and health and safety arrangements.
Physical consequences of living in captivity, neglect or poor environmental conditions – for example, infections including tuberculosis (TB), chest infections or skin infections, malnutrition and vitamin deficiencies or anaemia.
Dental problems – from physical abuse and / or not being able to see a dentist.
Worsening of existing long term medical conditions – these may be untreated (or poorly treated) conditions such as diabetes or high blood pressure.
Being disfigured – cutting, burning, or branding someone’s skin may be used as punishment or a way to show that an exploiter ‘owns’ the person.
Pain after a surgical operation – infection or scarring from organ harvesting, particularly of a kidney. Please note, under the Human Tissue Act 2004 (Supply of Information about Transplants) Regulations 2024, relevant clinicians in England, Wales and Northern Ireland must report any suspicions that an organ transplant-related offence has taken place to the Human Tissue Authority.

3.1.3 Psychological indicators

Expression – they may seem in fear or anxious.
Depression – they may have a lack of interest in getting involved in activities, in socialising with other people or appear to feel hopelessness.
Attachment and identity issues – they can become detached from other people or become over-dependent (or both). This can include being dependent on their exploiters.
Unable to control emotions – for example they may often swing between sadness, forgiveness, anger, aggression, frustration and / or emotional detachment or emotional withdrawal.
Difficulties with relationships – they may have difficulty trusting others (either have a lack of trust or be too trusting) which causes difficulties in their relationships and difficulties assessing warning signs in their relationships.
Loss of independence – for example they may have difficulty in making simple decisions, tendency to give in to the views / desires of others.

3.1.4 Situational and environmental indicators

Exploiters keep victims’ passports or identity documents, contracts, any payslips, bank information or health records.
They have a lack of information about their rights as a visitor in the UK or a lack of knowledge about the area in which they live in the UK.
They act as if they are being coerced or controlled by another person.
They may go missing for periods.
They may be fearful and emotional about their family or dependents.
They may have limited spoken English, for example only being able to talk about being exploited and not being able to have any other topic of conversation.
They may be limited in where they can go (victims may not be ‘locked up’ but are not able to move around freely) or being held in isolation.
They may have their wages withheld (including deductions from wages).
Debt bondage – they may have to work until they have paid off a debt to the traffickers / exploiters.
They may have abusive working and / or living conditions, including having to work a lot of overtime.

3.2 Impact on Victims

Victims of modern slavery are forced, threatened or deceived into situations of humiliation and being under the control of their exploiters, which undermines their personal identity and sense of self. The impact of these experiences can be devastating.

It is important for all professionals to understand the specific vulnerability of victims of modern slavery and use practical, trauma-informed methods of working which are based upon basic principles of dignity, compassion and respect and which recognise the impact of trauma on the emotional, psychological and social wellbeing of people.

Victim’s voices must always be heard, and their rights respected.

4. Reporting Concerns

4.1 Taking action

Any worker who has concerns about someone who they think may be a victim of modern slavery should follow their organisation’s safeguarding adults procedures. When responding to concerns of modern slavery, the safety, protection and support of the potential victim must be the first priority. They may need emergency medical care. Only independent interpreters should be used. Never any other adults who are with the potential victims as they may (unknown to the member of staff) be associated with the exploiters and therefore may not tell the truth about the person’s situation.

4.1.1 Immediate risk of harm

If it is suspected that someone is in immediate danger, the police should be contacted on 999.

4.1.2 No immediate risk of harm

There are a number of options that can be taken:

the police can be contacted on 101;
the Modern Slavery helpline can be contacted: 0800 0121 700.

4.1.3 Adult Social Care

Victims of modern slavery are often adults who are at risk of, or who are experiencing, abuse or neglect, particularly when they have been rescued from a situation of exploitation. In this instance, local authority adult social care should be informed as soon as possible to identify whether a Section 42 (safeguarding) enquiry is required. A safeguarding referral to the local authority should be made with the cooperation adult victim, taking into account their needs and wishes.

Even where an adult has been removed from a harmful situation, they can be at risk of re-victimisation. Even if there is no immediate risk relating to safety or the person’s welfare, it is important to discuss any concerns with your designated safeguarding adults lead or the local authority safeguarding adults team and follow local safeguarding adults policies and procedures.

4.2 Seeking advice

You can seek advice on what action to take from your designated safeguarding adults lead, the local authority safeguarding adults team, the police public protection unit (contactable via the Northumbria Police switchboard) or the Modern Slavery Helpline.

5. National Referral Mechanism and the Duty to Refer

For further guidance and the online referral forms see:

Modern Slavery Victims: Referral and Assessment Forms (gov.uk)

The National Referral Mechanism (NRM) provides a framework for identifying and referring potential modern slavery victims and ensuring they receive appropriate support.

Support for adult victims may include:

access to legal aid for immigration advice;
access to short-term Government-funded support through the Modern Slavery Victim Care Contract (accommodation, material assistance, translation and interpretation services, counselling, advice, etc.);
outreach support if already in local authority accommodation or asylum accommodation;
assistance to return to their home country if not a UK national.

5.1 Referral or Duty to Notify

An online referral system is used for making referrals into the NRM and also for Duty to Notify (DtN) referrals.

Referrals into the NRM can only be made by staff who work for designated ‘first responder’ organisations (see Appendix 1).

Whether a DtN referral or referral into the NRM is made depends on obtaining the consent of the adult victim.

For an adult to be referred to the NRM, they must provide informed consent. This means they should understand what the NRM is, what support it can provide, and what the possible outcomes are if they are referred.

It should be presumed that an individual has the mental capacity to make a decision about whether to consent to entering the NRM.

When there may be concern about a person’s mental capacity to make a decision about whether or not to consent to entering the NRM, steps should be taken to try to support them to make the decision. Where a person does not have the capacity to consent, a best interests decision should be taken. Before a decision is taken in the best interests of an individual, it is vital to consult with any other agencies involved in the care and support of the individual. See Mental Capacity chapter.

If the adult does not consent to a NRM referral, a DtN referral should always still be made, using the online form.

5.2 Support for potential victims who do not consent

Adult potential victims who choose not to enter the NRM may still be eligible for other state support. They may still be:

at immediate risk of harm, in which case the police should be contacted by calling 999;
eligible for housing support through the local authority or for other support from the government where they have recourse to public funds;
entitled to make a claim for asylum or another type of immigration status or stay in asylum support if they have an active claim (where the person does not have the right to reside in the UK);
able to receive emergency medical care;
at risk of further exploitation, see Section 4.1.3, Adult Social Care.

Appendix 1 – NRM First Responder Organisations and Responsibilities

In England and Wales, a ‘first responder organisation’ is an authority that is authorised to refer a potential victim of modern slavery into the National Referral Mechanism. The current statutory and non-statutory first responder organisations are:

police forces;
certain parts of the Home Office; UK Visas and Immigration, Border Force, Immigration Enforcement and National Crime Agency;
local authorities;
Gangmasters and Labour Abuse Authority (GLAA);
Salvation Army;
Migrant Help;
Medaille Trust;
Kalayaan;
Barnardo’s;
Unseen;
NSPCC (CTAC);
BAWSO;
New Pathways;
Refugee Council.

First responder organisations have the following responsibilities – it is for the organisation to decide how it will discharge these responsibilities:

identify potential victims of modern slavery and recognise the indicators of modern slavery;
gather information in order to understand what has happened to victims;
refer victims into the NRM via the online process (in England and Wales this includes notifying the Home Office if an adult victim doesn’t consent to being referred – DtN);
provide a point of contact for the competent authority to assist with the Reasonable and Conclusive Grounds decisions and to request a reconsideration where a first responder believes it is appropriate to do so.

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2.9 Financial or Material Abuse

RELEVANT CHAPTERS

Safeguarding Enquiries Process

RELEVANT INFORMATION

Friends against Scams, National Trading Standards

1. Introduction

This includes theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits. The potential impact of financial abuse should not be underestimated. It could significantly threaten an adult’s health and wellbeing.

According to the Office of the Public Guardian financial abuse is the most common form of abuse. Financial abuse can occur in isolation, but where there are also other forms of abuse, it is also likely to be a feature.

2. Indicators of Financial Abuse

Potential indicators of financial abuse include:

change in living conditions;
lack of heating, clothing or food;
inability to pay bills/unexplained shortage of money;
unexplained withdrawals from an account;
unexplained loss/misplacement of financial documents;
the recent addition of authorised signatories on a client or donor’s signature card; or
sudden or unexpected changes in a will or other financial documents.

This is not an exhaustive list, nor do these examples prove that there is actual abuse occurring. However, they do indicate that a closer examination and possible investigation may be required.

Financial abuse may amount to theft or fraud which the police should investigate. It may also require attention and collaboration from a wider group of organisations, including shops and financial institutions such as banks.

Where the abuse is by someone who has the authority to manage an adult’s money, the relevant body should be informed, for example, the Office of the Public Guardian for deputies and the Department for Work and Pensions (DWP) in relation to appointees.

If there are concerns that a DWP appointee is acting incorrectly, the DWP should be contacted immediately. The DWP should inform the local authority where it is aware that the adult is already known to the authority.

3. Internet, Postal and Doorstep Scams

Internet scams, postal scams and doorstep crime are more often than not, targeted at adults and are forms of financial abuse.

These scams are becoming ever more sophisticated and elaborate. For example:

internet scammers can build very convincing websites;
people can be referred to a website to check the caller’s legitimacy but this may be a copy of a legitimate website;
postal scams are mass produced letters which are made to look like personal letters or important documents;
doorstep criminals call unannounced at the adult’s home under the guise of legitimate business and offering to fix an often non-existent problem with their property. Sometimes they pose as police officers or someone in a position of authority.

All of these scams constitute financial abuse as the adult can be persuaded to part with large sums of money and in some cases their life savings. Such scams should always be reported to the police and local authority trading standards services for investigation. The SAB should consider how to involve local trading standards in its work.

These scams and crimes can seriously affect the health, including mental health, of an adult.

Agencies working together can better protect adults. Failure to do so can result in an increased cost to the state, especially if the adult loses their income and independence.

Where the abuse is perpetrated by someone who has the authority to manage an adult’s money, the relevant body should be informed – for example, the Office of the Public Guardian for deputies or attorneys and Department for Work and Pensions (DWP) in relation to appointees.

If there are concerns that a DWP appointee is acting incorrectly, the DWP should be contacted immediately, having the person’s National Insurance number, name and address is helpful to the DWP. But the important thing is to make DWP aware of the concern.

If DWP knows that the person is also known to the local authority, then it should also inform the relevant authority.

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2.1 Adults Vulnerable to Radicalisation and Violent Extremism

Radicalisation is the process through which people come to support increasingly extreme political, religious or other views. This can lead them to support violent extremism and terrorism. Both children and adults can be vulnerable to messages of violent extremism. If a practitioner has a concern that a child or adult is being exposed to extremist ideologies, they should follow the process set out in Sharing a Prevent Safeguarding Concern – Process to follow in South Tyneside.

Prevent is a Government strategy which aims to stop people becoming terrorists or supporting terrorism, in all its forms. Prevent works at the pre criminal stage by using early intervention to encourage individuals and communities to challenge extremist and terrorist ideology and behaviour. For more information see the Prevent Duty Guidance (Home Office)

SHARING CONCERNS IN SOUTH TYNESIDE

Sharing a Prevent Safeguarding Concern – Process to follow in South Tyneside (opens in pdf)

Prevent Referral Form (opens in Word)

If you are worried someone might be radicalised (South Tyneside council website)

September 2024: This guidance which contains information for practitioners on how to respond to concerns that an adult is being radicalised has been updated throughout.

If you are a member of the public who has concerns about someone being radicalised into terrorism or supporting terrorism, the ACT Early website offers advice and guidance, including signs of radicalisation to look out for, and information on how to share those concern. In an emergency, always phone 999.

1. Introduction

Radicalisation is the process through which people come to hold increasingly extreme views or beliefs that support terrorist groups or activities. The most common types of terrorism in the UK are extreme right-wing terrorism and Islamist terrorism. Multi-agency working is key to supporting vulnerable adults (and children) who have been radicalised, or who are at risk of radicalisation.

For information about extremism and radicalisation of children and young people, see the South Tyneside Safeguarding Children Partnership procedures.

Extremism is defined as the promotion or advancement of an ideology or beliefs based on violence, hatred or intolerance that aims to:

deny or destroy the fundamental rights and freedoms of others; or
undermine, overturn or replace the UK’s system of democracy and democratic rights; or
deliberately create an environment for others to achieve the results in (1) or (2).

(See Definition of Extremism, gov.uk)

Exposure to extremism can lead to radicalisation and acts of terrorism.

2. Government Approach to Preventing and Tackling Extremism and Terrorism

The national counter-terrorism strategy, CONTEST aims to reduce risks of terrorism in the UK and overseas.

Prevent is one of the key parts of CONTEST and aims to stop people becoming terrorists or supporting terrorism; it focuses on early intervention and safeguarding. Prevent is run locally by specialist staff who understand the risks and issues in the local area and know how best to support their communities. Through working together, organisations can identify people who are at risk of radicalisation and provide them with support. The objectives of Prevent are to:

tackle the ideological causes (the beliefs) of terrorism;
intervene early to support people to stop them from becoming terrorists or supporting terrorism; and
rehabilitate those who have become involved in terrorist activity.

The Prevent duty (Section 26, Counter-Terrorism and Security Act 2015 (CTSA) requires frontline staff working in specific organisations – including education, health, local authorities, police, prisons and probation – to work together to help prevent the risk of people becoming terrorists or supporting terrorism. It helps to make sure that people who are being radicalised are supported in the same way as they are under safeguarding processes.

3. Signs that an Adult is being Radicalised

Adults can be exposed to the messages of extremist groups or drawn into violence in different ways, including through family members, by direct contact with extremist groups or, most often, the internet.

Everyone is different and there is no single way of identifying who is at risk of being radicalised into terrorism or supporting terrorism. Signs that an adult is being radicalised include them:

accessing extremist content online or downloading propaganda material;
justifying the use of violence to solve issues / problems in society;
altering their style of dress or appearance in line with an extremist group;
being unwilling to engage with people who they see as different;
using certain symbols associated with terrorist organisations.

The likelihood of an adult being radicalised is often linked to their vulnerability. Adults who are receiving care and support or protection because of their age, a disability, or because they have experienced abuse or neglect can be more vulnerable. In many cases, these factors or characteristics are relevant to how likely they are to be radicalised and to the types of early intervention support they will be offered through Prevent.

4. Taking Action – Notice, Check, Share

4.1 Notice

Staff working in frontline roles will often be the first to notice if an adult displays concerning behaviour. If staff notice behaviours that are a cause for concern, they should consider whether the adult is at risk of radicalisation.

There could be many different reasons for the behaviours, not just radicalisation. It is important to understand the context and try to find out why these changes are happening, before reaching conclusions too quickly.

4.2 Check

Concerns about radicalisation or extremism should then be checked with the designated safeguarding lead in the organisation. The Prevent lead in the local authority or local police can also be contacted for advice.

Before deciding whether to make a referral to Prevent, it is important to gather as much information as possible, to assess if the adult may be on a pathway that could lead to terrorism.

4.3 Share

See also Prevent Referral Form (opens in Word)

Where there are concerns about radicalisation and extremism, relevant information should be shared by making a referral to the police for support under Prevent, using the Prevent national referral form (see Get help for radicalisation concerns , gov.uk). Staff can make the referral themselves or it can be made by their safeguarding lead, depending on the processes in their own organisation.

People who could be referred include those who:

are accessing extremist materials, usually online or in books, leaflets or pamphlets;
are repeating propaganda, grievances, and conspiracies based on violence, hatred or intolerance;
may have been witnessed traumatic events in war or conflict zones, either in person or online;
are showing signs of being intolerant to people from different ethnic backgrounds, cultures or with other protected characteristics.

REMEMBER – in an emergency, always ring 999.

5. Action Following a Prevent Referral

Once a referral is submitted to the local Prevent team, specialist police staff will assess it. Firstly, they will check if the adult is an immediate security threat. The police will then check if there is a risk of radicalisation which means that the adult should be discussed at the local Channel panel to see if they are eligible for support through Prevent. This is called a ‘gateway assessment’. Referrals into Channel are made by the Police. If the adult needs other support, this should continue unless there is a good reason not to do so.

Channel panels are chaired by the local authority, and attended by multi-agency partners such as police, education professionals, health services, housing and social services. They meet to discuss the referral, assess the risk, and, if appropriate, agree a package of support specific to the individual adult. Channel is a voluntary process, and the adult must give their consent before they receive support.

5.1 Mental capacity to consent to Channel

If there are concerns that the adult may not have mental capacity to consent to Channel support, a mental capacity assessment should be arranged (see Mental Capacity chapter).

If the assessment finds that the adult does not have mental capacity to make their own decision, any decision to consent to the Channel process which is made for the adult by other people must be in their best interests.

5.2 Safeguarding adults concerns

Where there are also safeguarding concerns about the adult or where there are radicalisation concerns involving a person in a position of trust, a safeguarding referral should be made to the safeguarding adults team (see also Section 6, Safeguarding).

For cases involving people in positions of trust, the chair of the Channel Panel will need to balance confidentiality with wider safeguarding concerns and should consider whether there is a need to notify relevant people (for example the person’s employer).

5.3 Types of support

The type of activities that are included in a support package will depend on risk factors, vulnerabilities, and local resources, but might include:

religious / ideological (beliefs) support – structured sessions to understand, assess or challenge ideological, religious or fixed thinking, which must be considered for all cases;
life skills – work on life skills or social skills, such as dealing with peer pressure;
anger management sessions – formal or informal work dealing with issues of anger;
cognitive / behavioural contact – cognitive behavioural therapies (CBT) and general work on their attitudes and behaviours (CBT can help identify and change negative patterns of thought and behaviour);
positive pursuits – supervised or managed positive leisure activities;
education skills contact – activities focused on education or training;
careers contact – activities focused on employment;
family support contact – activities aimed at supporting family and personal relationships, including formal parenting programmes;
health awareness contact – work aimed at assessing or addressing any physical or mental health issues;
housing support – to address living arrangements / accommodation provision;
drugs and alcohol awareness – substance misuse interventions;
mentoring – work with a suitable adult as a role model to provide personal guidance or pastoral (emotional, social and spiritual) care.

If the family or carers are identified as a protective, positive factor for the adult, they should be involved with the process, so long as the adult agrees to this. This agreement can be included on the consent form used when the adult consents to receiving support from Channel.

Where Channel is not considered suitable for the adult, alternative options will be explored, such as support from mental health services. Where the adult has not given consent or risks cannot be managed in Channel, they will be kept under review by the police.

5.4 Closing a case

Where the Channel panel decides to close a case, the adult should be told that their case is being closed and that they will no longer receive support through Channel. They should also be told that ongoing support they are receiving through mainstream services (such as the NHS, police or probation) will continue.

Identifying a lead professional at the point of the adult’s case being closed provides reassurance that they can be brought back for discussion at the panel quickly, should concerns about them re-emerge.

The panel is best placed to identify which agencies will continue to engage with the adult after their case with Channel has been closed and to identify a lead professional. Frontline practitioners involved in providing continuing support must be informed that Channel no longer has oversight of the adult’s case and advised on how to re-refer them to Prevent if there are any future concerns.

Where the family / carers have been involved, they should be informed that the adult is no longer being supported through Channel, and that while some mainstream service provision will continue beyond this point, Channel will no longer be monitoring Prevent related concerns.

6. Safeguarding

There will be times when there are concerns that an adult meets the thresholds for a safeguarding enquiry, as they have care and support needs and are at risk of, or are experiencing, abuse or neglect.

The assessment and support provided through Channel can run alongside safeguarding processes. In this way, the Channel support will often overlap with wider safeguarding duties.

It is important that Prevent referrals are considered by the local authority and panel partners alongside their work to safeguard vulnerable adults. Where an adult is receiving care and support from adult social care, as well as support through Channel, their social worker should be present at the panel and be involved in all decisions. Channel can run alongside, but must not be replaced by, other safeguarding meetings where safeguarding thresholds have been met.

7. Information Sharing

When sharing personal data about adults at risk of radicalisation, it is important to adhere to the requirements of data protection legislation.

Data protection legislation is not intended to prevent the sharing of personal data, but to make sure that it is done lawfully and with appropriate safeguards in place. Under the Data Protection Act and UK GDPR, there must be a legal basis to share personal data. The Prevent Duty is a lawful basis on which to share data.

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2.14 ‘Honour’ Based Abuse

RELATED CHAPTERS

Safeguarding Enquiries Process

Forced Marriage

RELATED GUIDANCE

So Called Honour Based Abuse and Forced Marriage, Crown Prosecution Service

1. Definition of ‘Honour’ Based Abuse

So called Honour-Based Abuse is defined as:

an incident or crime involving violence, threats of violence, intimidation coercion or abuse (including psychological, physical, sexual, financial or emotional abuse) which has or may have been committed to protect or defend the honour of an individual, family and/ or community for alleged or perceived breaches of the family and/or community’s code of behaviour (Crown Prosecution Service).

It can be a collection of practices, which are used to control behaviour within families or other social groups to protect perceived cultural and religious beliefs and / or so-called ‘honour’. Such abuse can occur when perpetrators perceive that a relative has shamed the family and / or community by breaking their code of ‘honour’, known as ‘izzat’.

Victims are usually girls or women, but not exclusively so. Men may also be victims. For the purposes of this chapter, however, it refers to adult women.

So called honour based abuse is a violation of human rights; it may also be a form of domestic abuse and / or sexual abuse or sexual violence. There is no honour or justification for abusing the human rights of others, nor can there be. There is no specific offence of ‘honour’ based crime. It is an umbrella term to encompass various offences covered by existing legislation.

2. Common Triggers

Behaviour by a woman (victims are usually young women, but not exclusively) which may be deemed by her family / community as breaching their code of ‘honour’ include:

wearing make-up or dress deemed inappropriate;
spending time without supervision from a family member;
being intimate with someone in public;
having a boyfriend, including loss of virginity;
having a relationship/s with males outside of the approved group;
being in a same sex relationship;
reporting domestic abuse;
rejecting a forced marriage;
leaving a spouse, seeking a divorce or refusing to divorce when ordered to do so by family members;
applying for custody of children following separation or divorce;
pregnancy outside of marriage.

Men may be targeted either by the family of a woman who they are believed to have ‘dishonoured’, in which case both parties may be at risk, or by their own family if they are believed to be homosexual.

So called honour based abuse is not a crime which is solely perpetrated by men; sometimes female relatives will support, incite or assist. It is also not unusual for younger relatives to be selected to undertake the abuse as a way to protect senior members of the family. Sometimes contract killers can be employed.

Shame may persist for a long time after the incident that was deemed to be dishonourable occurred. This may result in a new partner of a victim, their children, associates or siblings also being at risk.

3. ‘Honour’ Based Killings

‘Honour’ based abuse usually involves threats, intimidation and violence in an effort to get the victim to conform to the desired behaviour. These can escalate where deemed to be unsuccessful. On occasion, it may result in murder, which may involve premeditation, family conspiracy and a belief that the victim deserved to die.

In addition to information in Section 2, Common Triggers, incidents that may precede a killing include:

denied access to the telephone, internet, passport, friends;
house arrest and / or other excessive restrictions;
pressure to go abroad;
domestic abuse;
threats to kill or denial of access to children.

In some circumstances a victim’s immigration status may be used to dissuade them from seeking assistance from authorities, particularly if it is dependent on their spouse.

Victims may suffer in isolation, resulting in depression and attempt suicide.

4. Responding to Concerns about ‘Honour’ Based Abuse

When dealing with potential victims of so called honour based abuse, it is essential that professionals understand the seriousness of the situation and that immediate, but discreet, action is required.

If a woman discloses that she, or someone else, is at risk of ‘honour’ based abuse, the professional should:

speak with her in a setting that is confidential and where they cannot be overheard;
ensure that family members are not present;
take the disclosure seriously, and reassure her as such;
explain the limits of confidentiality and that a referral to the police and local authority will have to be made;
obtain sufficient information from her to make a referral to the Safeguarding Adults Team (see Local Contacts) and the Police;
agree method/s of maintaining contact.

See Stage 1: Concerns chapter

It is the responsibility of the police to initiate and undertake a criminal investigation as appropriate. This should be made clear during multi-agency discussions, as well as the roles and responsibilities of other involved professionals.

It is essential that women who return to their families are offered support. This should include escape plans and the option to deposit their DNA, finger prints and photograph with the police.

Professionals should ensure that they make a full record of all discussions, with whom these take place and any actions taken including referrals to other agencies. They should also inform their line manager who should sign off the discussions / actions (see also Case Recording chapter).

Victims are sometimes persuaded to return to their country of origin under false pretences, where the intention may be to either stop them from contacting the authorities or to kill them. If a woman is taken abroad, the Foreign and Commonwealth Office may assist in repatriating the woman back to the UK.

Professionals must not approach the family or community leaders, share any information with them or attempt any form of mediation.

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2.11 Gang Activity, Youth Violence and Criminal Exploitation Affecting Children, Young People and Vulnerable Adults

To see the guidance, click here:

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2.10 Forced Marriage

RELEVANT CHAPTERS

Honour Based Abuse

RELEVANT INFORMATION

A Right to Choose: Government guidance on forced marriage (Home Office and Foreign, Commonwealth & Development Office)

Forced Marriage and Learning Disabilities: Multi-Agency Practice Guidelines, (HM Government)

Forced Marriage Resource Pack- examples of best practice to ensure that effective support is available to victims of forced marriage (Home Office)

Forced Marriage: A Survivor’s Handbook (Foreign, Commonwealth & Development Office)

RESOURCES FOR RAISING AWARENESS

Forced Marriage – Free e-learning

The right to choose: what services and organisations should do to help people at risk of forced marriage (Easy Read version)

The Foreign and Commonwealth office have produced a series of short YouTube videos covering the consequences of forced marriage, and how to spot the signs of a forced marriage.

August 2024: Section 4, Adults with Care and Support Needs has been updated to reference information produced by the Forced Marriage Unit and ADASS. Appendix 1, which is new and based on the finding in the case of AG (Welfare: FMPO), Re [2024] EWCOP 18, lists suggested questions which can be helpful for practitioners to use if they have concerns about proposed overseas travel plans: A link to a forced marriage easy read published by the Home Office and Foreign, Commonwealth and Development Office has also been added.

FOR PEOPLE DIRECTLY AFFECTED – If you’re trying to stop a forced marriage or you need help leaving a marriage you’ve been forced into, contact the Forced Marriage Unit (FMU). In an emergency phone the Police on 999.

1. Introduction and Definition

A forced marriage is one where one or both people do not – or in cases of people without mental capacity cannot – consent to the marriage, and pressure or abuse is used to force them to marry.

The pressure put on people to marry against their will can be:

physical: for example threats and physical violence or sexual violence;
emotional and psychological: for example, making someone feel like they are bringing ‘shame’ on their family
financial: for example taking someone’s wages.

Adults who lack the mental capacity to consent to marriage do not have to be pressured or abused for the marriage to be forced.

It is also a forced marriage when a person arranges for a child to get married before they are 18, even if they are not forced or coerced into doing so. Any concerns in relation to a marriage of a child under 18 years should be shared with Children’s Social Care (see Safeguarding Children Procedures).

Forced marriage can happen to both men and women, although most cases involve women and girls between 16 to 25 years. There is no ‘typical’ victim of forced marriage. They can be over or under 18 years of age, they may have a disability and / or may have young children or spouses from overseas.

Most reported cases have been linked with South Asian countries. However, there have also been cases involving many other countries across the Middle East, Europe, Africa and North America. Forced marriages can also take place here in the UK without overseas travel. In many cases forced marriage involves a potential partner being brought into the UK from overseas or a British person being taken abroad for the forced marriage, often without them knowing that they are going to be married. Forced marriage of any person, regardless of sex, age, disability, ethnic origin or sexual orientation, is illegal in the UK (see Section 6, Forced Marriage Offences).

Forced marriage is very different to an arranged marriage, which is where families of both the woman and man take a lead in the arrangements for the marriage, but they are free to decide whether they want the marriage to go ahead or not.

2. Reasons Given for Forced Marriage

People who force others into marriage often try to justify their behaviour as ‘protecting’ their children, building stronger families and preserving so-called cultural or religious beliefs. However, the act of forcing another person into marriage can never be justified on religious grounds: every major faith condemns the practice of forced marriage.

Some of the key motives given for forced marriage are:

to try to control someone’s sexuality (including alleged promiscuity, or being lesbian, gay, bisexual or transgender) – particularly the behaviour and sexuality of women;
to try to control someone’s behaviour, for example, drinking alcohol or taking drugs, wearing make-up or behaving in what is seen to be a ‘westernised manner’;
preventing what is seen as unsuitable relationships, for example outside the ethnic, cultural, religious, class or caste group;
protecting ‘family honour’ (known as ‘izzat’, ‘ghairat’, ‘namus’ or ‘sharam);
responding to pressure from family, friends or their community;
attempting to strengthen family links;
in order to gain financially or reduce poverty;
making sure land, property and wealth remain within the family;
protecting apparent cultural or religious ideas;
making sure that there is someone to care for a child or adult with special needs, when parents or existing carers are unable to fulfil that role;
to help people from overseas claim for UK residence and citizenship;
long-standing family commitments.

3. Impact of Forced Marriage

Victims trapped in, or under the threat of, a forced marriage are often very isolated. They may feel there is nobody they can trust to keep this secret, and they have no one to speak to about their situation – some may not be able to speak English.

People who are forced to marry find it very difficult to leave the marriage, and women may be subjected to repeated rape (sometimes until they become pregnant) and domestic abuse within the marriage. In some cases, victims suffer violence and abuse from extended family members and are forced to do all the household jobs and / or are kept under virtual ‘house arrest’ and not allowed to leave the home without a family escort.

Both male and female victims may feel that running away is their only option. For many leaving the family can be very hard. They may have little experience of life outside the family and worry about losing their children and support network. Also, leaving their family (or accusing them of a crime, or asking the police or the council for help) may be seen as bringing shame on their ‘honour’ and on the ‘honour of their family’. Those who do leave often live in fear of their own families, who may go to considerable lengths to find them and bring them back home.

Victims of forced marriage, their siblings and other family members are at risk of real harm – particularly if they are found to asked for help or are planning to leave the marriage. Victims can face the possibility of ‘honour’-based abuse, rape, kidnap, being held against their will, threats to kill, being abducted overseas and even murder.

4. Adults with Care and Support Needs

Adults with care and support needs can be particularly vulnerable to forced marriage because they are likely to rely on their families for care, may have communication difficulties and do not have many opportunities to tell anyone outside their family about what is happening.

4.1 Supporting Victims with Learning Disabilities

The My Marriage, My Choice Toolkit includes practice guidance and tools to assist practitioners who are working with people with learning disabilities to recognise and take appropriate action when there is a risk of forced marriage

People with learning disabilities may lack the mental capacity to consent to marriage, others may have the capacity to consent, but they can be more easily tricked or coerced into marriage.

Key motives why families may force a person with learning disabilities to marry, include:

obtaining a carer for their son / daughter;
getting help to look after elderly parents;
obtaining financial security for the person with a learning disability;
believing the marriage will somehow ‘cure’ the victim’s disability;
a belief that marriage is a ‘rite of passage’ and necessary for all young people;
a fear that younger siblings may be seen as undesirable if older sons or daughters are not already married;
using the marriage as the basis for sponsoring a visa, so a foreign national can live in the UK;
the marriage being seen as the only option and that there is no alternative.

4.1.2 Assessing mental capacity

The Mental Capacity Act (MCA) provides a framework for making decisions on behalf of those who lack capacity to do so themselves. It sets out who can take decisions, in which situations, and how they should go about this.

The MCA starts from the basis that everyone has the capacity to make decisions. Where someone is found to lack capacity to make a particular decision, the Act says which other people can make those decisions on their behalf. Any decision must always be made in the best interests of the person who lacks capacity. However, there are certain decisions which can never be made on behalf of someone else, and these include the decision to marry or to have sexual relationships. Therefore someone else cannot agree to marriage, civil partnership or a sexual relationship on behalf of a person who lacks the capacity to make these decisions themselves.

It is not just those people with learning disabilities whose mental capacity can be affected. People with a brain injury, dementia, Alzheimer’s and / or mental ill health can lack capacity. If a person does not consent or lacks capacity to consent to marriage, that marriage is a forced marriage, no matter what the reason for the marriage taking place.

4.2 Action when an adult with care and support needs is at risk of forced marriage

If an adult with care and support needs tells a practitioner they are going on a family holiday overseas and they are concerned about this, or a professional has their own worries about a holiday or other signs that a forced marriage is being planned, as much information as possible should be gathered (see Appendix 1 for examples of questions to ask). The practitioner should then:

discuss the case with the safeguarding lead in their organisation;
contact the Forced Marriage Unit (FMU) for advice. Their expertise can help to ensure the most effective response;
arrange a mental capacity assessment (if there are concerns about the adult’s mental capacity) to determine if the adult is able to consent to marriage. If the assessment finds that the adult lacks the mental capacity to consent to a marriage, then any marriage to that person must be viewed as a forced marriage;
consider whether a communication specialist is needed if a person is hearing or visually impaired or has a learning disability.

Where an adult with care and support needs appears to be at risk of, or experiencing, abuse or neglect and unable to protect themselves, then a safeguarding concern must be raised so the local authority can make enquiries under Section 42 of the Care Act 2014 (see Safeguarding Enquiries Process section)

If the risk of forced marriage is immediate, emergency action to remove the adult from their home might be needed. Advice should be sought from the police and the local authority legal department.

Do NOT:

Go directly to the person’s family, friends, or those people with influence within the community, as this will alert them to your enquiries and may place the person in further danger.
Attempt to be a mediator or encourage mediation, reconciliation, arbitration or family counselling.

For more information see: Forced marriage and learning Disabilities: multi-agency practice guidelines (HM Government) and Information from the Forced Marriage Unit and ADASS.

5. Taking Action – Where there is a Risk of Forced Marriage or a Forced Marriage has Taken Place

The Forced Marriage Unit (FMU) is available to talk to frontline professionals handling cases of forced marriage. It also offers information and advice on the wide range of tools available to tackle forced marriage, including how the law can be used in particular cases, what assistance is available to British victims in different countries and how to approach victims.

5.1 One Chance Rule

All practitioners working with suspected or actual victims of forced marriage should be aware of the “one chance” rule. This is that they may only have one opportunity to speak to a victim and may only have one chance to save their life. If the victim leaves the meeting with the practitioner without the appropriate support and advice being offered, that one chance might have been missed.

If someone discloses that they are in or at risk of a forced marriage, it should never be dismissed as just a ‘family matter’. For many people, asking for help from an agency is a last resort and so all disclosures of forced marriage must be taken seriously.

5.2 Best practice in all cases

Wherever possible, see the person on their own, in a private place where the conversation cannot be overheard.
Gather as much information as possible to establish the type and level of risk to the safety of the person. Find out whether there are any other family members at risk of forced marriage or if there is a family history of forced marriage and abuse.
Contact the Forced Marriage Unit as soon as possible for advice, including whether a Forced Marriage Protection Order is appropriate (see Section 6.1, Forced Marriage Protection Orders).
If the person is an adult with care and support needs, concerns should be shared with adult social care as a safeguarding referral.
As forced marriage is a crime, it should also be reported to the police even if the adult does not have care and support needs. In an emergency call 999.
If the person does not want to return to the family home, then a strategy for leaving should be devised and personal safety advice discussed. Research shows that leaving home is the most dangerous time for women experiencing domestic abuse and this is often the case when someone flees a forced marriage.
A safety plan should be agreed in case they are seen, for example prepare another reason why you are meeting. Agree a code word with the victim to make sure that you are speaking to the right person.
If the person wants to stay at the family home and has the mental capacity to make this decision, try to arrange a way of keeping in touch without placing them at risk.
Refer the victim, with their consent, to local and national support groups with a history of working with victims of domestic abuse and forced marriage. (See the statutory guidance for details of support groups).
Advise the victim not to travel overseas.

Do NOT:

Send them away.
Approach members of their family or the community – unless it involves a victim with a learning disability and you need to work alongside the family in assessing their mental capacity.
Share information with anyone without the victim’s clear consent, unless it is in the public interest or to safeguard a child.
Breach confidentiality – unless there is an immediate risk of serious harm or threat to the life of the victim or it is in the public interest.
Attempt to be a mediator or immediately encourage mediation, reconciliation or family counselling.

A multi-agency response is vital.

REMEMBER – Younger siblings might be at risk of being forced to marry when they reach a similar age. Consider speaking to younger siblings to explain the risk of forced marriage and give them information about the help available. Discuss the situation with your line manager, and share information with safeguarding children services (see Safeguarding Children Procedures).

5.3 Take a victim-centred approach – listen to the victim and respect their wishes whenever possible

There may be times when someone wants to take action that places themselves at risk. If this is the case, explain all the risks and consider if a referral to the safeguarding adults team is appropriate. Discuss it with your line manager.

6. Forced Marriage Offences

The Anti-social Behaviour, Crime and Policing Act 2014 made it a criminal offence in England (Wales and Scotland) to force someone to marry.

This includes:

taking someone overseas to force them to marry (whether or not the forced marriage actually takes place);
doing anything to force a child to marry before their eighteenth birthday;
being involved in the marriage of someone who lacks the mental capacity to consent to marry (whether they are pressured to or not).

Forcing someone to marry can result in a prison sentence of up to seven years.

6.1 Forced Marriage Protection Orders

Anyone threatened with forced marriage or forced to marry against their will can apply for a Forced Marriage Protection Order (FMPO). Relatives, friends, voluntary workers, police officers and local authority staff can also apply for a FMPO, see Apply for a Forced Marriage Protection Order.

The order is to protect a person from being forced to marry. The details of each order will be specific to the case, for example the court may order someone to hand over the person’s passport or reveal where they are if they cannot be found.

Breaching a FMPO can result in a prison sentence of up to five years.

7. Information Sharing and Confidentiality

See South Tyneside Multi Agency Information Sharing Agreement

To protect victims of forced marriage, practitioners may need to share information with other agencies such as the police. Issues of confidentiality and information sharing are very important for anyone threatened with, or already in, a forced marriage – as they are likely to be worried what will happen if their family finds out they have asked for help.

All professionals need to be clear therefore about when confidentiality can be promised, but also when and how information may need to be shared.

If a decision is made to disclose information to another professional, the adult should be asked to consent to this. Most people will agree if they understand why it is important and are reassured about their safety (for example that the information will not be passed to their family) and what will happen following such a disclosure.

In some situations, including to safeguard an adult or prevent a crime, information can be shared even without the person’s consent. However, where possible, the person should still be told that their information will be shared.

8. Record Keeping

See Case Recording chapter

Keeping records of forced marriage is important. These may be used in court proceedings or to assist a person (particularly women who say that they have experienced domestic abuse) in immigration cases.

Staff should keep records of all actions taken, including the reasons why particular actions were taken. There should be a recorded agreement of which agency has agreed to each proposed action, together with the outcomes of the action.

Records should:

be accurate, detailed and clear, and include the date;
use the person’s own words in quotation marks;
document any injuries –.

Even if forced marriage is not disclosed, a record of the concerns may be useful in the future.

All records should be kept secure, and only accessed by staff directly involved in the case. This is particularly important for victims / potential victims of forced marriage, to make sure no one could pass on confidential information to a victim’s family.

If no further action is to be taken this should be clearly documented, together with the reasons.

Appendix 1 – Information Gathering Before an Overseas Trip

The case of AG (Welfare: FMPO), Re [2024] EWCOP 18 suggests the following questions can be helpful for practitioners to use, when they have concerns about proposed overseas travel plan.

Where is the adult travelling to? Find out about the destination, travel options to get there, the facilities available there (including access to medical care), accessibility and transport options.
What are the dates of travel?
Where is it proposed that the adult will stay?
Who will be travelling with the adult?
What care and support will be required during the stay and who will provide it?
Consider writing and / or carrying a ‘travelling letter’ which provides a brief description of the adult’s needs and any diagnosis / diagnoses, as well as details of their GP.
Consider whether international roaming is available (so that the adult can use their mobile phone on a foreign network) and ensure they have a travel plug adaptor and charger so any mobile phone can be charged.
What are the visa requirements?
What, if any, vaccinations are needed before travel?
What medication is needed? Ensure there the adult will have enough medication for the trip and possible delays.
How will the trip be funded?
Who will help the adult with their money and finances when abroad (as necessary)?
What travel insurance is needed? Does it cover the places that the adult will visit, the duration of the visit and any planned activities.
Is the adult’s passport valid? Have the emergency contact details on the back of the passport have been completed?
Consider any advice that has been provided by the Foreign, Commonwealth & Development Office (FCDO) regarding travel to the area.
Provide the adult with contact details for the nearest British embassy, high commission or consulate, or the FCDO in the UK.
Consider what to do if the adult goes missing abroad, including detail of how to report it to the police and how the FCDO can assist.
Whether advice or training on independent travel can be given to the adult before the proposed trip to maximum independence and autonomy.
Ascertain the wishes of the adult and all those who should be consulted regarding the trip.

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2.8 Female Genital Mutilation (FGM)

RELEVANT CHAPTERS

Safeguarding Enquiries Process

RELEVANT INFORMATION

Female Genital Mutilation: Multi-Agency Statutory Guidance (Home Office, Department for Education and Department of Health and Social Care)

FGM Resource Pack (Home Office) – case studies, support materials and information on specialist organisations

Free E-Learning ‘Recognising and Preventing FGM’ (Home Office)

Amendment – In May 2023 this guidance was rewritten to reflect the latest statutory guidance.

1. What is Female Genital Mutilation (FGM?)

FGM is a procedure where the female genital organs are deliberately cut, injured or changed and there is no medical reason for this. It is often a very traumatic and violent act and can cause harm in many ways. FGM can cause immediate as well as long-term health consequences, including pain and infection, mental health problems, difficulties in childbirth and/or death (see Section 2, Consequences of Female Genital Mutilation).

The age at which FGM is carried out varies according to the community. The procedure may be carried out on newborn infants, during childhood or adolescence or just before marriage or during a woman’s first pregnancy. There is no religious reason, in the Bible or Koran for example, for FGM and religious leaders from all faiths have spoken out against the practice. The exact number of girls and women alive today who have undergone FGM is unknown; however, UNICEF estimates that over 200 million girls and women worldwide have had FGM procedures.

FGM has been classified by the World Health Organisation (WHO) into four types:

Type 1 – Clitoridectomy: part or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);
Type 2 – Excision: removal of part or all of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina);
Type 3 – Infibulation: narrowing the vaginal opening by creating a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and
Type 4 – Other: all other harmful procedures to the female genitals for non-medical reasons, for example pricking, piercing, incising, scraping and cauterising (burning) the genital area.

Under the Female Genital Mutilation Act 2003, FGM is a criminal offence and a form of violence against women and girls. This chapter, however, only references women. For information about FGM in relation to girls, please see the Safeguarding Children Procedures.

2. Consequences of Female Genital Mutilation

There are no health benefits to FGM. Removing and damaging healthy female genital tissue interferes with the natural functions of women’s bodies.

2.1 Immediate effects

severe pain;
shock;
bleeding / haemorrhage;
wound infections;
difficulty urinating;
injury to adjacent tissue;
genital swelling;
in some cases, death.

2.2 Long term consequences

genital scarring;
genital cysts and keloid (a thick) scar formation;
re-occurring urinary tract infections and difficulties in passing urine;
possible increased risk of blood infections such as hepatitis B and HIV;
pain during sex, lack of pleasurable sensation and impaired sexual function;
psychological concerns such as anxiety, flashbacks and post traumatic stress disorder;
difficulties with menstruation (periods);
complications in pregnancy or childbirth (including long labour, bleeding or tears during childbirth, increased risk of having a caesarean section); and
increased risk of stillbirth and death of child during or just after birth.

Personal accounts from survivors show that FGM is an extremely traumatic experience for girls and women, the effects of which remain with them throughout their life. Young women may feel betrayed by their parents, when they are involved in the decision to have the procedure, as well as feeling regret and anger.

3. Law in England, Wales and Northern Ireland

In England (as well as Wales and Northern Ireland), under the Female Genital Mutilation Act 2003 (‘the 2003 Act’) it:

is illegal to carry out FGM in the UK;
is illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM, whether or not it is lawful in that country;
is illegal to aid, assist, guide or arrange the carrying out of FGM abroad;
has a penalty of up to 14 years in prison and / or, a fine.

3.1 Female Genital Mutilation Protection Orders (FGMPO)

A FGMPO is a civil order which can be made to protect a woman against FGM offences or protect a woman against whom a FGM offence has taken place. Breaching an order carries a penalty of up to five years in prison.

The terms of the order can be flexible, and the court can include whatever terms it thinks are necessary and appropriate to protect the woman, including to protect her from being taken abroad or to order giving up her passport so she cannot leave the country. See also: Making an Application for an FGM Protection Order (FGMPO) – Flowchart.

4. Risk Factors

The most significant factor to consider when assessing if a woman may be at risk of FGM is whether her family has a history of practising FGM. In addition, it is important to consider whether FGM is known to be practised in her community or country of origin.

As FGM is illegal and therefore not discussed openly, women who have undergone FGM may not fully understand what FGM is, what the consequences are, or that they themselves have had FGM. Discussions about FGM should therefore always be undertaken with care and sensitivity.

There are a number of other factors which could indicate a woman is at risk of being subjected to FGM.

a woman / family believe FGM is essential in their culture or religion;
the family mainly associates with other people from their own culture and has not mixed much with the wider UK community;
parents have limited access to information about FGM and do not know about the harmful effects of FGM or UK law;
a family is not engaging with professionals (health, education or other professionals).

Signs that FGM may have taken place include:

a woman asks for help or confides in a professional that FGM has taken place;
a woman has difficulty walking, sitting or standing or looks uncomfortable;
a woman spends longer than normal in the bathroom or toilet due to difficulties passing urine;
a woman has frequent urine, period or stomach problems;
a woman does not want to have any medical examinations.

If you have concerns, do not be afraid to ask a girl or woman about FGM, using appropriate and sensitive language. Women sometimes say that professionals have avoided asking questions about FGM, and this can then lead to a breakdown in trust. If a professional does not give a woman the opportunity to talk about FGM , it can be very difficult for the woman to bring this up herself.

5. Action in Suspected Cases

FGM is illegal in England and Wales, and professionals should act if they have concerns in relation to women who may be at risk of FGM or have been affected by it. The type of safeguarding intervention needed will depend on how immediate the risk of harm is thought to be. The most appropriate course of action should be decided on a case-by-case basis, with input from all relevant agencies. The wishes of the woman should always be respected.

Action should include:

making sure the woman receives the care and support she needs, for example by offering referral to community groups for support, clinical intervention or other services as appropriate, such as a referral to an NHS FGM clinic;
making enquiries about other female family members who may need to be safeguarded from harm. This includes considering the needs of any unborn child if the woman is pregnant (see Section 6, Safeguarding Other Family Members); and / or
considering criminal investigations into the perpetrators, including those who carry out the procedure, to prosecute those who have broken the law and to protect others from harm.

5.1 When an adult has had FGM

Adult women who have had FGM should not be automatically referred to adult social care or the police. All cases must individually assessed.

Professionals should be aware that any disclosure may be the first time that a woman has ever discussed her FGM with anyone, so conversations should always be handed sensitively and the woman’s wishes respected. She should be given the time to speak, receive a non judgemental response and be offered details of local and national support groups.

5.2 Adult with care and support needs who has had or is at risk of FGM

When a woman with care and support needs is identified as having had or being at risk of FGM, adult safeguarding procedures should be followed (see the guidance in Stage 1: Concerns). Where there is an immediate or serious risk, an urgent response may be needed, either an urgent referral to adult social care or contacting the police; a FGM Protection Order and / or an Emergency Protection Order may be necessary.

6. Safeguarding Other Family Members

Whenever a woman is identified as having had, or being at risk of, FGM professionals must consider whether she is at risk of further harm, and whether there are other girls or women in her family or wider social network who may be at risk of FGM. Safeguarding children procedures should be followed where there are concerns in relation to children under 18 years.

7. NHS FGM Data Collection

NHS England collects the following data from NHS acute trusts, mental health trusts and GP practices:

If a patient has had Female Genital Mutilation;
If there is a family history of Female Genital Mutilation;
If a Female Genital Mutilation-related procedure has been carried out on a patient.

For more information please see NHS England – FGM Female genital mutilation (FGM) – NHS (www.nhs.uk).

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2.7 Domestic Abuse

RELEVANT CHAPTERS

Safeguarding Enquiries Process

Multi-Agency Risk Assessment Conference (MARAC)

SUPPORTING INFORMATION

Domestic Abuse Statutory Guidance (Home Office)

Controlling or Coercive Behaviour Statutory Guidance Framework (Home Office)

Adult Safeguarding and Domestic Abuse (LGA and ADASS)

Supporting Male Victims of Crimes Considered Violence Against Women and Girls (Home Office)

Domestic Abuse: How to Get Help (Home Office)

SafeLives – Resources for professionals working with victims of domestic abuse and their families

SUPPORT IN SOUTH TYNESIDE

Domestic Abuse Services Directory (South Tyneside Council website)

Perpetrator Intervention Programme

June 2025: A new Section 3.2.6 Dementia has been added, to highlight issues to consider when domestic abuse and dementia are both present in a relationship. A link to a practitioner toolkit and safety planning tool developed by Aberystwyth University have also been added. Section 5.1 Multi Agency Risk Assessment Conference has also been updated.

1. Introduction and Definition

Domestic abuse is a very common crime which remains largely hidden, despite perpetrators being able to inflict significant physical and psychological damage on their victims. Data from the Crime Survey for England and Wales estimates that 2.1 million people aged over 16 experienced domestic abuse during the year ending March 2023. The police recorded over 800,000 domestic abuse offences over the same period. On average victims’ experience 50 incidents, over a two and a half year period, before seeking support (see SafeLives), meaning it is essential that all agencies can identify and respond to concerns around domestic abuse.

1.1 Domestic abuse

The Domestic Abuse Act 2021 provides a statutory (legal) definition of domestic abuse. The definition includes children who have seen, heard, or experienced the effects of domestic abuse, and are related to either the victim of the abusive behaviour, or the perpetrator.

Domestic abuse is, the behaviour of a perpetrator towards a victim where:

both people are aged 16 or over and are personally connected to each other (see Section 1.2); and
the behaviour is abusive.

Behaviour is defined as abusive if it consists of any of the following:

physical or sexual abuse;
violent or threatening behaviour;
controlling or coercive behaviour;
economic abuse;
psychological, emotional or other abuse.

It does not matter whether the behaviour is a single incident or consists of a number of incidents over a period of time.

Under the Act, a perpetrator’s behaviour may still be seen as behaviour towards the victim even it is directed at another person (for example children in the house).

1.2 Personally connected

Under the Domestic Abuse Act, two people are personally connected if any of the following apply:

they are married to each other;
they are civil partners of each other;
they have agreed to marry one another or enter into a civil partnership (whether or not they are still planning to);
they are or have been in an intimate personal relationship with each other;
they each have, or there has been a time when they each had, a parental relationship in relation to the same child;
they are relatives.

Domestic abuse can be perpetrated by family members and includes so called honour based abuse (see So Called Honour Based Abuse), female genital mutilation (see Female Genital Mutilation) and forced marriage (see Forced Marriage). Abuse within the family also includes child to parent abuse or adolescent to parent violence / abuse (APV/A). If the child is over 16 years of age, this behaviour falls within the statutory definition of domestic abuse.

2. Types of Domestic Abuse

Domestic abuse can cover a wide range of behaviours. To be able to respond to victims, practitioners need to be able to identify different types of domestic abuse.

Domestic abuse does not have to involve physical acts of violence; it includes threatening behaviour, controlling or coercive behaviour, emotional, psychological, sexual and / or economic abuse. It can also take place online. The perpetrator’s desire to exercise power and control over the victim is at the centre of most abusive behaviours.

Domestic abuse most commonly takes place in intimate partner relationships, including same sex relationships.

Abuse can continue or get worse when a relationship ends or is in the process of ending. This can be a very dangerous time for a victim, and there may be an increased risk to their physical safety.

2.1 Physical abuse

Includes being or threatened to be:

being, or threatened to be, kicked, punched, pushed, dragged, shoved, slapped, scratched, strangled, spat on and bitten;
use, or threats of use, of weapons including knives and irons;
being, or threatened to be, burned, scalded, poisoned, or drowned;
throwing of objects;
violence, or threats of physical abuse or violence, against family members;
damaging or denying access to medical aids or equipment – for example a Deaf person may be prevented from communicating in sign language or may have their hearing aids removed; and
harming someone as part of ‘caring’ duties. This is especially relevant for adults who depend on others, such as disabled and older people and can involve force feeding, over-medication, withdrawal of medicine or denying access to medical care.

2.2 Sexual abuse

Includes:

rape and sexual assaults;
being pressured into sex, or sexual acts, including with other people;
being forced to take part in sexual acts because of threats to others, including children;
‘corrective’ rape (the practice of raping someone with the aim of ‘curing’ them of being lesbian, gay, bisexual or transgender – LGBT);
intentional exposure to sexually transmitted infections;
being pressurised or being tricked into having unsafe sex, including deception over the use of contraception;
being forced to make or watch pornography; and
hurting a victim during sex including non-fatal strangulation.

2.3 Controlling or coercive behaviour

An offence of controlling or coercive behaviour is committed when the victim and perpetrator are personally connected at the time the behaviour takes place, and:

the behaviour has a serious effect on the victim, meaning that it has caused the victim to fear violence will be used against them on two or more occasions, or it has had a substantial adverse effect on their usual day to day activities; and
the behaviour takes place repeatedly or continuously.

Examples of controlling or coercive behaviour include:

controlling or monitoring the victim’s daily activities and behaviour, including making them account for their time, controlling what they can wear, what and when they can eat, when and where they may sleep;
controlling a victim’s access to money / monitoring their bank accounts;
isolating the victim from family, friends and professionals and intercepting messages or phone calls;
refusing to interpret and/or hindering access to communication;
preventing the victim from taking medication, or accessing medical equipment and assistive aids, over-medicating them, or preventing the victim from accessing health or social care (especially relevant for disabled victims or those with long-term health conditions);
using substances to control a victim through dependency, or controlling their access to substances;
using children to control the victim, e.g. threatening to take the children away;
using animals to control or coerce a victim, e.g. harming or threatening to harm, or give away, pets or assistance dogs;
threats to expose sensitive information (e.g. sexual activity or sexual orientation) or make false allegations to family members, religious or local community including via photos or the internet;
intimidation and threats of disclosure of sexual orientation and/or gender identity to family, friends, work colleagues, community and others;
intimidation and threats of disclosure of health status or an impairment to family, friends, work colleagues and wider community – particularly where this may carry a stigma in the community;
threats of institutionalisation (particularly for disabled or elderly victims).

For more information on developing knowledge and skills in working with situations of coercive control see, Coercive Control (Research in Practice for Adults).

2.4 Harassment and stalking

Harassment or stalking fall within the definition of domestic abuse if the perpetrator and victim are 16 or over and ‘personally connected’ (see Section 1.2 Personally connected).

There is no legal definition of harassment, but it includes repeated, unwanted communications and contact with a victim, in a way that could be expected to cause distress or fear.

There is no legal definition of stalking either, but it includes:

following a person;
contacting, or attempting to contact, a person by any means;
monitoring a person’s use of the internet, email or any other form of electronic communication;
loitering in any place (whether public or private);
interfering with the person’s belongings or property; and
watching or spying on a person.

2.5 Economic abuse

Economic abuse is behaviour that has a significant negative effect on a person’s ability to obtain, use or keep money or other property, or to obtain goods or services. This can include the ability to buy food or clothes or pay for transport fares or utilities like gas and electricity.

Examples include:

controlling the family income;
running up bills and debts in a victim’s name, including without them knowing;
refusing to contribute to household income or costs;
preventing a victim from claiming welfare benefits, or forcing someone to commit benefit fraud or taking a person’s benefits;
not allowing a victim access to mobile phone / car / utilities;
coercing the victim into signing over property or assets.

2.6 Emotional or psychological abuse

Domestic abuse often involves emotional or psychological abuse, it includes:

manipulating a person’s anxieties or beliefs or abusing a position of trust;
hostile behaviours or silent treatment as part of a pattern of behaviour to make the victim feel fearful;
being insulted, and or belittled;
keeping a victim awake/preventing them from sleeping;
using violence or threats towards assistance dogs and pets to intimidate the victim and cause distress, including threatening to harm the animal as well as controlling how the owner is able to care for the animal;
threatening to harm third parties (for example family, friends or colleagues);
persuading a victim to doubt their own mind (including ‘gaslighting’).

2.7 Verbal abuse

Verbal abuse may amount to emotional or psychological abuse, threatening behaviour, or controlling or coercive behaviour. Examples include:

repeated yelling and shouting;
abusive, insulting, threatening or degrading language;
being laughed at and being made fun of; and
discriminating against someone or mocking them about their disability, sex or gender identity, gender reassignment, religion or faith belief, sexual orientation, age or physical appearance.

2.8 Abuse using technology

Perpetrators can use technology, including social media to abuse victims. This can happen both during and after a relationship. Examples of technology-facilitated abuse include:

placing false information about a victim on their or others’ social media;
setting up false social media accounts in the name of the victim;
‘trolling’ with abusive or offensive messages through social media platforms or online forums;
image-based abuse – for example, the creating and sharing (or threatening to share) false/digitally altered image or private sexual photographs and films with the intent to cause distress (‘revenge porn’);
hacking into, monitoring or controlling email accounts, social media profiles and phone calls;
blocking the victim from using their online accounts, responding in the victim’s place or creating false online accounts;
using spyware or GPS locators on, for example, phones, computers, smart watches, cars, motorbikes and pets;
using personal devices such as smart watches or smart home devices (such as Amazon Alexa, Google Home Hubs, etc) to monitor, control or frighten; and
using hidden cameras.

2.9 Abuse relating to faith

Although a person’s faith can be a source of support and comfort, perpetrators of domestic abuse can use, manipulate or exploit someone’s religious beliefs. It can include:

using the influence of religion to manipulate and exploit a victim;
insist on secrecy and silence;
rape within marriage and the use of religion to justify this;
coercion to conform through the use of sacred or religious texts / teaching;
causing harm, isolation and / or neglect to get rid of an ‘evil force’ or ‘spirit’ that is believed to have possessed the victim; and
requiring obedience to the perpetrator, owing to religion or faith..

3. Victims and Perpetrators of Domestic Abuse

Anyone can be affected by domestic abuse, regardless of their age, sex, sexual orientation, gender identity, gender reassignment, race, religion or any disability.

There is no justification for domestic abuse. The perpetrator and others may blame the victim for causing their behaviour, but it is never their fault. Some perpetrators do not recognise that their behaviour is domestic abuse, but all perpetrators are responsible for their behaviour and should be held accountable for it.

3.1 Impact of domestic abuse

The impact of domestic abuse can be devastating. It can cause:

repeated short-, long-term / chronic physical and mental health problems;
miscarriage, stillbirth and other complications of pregnancy;
long-term social difficulties;
poor mental health such as anxiety, depression and post-traumatic stress disorder;
isolation from family, friends and community;
negative effect on work and possible loss of independent income.

For some, mainly women and their children, domestic abuse can result in serious injury or death.

3.2 Adults with care and support needs

Adults who are reliant on intimate partners or family members for their care and support needs can be particularly vulnerable to domestic abuse, as the perpetrator may use their caring responsibilities and power over the adult as a cover for abuse. They may therefore experience additional impacts from domestic abuse, including:

be reluctant to use essential routine medical services or to attend services outside the home where personal care is provided;
increased powerlessness, dependency and isolation;
feeling that their care and support needs are to blame and being made to feel shame about their needs.

If an adult has care and support needs and is not able to safeguard themselves, any concerns practitioners have about domestic abuse should be shared with the local authority safeguarding adults team (see Stage 1: Concerns).

3.2.1 Older people

Older people can be victims of intimate partner abuse, or abuse by family members including adult children. This can include controlling or coercive behaviour, economic, emotional, psychological, sexual or physical abuse or neglect and can affect both men and women.

It is important to avoid making assumptions about a victim’s condition or health based on their age. For instance, injuries or mental health issues may be viewed as the result of a victim’s health and social care needs, without enquiries being made about domestic abuse.

Older victims can face significant barriers when asking for help or when trying to leave a relationship with a perpetrator, including:

having experienced years of prolonged abuse;
being isolated within a particular community through language or culture;
having experienced long term health impacts or disabilities;
being reliant on the perpetrator for their care or money.

Dewis Choice provides practitioner guidance on supporting older victims and responding to domestic abuse in later life.

3.2.2 Adults with disabilities

Disabled victims (which includes people with physical or sensory impairments, mental health issues, learning disabilities, neuro-diverse and / or cognitive impairments and long-term health conditions) can face additional forms of abuse where their particular vulnerabilities are exploited as part of the abuse.

In 2021, the Crime Survey for England and Wales found that people with a disability were more twice as likely to have been victims of domestic abuse

Disabled victims may be at increased risk in relation to particular examples of abusive behaviour, either from an intimate partner, family member, or carer (who is personally connected to them), or face specific risks relating to their disability and related circumstances including: control of their medication; refusal to interpret for them if they have additional communication needs (see Interpreting, Signing and Communication Needs chapter); denial of access to health services or equipment; actions which makes the adult’s health condition worse and using their disability in other ways to control them.

Adults with vision impairments may be at greater risk of harm than a sighted person. They may be more at risk of physical abuse in terms of awareness of the threat of harm and the extent of harm caused. Furthermore, if information and services are not accessible, they may need to rely on others, such as a partner or family member, to read information for them. Disabled victims, particularly disabled young people, may experience coercive or controlling behaviours including treating them like children and denying their independence.

Disabled victims can also face multiple barriers to seeking and receiving help to escape domestic abuse, for example, accommodation and transport which is accessible if they are not very mobile or use a wheelchair and the need for assistance with personal care. These factors can impact an adult’s decision and ability to leave a relationship or to seek help. Disabled victims can be more isolated and / or have smaller support networks and may be more vulnerable to domestic abuse as a result. Disabled victims may be unable to leave or access a refuge because of poor access to safe accommodation, or because they rely on a perpetrator for care or support.

Disabled victims may have had negative experiences with services in the past which can create a feeling of distrust or impact their perception of the help that can be provided. Practitioners should speak to the victim on their own, without a carer or other family member. The relationship between carers and the adult being cared for is not covered by the definition of domestic abuse in the 2021 Act unless there is also a personal connection between them.

Deaf people may encounter specific barriers to accessing support as they might not be aware of the available support and / or professionals may not know to use appropriate communication methods. Professionals and service providers should be aware that deaf victims need specialist support services who can understand their cultural and linguistic needs. Where possible, professionals working with deaf victims should have some personal experience of deafness, as having to relive their trauma time and again with new people (for example sign language interpreters) may result in them not engaging with support that they very much need. This may also be relevant for those with a learning disability who may use an advocate or carer to support their process of talking about their experience (see Independent Advocacy chapter).

People with speech, language, and communication needs may be actively targeted by perpetrators or experience abuse for longer periods of time because of difficulties they face in explaining what has happened to them, asking for help, and accessing the support available.

3.2.3 Immigration status and migrant victims

Victims who have entered the UK from overseas may face barriers when attempting to escape domestic abuse because of their immigration status.

They may be dependent on their partner or family if they have supported them coming to the UK. They may also face greater economic impact of leaving a perpetrator if they are unable to claim benefits or access housing, or if they lose their immigration status by leaving their partner, including destitution and homelessness. See No Recourse to Public Funds and Homelessness chapters.

3.2.4 Drug and alcohol misuse

Some victims may use alcohol and drugs as a way of coping with abuse. Alcohol can also be a significant factor, with perpetrators using alcohol to control victims or being particularly abusive when under the influence of drugs and / or alcohol. Levels of of alcohol-related domestic violence are five times higher among the most disadvantaged groups compared to the least disadvantaged. Drug and alcohol use, homelessness, criminal justice system involvement and mental health are often present in the same relationships, which mean that victims face many challenges when seeking support.

3.2.5 Mental health

Mental health problems are not a cause of domestic abuse, but they can be a risk factor for perpetrators and victims. Domestic abuse can have a long-lasting effect on victims and lead to the development of long-lasting mental health problems.

Mental health support services and providers should be aware of the signs of possible domestic abuse, so they can ask adults about their experiences in private and know how to respond.

3.2.6 Dementia

Dementia and domestic abuse may co-exist (both be present in a relationship) where:

a person with dementia is the perpetrator of domestic abuse;
a person with dementia is the victim-survivor of domestic abuse;
both the perpetrator and the victim-survivor of domestic abuse have dementia.

This can include both situations where there has been domestic abuse in the relationship before one of the adults was diagnosed with dementia, and situations where there had been no history of domestic abuse within the relationship prior to the dementia diagnosis. Dementia can change the nature of previously positive relationships. Where a relationship has been positive in the past, displays of aggression by the person with dementia may be due to changes in their brain, pain, confusion, or fear.

Where domestic abuse and dementia co-exist, practitioners may miss signs of dementia or mistake them for signs of ageing, increasing the risk of harm to the older victim-survivor.

Domestic Abuse and the Co-existence of Dementia (Centre for Age, Gender and Social Justice, Aberystwyth University) contains a toolkit which has been developed using findings from research. The toolkit aims to address gaps in practitioners’ knowledge on the co-existence of domestic abuse and dementia and offers practical information and advice to help practitioners engage with victim-survivors who are living with dementia. A safety planning tool is also available in the publication.

3.3 Barriers to seeking help

When working with victims of domestic abuse, it is important to understand the reasons why people stay in abusive relationships, and why they may not seek or respond to offers of help.

Some barriers are because of the emotional and psychological impacts of domestic abuse. Others may be practical or social / cultural. Often they are similar to the barriers that prevent people from seeking help over other safeguarding issues.

They may include:

fear of the abuser and / or what they will do (these may be realistic fears based on past experience and threats that have been made);
lack of experience or knowledge of other victims who have dealt with abuse successfully;
lack of experience of positive action from statutory agencies, including the courts;
lack of knowledge / access to support services;
lack of resources, financial or otherwise;
previous experiences and / or a fear of being judged or not being believed;

love, loyalty or emotional attachment towards the abuser and the hope that their partner / family member / abuser will change;
feelings of shame or failure, blaming themselves for their abuse;
pressure from family / children / community / friends;
religious or cultural expectations;
the long-term effects of abuse such as prolonged trauma, disability resulting from abuse, self-neglect, mental health problems;
low self-esteem / self-worth.

4. Responding to Concerns about Domestic Abuse

Fewer than one in five victims report their abuse to the police, meaning that many do not come into contact with the criminal justice system. It is important therefore that staff in a wide range of organisations can identify victims and know how to respond; this includes being able to:

support victims to get protection from abuse by providing relevant practical and other assistance;
identify those who are responsible for perpetrating such abuse, so that there can be an appropriate criminal justice response;
provide victims with full information about their legal rights, and about the extent and limits of statutory duties and powers;
support non-abusing parents in making safe choices for themselves and their children, where appropriate.

Professionals in contact with adults who are threatening or abusive towards them, should consider the possibility that the individual could also be abusive in their personal relationships.

4.1 Asking questions and assessing risk

4.1.1 Asking questions safely

Whenever there are concerns about possible domestic abuse, practitioners should try to see the adult on their own so they can ask them whether they are experiencing, or have previously experienced, domestic abuse. This can include asking direct questions about domestic abuse. It will take time to build trust and confidence, and adults may not feel able to share all aspects of their situation initially. It can take time for adults to develop trust, disclose abuse, and seek help.

4.1.2 Assessing risks

An assessment of risk should take place in all situations where an adult with care and support needs is experiencing domestic abuse. This assessment should be personalised to reflect the needs of adult, use the principles of making safeguarding personal and involve the support of an independent advocate if required (see Assessing and Managing Risk, Making Safeguarding Personal and Independent Advocacy chapters).

When assessing domestic abuse and the needs of with a victim of domestic abuse, the following should be considered:

age and vulnerability of the adult;
the adult’s description of the abuse and its impact on them;
frequency and severity of the abuse;
whether there were any children or other adults who either witnessed the abuse or were in the property at the time;
if any weapons used or threatened to be used;
if other agencies may have information which needs to be considered.

Tools including the Domestic Abuse, Stalking and Harassment (DASH) checklist can be used as an aid to professional judgement.

4.2 Responding to concerns

Take immediate safety measures If there is an imminent risk of harm: If, on the basis of information received or concerns witnessed, a practitioner believes an adult or child is at imminent risk of harm, they should contact the police immediately by telephoning 999.

If there are safeguarding children concerns: Section 3 of the Domestic Abuse Act 2021 recognises children as victims of domestic abuse if they see, hear, or experience the effects of the abuse, and are related to, or falls under ‘parental responsibility’ of, the victim and / or perpetrator of the domestic abuse. A child is therefore considered a victim of domestic abuse if one parent is abusing another parent, or where a parent is abusing, or being abused by, a partner or relative.

Adult practitioners who become aware of children living in households affected by domestic abuse (or a young person over 16 who is a victim of domestic abuse) should always act by sharing this information with Children’s Social Care (see Safeguarding Children Partnership procedures).

If there are safeguarding adults’ concerns: Under the Care Act 2014, the local authority has a safeguarding duty to an adult who appears to have needs for care and support (whether or not the local authority is meeting those needs), is experiencing or is at risk of abuse or neglect, and, as a result of those care and support needs, is unable to protect themselves from the risk of, or experiencing, abuse or neglect. This includes domestic abuse, if the adult appears to have needs for care and support.

When a safeguarding adults’ referral is received, it will be reviewed by the local authority to see if it meets the criteria for a safeguarding enquiry under Section 42 of the Care Act.

Making safeguarding personal means that safeguarding adults’ responses should always be person-led and outcome-focused. The adult should be asked about how they would like agencies to respond to their safeguarding situation in a way supports their involvement, choice and control as well as improving quality of life, wellbeing and safety. It is important to listen the adult, respect their views and place them at the centre of decision-making.

4.3 Mental capacity

See Mental Capacity chapter

Assessing mental capacity can be challenging in domestic abuse situations, if the adult is cared for by, or lives with, a family member or intimate partner and is seen to be making decisions which put or keep themselves in danger. Skilled assessment and intervention are required to judge whether such decisions should be described as ‘unwise decisions’ which the person has the mental capacity to make, or decisions that are not being made freely, because they are being coerced and / or controlled. For example, an adult may make a decision to continue to live with an abusive partner which is a free and informed decision, when they know all the risks and the alternative courses of action, including support which is available to them.

When a person who appears to have mental capacity chooses to stay in a high-risk abusive relationship, careful consideration must be given to whether they are making that choice freely, and are not being influenced by the perpetrator. It may be that the relationship is more important to them than the harm that is being done, perhaps more so if the harm is not life threatening (for example, the financial abuse they are experiencing is not to the extent that they cannot keep themselves warm and fed).

Whatever action is agreed, practitioners should continue to support and safeguard the adult and keep their needs and risks under review, remembering that situations can change and escalate quickly. Where an adult who has mental capacity chooses to stay or return to their home, a safety plan should be developed with them to help them stay as safe as possible.

All discussion and actions agreed should be recorded (see Case Recording chapter).

5. Multi Agency Response

Agencies should work together and share information to ensure they are able to draw on all the available information held within each agency to build a full picture of the victims, including children, and perpetrators.

All agencies have a duty to assess whether a safeguarding response is required before referring an incident to a multi-agency partnership.

5.1 Multi-Agency Risk Assessment Conference

A Multi-Agency Risk Assessment Conference (MARAC) brings together statutory and voluntary agencies to jointly support adult and child victims of domestic abuse who are at a high risk of serious harm or homicide, and to disrupt and divert the behaviour of the perpetrator/s. These are the police, Independent Domestic Violence and Abuse (IDVA) services, housing, children’s services, the Probation Service, primary health, mental health, substance misuse service and adult social care.

At the beginning of the process, local agencies will refer victims to the local MARAC. Before the meeting, all participating agencies will gather relevant, proportionate, and necessary information regarding the victims, including children, and the perpetrator/s. The local agency representatives attend the MARAC meeting to discuss the shared information and expertise and suggest actions.

The IDVA is a specialist practitioner who works in partnership with other agencies to implement the action plan. They also represent the victim at the MARAC, making sure their voice is heard. Victims and perpetrator/s do not attend the meeting. The victim is informed that the case is being taken through the MARAC process, unless it is deemed unsafe to do so. If the victim objects to the disclosure of personal information, this should be considered in proportion to the risks present. If it is believed that withholding information puts a child at risk of significant harm, or another adult is at risk of serious harm, then disclosure may be justified in the public interest and / or in order to protect the vital interests of the third party. If the victim is at significant risk of harm, then this would be in the public interest.

In South Tyneside, the MARAC Panel meets weekly, and is chaired by a Northumbria Police MARAC co-ordinator. To make a referral into the MARAC, a Risk Indicator Checklist (RIC) needs to be completed and will be Triaged by the MASH Police team.

A revised MARAC protocol has been developed by the MARAC steering group which outlines the process, policy and referral forms. A MARAC steering group led by Public Health along with multi agency representatives aims to monitor the panel meeting performance, any items for escalation, improvement and auditing of cases to ensure the process and policies are being implemented accordingly. The MARAC data is captured within the DA data Dashboard that is shared at the Domestic Abuse Partnership Board.

5.2 Specialist support services

Restart, the local specialist domestic abuse service, should be contacted for support as they are experts in risk assessment and management. They can also provide practical services, emotional support, and statutory advocacy. Support and safety planning can also include health and social care services.

If a practitioner refers into MARAC they should also refer into Restart by emailing: [email protected]

6. Domestic Violence Disclosure Scheme

The Domestic Violence Disclosure Scheme (also known as Clare’s Law) contains two elements: the Right to Ask and the Right to Know.

Under the Right to Ask, a person or relevant third party (for example, a family member) can ask the police to check whether a current or ex-partner has a violent or abusive past. If records show that an individual may be at risk of domestic abuse from a partner or ex-partner, the police will consider disclosing the information.

The Right to Know enables the police to make a disclosure on their own initiative if they receive information about the violent or abusive behaviour of a person that may impact on the safety of that person’s current or ex-partner. This could be information arising from a criminal investigation, through statutory or third sector agency involvement, or from another source of police intelligence.

7. Professional Safety

Any potential risks to professionals, carers or other staff should be assessed. In such cases a risk assessment should be undertaken. Staff should speak to their manager and follow their own agency’s guidance for staff safety. Such issues should also be discussed during supervision (see Supervision chapter).

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2.6 Cuckooing

This chapter discusses ‘cuckooing‘, which is the term used when professional criminal gangs target the homes of adults who they have identified as vulnerable. It provides information about victims, perpetrators, signs and what action to take if cuckooing is suspected.

RELEVANT CHAPTER

County Lines: Criminal Exploitation of Adults

RELEVANT INFORMATION

County Lines and Cuckooing (Crimestoppers)

April 2024: This section has been updated throughout to reflect the latest Home Office County Lines guidance.

1. Introduction

‘Cuckooing‘ also known as forced home invasion, is when criminals (usually drug dealers) takeover the home of a vulnerable person, for example care leavers or people with addiction, physical disabilities or mental health issues. They then use the property as a base for their criminal activity, including dealing and storing drugs, storing weapons and / or money or as a base for sex work. Cuckooing is a form of criminal exploitation and is a common feature in county lines exploitation (see County Lines: Criminal Exploitation of Adults chapter).

2. Who is at Risk?

Adults at risk of cuckooing include:

people with drug or alcohol problems;
young people who are care leavers;
people already known to the police;
older people who live alone with no support network;
people who have mental or physical health problems;
people with learning disabilities;
female sex workers;
single mums; and
people living in poverty.

Victims are often people with care and support needs, even if they are not already receiving support from services.

Where the victim is known to use drugs, criminals often offer them free drugs in return for being able to use their home for dealing.

Once the criminals have gained control of the adult and their home, the victim is at significant risk of physical and psychological abuse, sexual exploitation and violence. Victims are often used as drug runners, forced to move drugs from one place to another on behalf of the criminals. They are threatened with violence if they do not agree (see also County Lines: Criminal Exploitation of Adults chapter).

Victims are unlikely to the police or tell other professionals what is happening, as they may be frightened that they will be suspected of being involved in drug dealing themselves or that they will face repercussions or punishment from the gang.

They may also be afraid that they could be evicted from their home. Some victims feel they are forced out of their homes, or are actually made to leave their home by the gang, which makes them homeless.

3. Signs of Cuckooing

3.1 Signs an adult is being exploited or abused

Signs that an adult is being exploited or abused include:

they get more telephone calls or people calling to their property than they usually do;
they have physical injuries that they cannot, or do not, explain;
they seem quiet and withdrawn;
they are known or suspected to be carrying or selling drugs;
they are going missing from home or college, work or work placements;

they have new clothes and / or possessions, more than one mobile phone or money than they can usually afford;
they start to miss appointments with services and do not respond to messages.

3.2 Signs of cuckooing in a local neighbourhood

All types of properties can be cuckooed including rental and private properties, student accommodation and commercial premises. Signs that a property has been cuckooed include:

unfamiliar people are entering and leaving the property, often throughout the day and night. In supported or shared accomodation, staff might notice an increase in key fob activity;
an increase in the number of people walking to the property or loitering in the area around it;
young people visiting the property;
an increase in the number of cars (including vehicles which have not visited before), bikes, or taxis or hire cars outside the property;
electric scooters and scooter helmets around the property;
an increase in anti-social behaviour and signs of drug use in and around the property, including litter and discarded needles or crack pipes for example;

an increase in noise and disturbance levels, including late night parties or arguments;

damage to the property such a broken windows or doors;
curtains and blinds which are always closed;
threats or intimidation towards other residents or neighbours.

Information about possible cuckooing cases can come from a range of different sources such as neighbours, partner agencies and the wider public. Professional curiosity is therefore important as information from different sources may need to be pieced together.

4. Taking Action

Where an individual is at risk of, or experiencing exploitation, it is a legal requirement that practitioners share that information with the relevant agencies. This may include sharing information without the adult’s consent where they may be being coerced or under duress, to prevent a crime being committed.

If a person is at immediate risk of harm, the police should be contacted by calling 999.

If the person is not at immediate risk of harm, staff should talk to the adult and then concerns should be shared with the local authority safeguarding adults team (see Local Contacts) and the police on 101.

This might involve a practitioner contacting the designated lead for safeguarding adults in their own organisation, who will then make a safeguarding adults referral; or, the practitioner can contact adult social care directly.

The local authority and partners agencies will then consider whether action is required to protect the adult victim. This may include a discussion about whether the person has care and support needs, if they have mental capacity (see Mental Capacity chapter) and if they do, whether the inherent jurisdiction applies in their case. This is when a person with mental capacity is coerced or unduly influenced by another person, in a way which restricts their ability to freely make their own decisions.

The adult should be at the centre of discussions and any decisions that are taken during the safeguarding or inherent jurisdiction process. See Making Safeguarding Personal chapter.

All concerns should be recorded in the adult’s records as along with details of all actions that have been taken and decisions that have been made (see Case Recording chapter).

4.1 Modern slavery and the National Referral Mechanism

If the adult has also been forced by a criminal gang to move drugs from one place to another, this is criminal exploitation and a form of modern slavery. The National Referral Mechanism (NRM) provides a framework for identifying and referring potential modern slavery victims and ensuring they receive appropriate support.

First responder organisations, which include the local authority and the police (see Modern Slavery chapter, appendix 1) should refer adult victims of modern slavery to the NRM if they give their consent to this. Even if the adult does not consent to the NRM referral, there is still a ‘duty to notify’ the Home Office that a potential victim of modern slavery has been identified. Full details can be found in the Modern Slavery chapter. Any referral to the NRM or notification to the Home Office should come after the appropriate safeguarding steps have been taken and multi-agency discussions have been held.

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2.4 Child to Parent Violence and Abuse

LOCAL INFORMATION

Child to Parent Violence (leaflet for family members)

1. Introduction

Adolescent to Parent Violence (APVA) is a hidden form of domestic abuse that still has no legal definition, however it is referenced within current government domestic abuse literature.

1.1 Definition

Domestic abuse is defined as:

Abusive behaviour that is: physical or sexual abuse; violent or threatening behaviour; controlling or coercive behaviour; economic abuse; psychological, emotional or other abuse. Applies to people aged 16+, who are personally connected to each other (Domestic Abuse Act 2021).

It is important to consider that APVA is likely to involve a pattern of behaviour.

Child to Parent violence (CPVA) encompasses children of a younger age:

Child to Parent Violence is any harmful act by a child whether physical, psychological or financial which is intended to gain power and control over parent /care giver (Cottrel, B. and Monk, P. 2004).

Behaviour considered to be violent if others in the family feel threatened, intimidated or controlled by child if they believe that they must adjust their own behaviour to accommodate threats or anticipation of violence (Patterson et al 2002).

It should be considered that due to there not being a government definition some organisations will categorise as APVA and some as CPVA. Within South Tyneside we will use CPVA to encompass children of a younger age range within intervention work and care pathways.

Whilst it is not unusual for adolescents and children to demonstrate healthy anger and at times there will be conflict with parents, it should be noted that there is a difference between healthy anger and abuse or behaviour which instils fear in their parents or carers.

Consideration should be given at all times to the level of violence or abuse for example:

is the abuse persistent;
is the abuse planned and deliberate; and
not a reckless act.

This procedure should be read in conjunction with the Care Pathway:

1.3 Following disclosure

Once a disclosure of APVA / CPVA is made the professional should complete the CPVA risk screening tool with the parent / carer, this will indicate the level of risk posed and inform the process that should be followed within the care pathway. In all cases where risks have been identified the emergency safety plan should be implemented with parent/carer. Where CPVA involves a victim who meets the Care Act 2014 safeguarding adult’s definition, adult safeguarding procedures should be followed accordingly (see the chapter on Responding to Signs of Abuse and Neglect).

Consideration should be given to other family members and the potential risks posed.

If you are worried about an adult, a referral to Adult Social Care should be considered (see Stage 1: Concerns).

2. Immediate Safeguarding Concerns

If an individual is at immediate risk of harm then police should be notified via 999, the high risk pathway should then be followed.

2.1 High risk

A referral should be made to children’s services; the parent(s) should be informed that a referral is going to be made and their permission sought to share information with other agencies unless there are concerns that to do so would:

Prejudice any investigations or enquiries;
Be prejudicial to the child’s welfare and/or safety;
Cause concern that the child would be likely to suffer Significant Harm as a result.

(see Report a Concern about a Child, South Tyneside Council)

On receipt of the referral, consideration will be given by children’s services regarding the threshold being met for Strategy meeting (see Strategy Meeting / Discussion, Safeguarding Children Procedures).

If the young person is over 16, a referral to MARAC by CFSC worker should be made.

Consideration should be given re referral to Impact Family Services to offer intervention to the parent.

Social worker and CPVA worker allocated to the family. The social worker should complete the assessment (see Assessment, Safeguarding Children Procedures).

2.2 Standard and medium risk

Consideration should be given to involving Early Help.

The police should be informed via 101 of the disclosure of APVA / CPVA.

If consent is gained from the parent / carer, a referral should be made to the Impact Family services for intervention.

A CPVA worker can be contacted for advice where standard and medium risk has been identified.

Never assume that someone else will take care of the violence / abuse issues. You should seek confirmation that other professionals / agencies have acted in a way which you would expect. You may be the parent / carers / child / young person’s first and only contact.

Remember they can deny abuse is happening and minimise the risk and / or harm. Discuss with your line manager, assess the threshold level and act accordingly.

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10.11 Working with People Living in Poverty

RELEVANT INFORMATION

Joseph Rowntree Charitable Trust

The Trussell Trust

Cost of Living Crisis – Easy Read Guide (Mencap)

SOURCES OF ADVICE AND ASSISTANCE IN SOUTH TYNESIDE

South Tyneside Foodbank

1. Introduction

There are many different factors that contribute to a person living in poverty. Broadly these can be described as a) personal – meaning they are a result of their individual situation, including employment, opportunities, life circumstances etc and b) universal – meaning factors that affect everyone such as the costs of food, fuel, heating and lighting etc.

This chapter outlines the main issues regarding poverty, how it affects people, how it can additionally affect people with care and support needs and contains details of specialist organisations that can provide support.

2. What is Poverty?

The Joseph Rowntree Trust (JRF) is the leading UK charity which aims to end poverty. It defines poverty simply as being when someone’s resources are well below their minimum needs.

The JRF is clear that there is not just one definition of poverty and that it is a complicated issue and that a range of measures are needed to help us understand the different features of poverty. For more information, see What is Poverty?).

There are two main ways of measuring poverty – absolute and relative poverty.

Absolute poverty:

Absolute poverty is when the income of a household is below a certain level, with the result that it is not possible for an adult or family to meet the basic needs of life including food, shelter / accommodation, safe drinking water, education and healthcare for example. Absolute poverty compares households based on a set income level. This level varies from country to country, depending on the particular nation’s overall economic conditions.

Relative poverty:

Relative poverty is when a household receives 50% less than the average income for a household. While they do have some money coming in, it is not enough money to afford anything above the basic needs of life. This type of poverty changes depending on the economic growth of the country.

Relative poverty is also called ‘relative deprivation’, because people in this category are not living in total poverty. They cannot, however, afford the same standard of living as everyone else in the country. It can be for example TV, internet, clean clothes and a safe home (a healthy environment, free from abuse or neglect).

Relative poverty can also be permanent; people can be ‘trapped’ in a low relative income. Since long-term poverty has an impact on economic and social conditions, persistent poverty is an important concept to remember. For more information see Relative vs Absolute Poverty Habitat for Humanity.

3. What are the Causes of Poverty in the UK?

The causes of poverty are issues that either reduce a person’s financial resources and / or increases their needs and the cost of meeting those needs. Life events and moments of change – such as getting ill, suffering bereavement, losing a job or a relationship breaking down – are common triggers for poverty.

JRF states that some of the causes of poverty in the UK today are:

unemployment and low-paid jobs which have little prospect of getting better paid and are insecure (or a lack of jobs): many areas in the country have a lot of these jobs or do not have enough well-paid jobs. Low pay and unemployment can also lead to not being able to save or have a pension;
low levels of skills or education: young people and adults who do not have the right skills or qualifications can find it difficult to get a job, especially one with security, prospects and decent pay;
the benefit system: the level of welfare benefits for some people – who are either already in work (which is low paid), looking for work or unable to work because of health or care issues – is not enough to avoid poverty, when combined with other resources and high costs. The benefit system is often confusing and hard to engage with, leading to errors and delays. The system can also make it difficult for a person to move into work or increase their working hours. For more information see Benefits A-Z, Community Care Inform;
high costs: the high cost of housing and essential goods and services (for example gas, electricity, water, Council Tax, telephone or broadband) creates poverty. Some people face particularly high costs because of where they live, because they have increased needs (for example, personal care for disabled people) or because they are paying a ‘poverty premium’ – where people in poverty pay more for the same goods and services;
discrimination: people can be discriminated against because of their class, gender, ethnicity, disability, age, sexuality, religion or parental status (or even because of poverty itself). This can prevent them from getting out of poverty and can restrict access to services;
relationship issues: a child who, for whatever reason, does not receive warm and supportive parenting can be at higher risk of poverty when they are older, because of the impact on their development, education and social and emotional skills. Family relationships breaking down can also result in poverty;
abuse, trauma or chaotic lives: for some people, problematic or chaotic use of drugs and / or alcohol can make poverty worse and longer. Neglect or abuse in adult life can also cause poverty, as the impact on mental health can lead to unemployment, low earnings and links to homelessness and substance misuse. Being in prison and having a criminal record can also make poverty worse, by making it harder to get a job and its impact on relationships with family and friends;
disability and ill health: these are the main causes of poverty. Disabled adults and families with a disabled child are disproportionately represented in groups which are experiencing poverty.

In recent years worldwide factors have pushed up prices, further impacting on the number of people in poverty and worsening levels of poverty.

4. What are the Consequences of Poverty in the UK?

JRF state that some of the consequences of poverty include:

‘health problems;
housing problems;
being a victim or perpetrator of crime;
drug or alcohol problems;
lower educational achievement;
poverty itself – poverty in childhood increases the risk of unemployment and low pay in adulthood, and lower savings in later life;
homelessness;
teenage parenthood;
relationship and family problems;
biological effects – poverty early in a child’s life can have a harmful effect on their brain development.’

In addition, people may:

be less able or unable to afford:
- clothing;
- vital home equipment such as oxygen and dialysis machines due to electricity costs;
- leisure or sports activities;
- transport (this is particularly an issue for people who live in the countryside and also may result in people not being able to attend social care, hospital and other important appointments);
- broadband – further limiting their opportunities for finding work or saving money;
- attend employment / training;
need to go to food banks;
need to borrow money either from family or friends, official (banks or credit unions), or unofficial sources such as loan sharks which can result in threats, intimidation and their possessions seized if they cannot afford to repay them;
have to pay for goods and services on high interest credit;
resort to crime or sex work to get money to pay bills.

In turn this can lead to increased stress, anxiety and mental health problems.

This guidance is specifically referring to adults. But where there are children living in families suffering from poverty, there are additional issues. See Child Poverty (JRF).

5. How Poverty Affects People with Care and Support Needs?

60 per cent of those who died from Covid-19 in the first year of the pandemic were disabled. The health inequalities disabled people already faced were made worse by the pandemic and a decade of austerity …. Disabled people are more likely to live in poverty, have less access to education and employment, and experience poorer ratings of personal wellbeing compared with non-disabled people.’ (The Kings Fund).

People with care and support needs may be particularly vulnerable to poverty because:

they may be less able to work, or work in lower paid jobs, due to ill health or having a disability;
if their health issues have been long term, this may have impacted on their education and training opportunities, which may have resulted in them never being able to get decent paid jobs, or any job;
their health needs or disability may result in them having to:
- pay for care and support services, such as home carers;
- regularly buy equipment or supplies;
- make adaptations to their house as a result of mobility and other issues;
- having to move home, if it becomes unsuitable for them as a result of their needs;
- have the heating and / or lighting on more often;
- rely on local food shops which may be more expensive / have less choice;
- buy food for specialist diets;
- use their own car or pay for taxis if they cannot walk or use public transport due to health issues.

In addition, their carers may also be living in poverty, because:

they are not able to work / work full time because they need to look after their family member with care and support needs;
the household income is reduced because of having to pay for those issues listed above.

6. Poverty and Safeguarding

Living in poverty can increase the likelihood of an adult experiencing or being at risk of abuse and / or neglect. There may be safeguarding incidents committed – accidentally or deliberately – by people close to the adult who are struggling as a result of living in poverty. These people include:

spouses or other family members;
neighbours or friends;
carers – paid or unpaid;
other professionals.

People with care and support needs who are living in poverty are more likely to experience the following types of abuse:

physical abuse;
domestic abuse;
sexual abuse;
psychological abuse;
financial or material abuse;
modern slavery;
discriminatory abuse;
organisational abuse;
neglect.

6.1 Self neglect

In addition, incidences of self-neglect are likely to rise as a result of more people living in poverty due to the reason outlined in Section 5, How Poverty Affects People with Care and Support Needs. Chronic illness and disability increase the risk of self-neglect, both of which are associated with poverty.

6.2 Taking action where there are safeguarding concerns

Where there are concerns that a person with care and support needs is experiencing or at risk of abuse or neglect, whether as a result of poverty or not, staff should follow these safeguarding adults procedures (see Adult Safeguarding Process: Overview).

7. Supporting People who are Living in Poverty

7.1 Practical help

People with care and support needs may need support with specific areas of their lives that are contributing towards them living in poverty.

There are some areas where practical help and advice is available. Whilst social work staff may have knowledge about appropriate interventions for people living in poverty, there are also specialist agencies that can help. These include:

employment or education advice: specialist agencies can provide support and advice to people with care and support needs, based on their individual needs and wishes, to help them get into work or education, although it should be acknowledged that this may not be possible for everyone;
benefits advice: specialist services can work with people, and their carers, to make sure that both are receiving all the benefits they are entitled to and can support them to apply for new benefits, such as carers allowance, personal independence payment (PIP) and attendance allowance. Advisers can also support people who feel their benefits have been unfairly ended or refused. People who are ill and / or disabled are more likely to be missing out on receiving the correct level of financial support from the benefit system. The benefits system is very complex and can be overwhelming, so people will often gain from having expert advice;
medical and associated professions: where people are receiving care and treatment for specific health issues from doctors, nurses, occupational therapists or physiotherapists for example, they should be supported to make sure that they attend all their appointments and any obstacles, such as transport problems or a clash of appointment times are addressed well in advance to avoid stress for the person or the likelihood of them missing an appointment. If they do miss an appointment, they should be supported to contact the professional to explain what happened and to rebook it, rather than risk being removed from the service. Ensuring they receive the best possible health care can help improve their life circumstances with the goal of being less susceptible to poverty;
care and support services: where a person is living at home and receiving care and support services, they should be supported by staff to ensure that services from providers run according to the care and support plan, are timely and if any issues arise the person, and their carer, are supported in addressing them. A financial assessment should be conducted to make sure that people are not asked to pay more for their care and support than they can afford;
equipment, supplies and adaptations: where someone requires equipment, supplies or adaptations to the home as a result of their care and support needs, staff should make sure that they are referred to an occupational therapist, physiotherapist or other service as appropriate, to be assessed and provided with the equipment they need rather than have to pay for it themselves. This includes technology enabled care;
moving home: if a person has to move home as a result of their changing care and support needs, or for any other reason, staff should make sure that they are given all the available assistance and financial support to enable this to happen. The local authority housing department should be contacted to see if the person is eligible for any financial support for their move and refurbishment of the new accommodation. In certain circumstances, including when a person is fleeing violence or a property needs work because of a person’s disability, housing benefit can be paid on two properties (see Shelter for more information);
utility bills: if a person is struggling to pay their gas, electricity and water bills, staff should support them to contact the relevant utility company to come to an arrangement about the overdue amounts. This also applies to internet providers, which may be essential for people with care and support needs living at home. If a company is not willing to agree a repayment plan, an adult with care and support needs who receives benefits can ask for payments to be taken directly from their benefits to pay essential bills and contribute to repayment of accumulated debt. Most gas / electric, water and broadband providers have special tariffs to support ill and disabled adults who have a low income. Debt counselling and budgeting support is also available from local and national agencies (see Section 7.2, Local and national organisations);
leisure and sport: leisure and sport can be essential for mental and physical health. Where people with care and support needs are able and want to take part, staff should help them source free activities, including through social prescribing services, and / or grants to enable them to take part. Local organisations can be key in offering events and activities;
specialist diets: where someone with care and support needs requires a specialist diet, staff should support them to speak to their GP or dietician to see what support is available, such as prescriptions, to reduce the cost of buying specialist foods;
prescriptions, dental care, eye tests: people on low incomes may be able to get free prescriptions, dental treatment eye tests and help with other NHS costs, see Get Help with NHS Prescriptions and Health Costs (gov.uk);
transport: a person with care and support needs who is living in poverty may not be able to afford bus or taxi fares, or afford to run their own car. Staff should support them to find out what financial support is available for them. This will be dependent on their particular needs, but will be particularly important for those who cannot walk far or whose mental health affects their ability to travel. The mobility component of the personal independence payment (PIP) can support people with transport costs, blue badge and local travel passes (see What is Personal Independence Payment (PIP).

7.2 Local and national organisations

Poverty can be a very complex and challenging issue for staff who do not have a lot of knowledge and experience in this area. There may be local organisations which specialise in addressing issues caused by poverty, including food banks. Staff can put the person, or their carer, in touch with these organisations or otherwise take advice on an anonymous basis about specific aspects of supporting someone in poverty. Information about local support with the cost of living can be found on the South Tyneside Council website.

There are also a number of national organisations whose aim is to support people living in poverty. They have lots of information and advice for people. Again, staff can give their details to adults or their carers, or contact them directly for general advice. They include:

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10.10 Preventing Falls

RELEVANT CHAPTERS

Working with People Living with Frailty

Working with People Living with Dementia

RELEVANT INFORMATION

Avoiding a Fall (Age UK)

Falls Prevention (NHS)

This guidance was added to the APPP in March 2022.

1. Introduction

Falling, or worrying about falling, can be a great concern and anxiety for those who are getting older or have illnesses or disabilities that may make them more vulnerable to falls.

Often people do not worry about having a fall until it actually happens. Straight after a fall, the main concerns will probably be about the physical impact and whether they need to see a doctor, go to Accident and Emergency or even be admitted to hospital.

However, after the physical effects have faded, a fall can affect a person’s confidence, self-esteem and impact on the activities they enjoy, especially if they are frightened it will happen again. A fall does not have to result in broken bones and bad bruising to seriously impact on a person’s mental wellbeing; even trips and small falls can have a significant effect.

As well as the physical and psychological effects of a fall for adults and their family, there is also an impact on health and social care services. For example, they may need to be admitted to hospital for an operation to repair a broken hip, or other significant injuries; referral for home care services may be needed for support at home, or they may not be able to return home and need to move into permanent residential or nursing care. As well as the psychological impact on the adult and their family and friends, this puts additional pressure on hospital beds (particularly related to delayed discharge), hospital and social care staff and domiciliary and residential care services.

For a number of reasons therefore, reducing the possibility of someone having a fall is vital. This chapter outlines some of the main issues to consider about falls and actions that can be taken to reduce the possibility of people having a fall. Issues raised that relate to preventing falls may be considered as part of a strengths based assessment.

2. Preventing Falls

There are a number of ways that people can reduce their risk of having a fall. These can be divided into actions for the person, as well as their environment.

2.1 Actions for the person

2.1.1 Contacting the GP

The adult should discuss any falls they have had with their GP and let them know if it has had any impact on their physical and mental health and wellbeing.

The GP can carry out some easy balance tests, to see if they are likely to have another fall in the future. They can also refer them to appropriate services in the local area. They may also need to review any medication the adult is taking as the side effects of some prescription drugs may increase someone’s risk of having a fall; if it is making them feel dizzy for example.

2.1.2 Strength and balance exercises

Doing regular strength exercises and balance exercises can improve people’s strength and balance and reduce their risk of having a fall. These can be:

simple exercises such as walking or dancing;
community centres and local gyms often offer training programmes specifically for older people;
exercises that can be carried out at home;
tai chi can reduce the risk of falls. This is a Chinese martial art that focuses on movement, balance and co-ordination. It does not involve physical contact or rapid physical movements, so it is a good exercise for older people.

When someone has had a fall, strength and balance training programmes should be personalised for that individual person and monitored by an appropriately trained professional. In such circumstances, a GP should be consulted, who should make a referral to other services and professionals as appropriate.

2.1.3 Eye tests

Eyesight changes as people get older and can lead to a trip or loss of balance. People should make sure they have eye tests at least every two years and wear the right glasses for them, as problems with vision can increase the risk of having a fall. They should also get a test if they think their vision has got worse, even if it is before two years.

Not all vision problems can be cured, but some can be treated with surgery, for example cataracts can be removed which will improve a person’s sight.

2.1.4 Hearing tests

Hearing also changes as people get older. Adults should get a hearing test if they think their hearing has got worse. They should also talk to their doctor, as ear problems can affect balance. It may be something which is easily treated, such as a build-up of ear wax or an ear infection, or they may need a hearing aid.

2.1.5 Alcohol and drugs, including prescription drugs

Drinking alcohol or taking drugs – including some prescription drugs – can lead to loss of co-ordination. Alcohol can also make the effects of some medicines worse. This can significantly increase the risk of a falls.

Avoiding alcohol or illegal drugs or reducing the amount a person drinks can reduce their risk of having a fall. People should see their GP if they think their dizziness or lack of coordination may be related to prescription medication.

2.1.6 Footcare

People should take care of their feet by trimming toenails regularly and seeing a GP or podiatrist (foot health professional) about any foot problems. If someone has foot pain it may cause them to walk differently or limp, which may affect balance. Wearing well-fitting shoes and slippers that are in good condition and support the ankle can also reduce the risk of having a fall:

footwear should fit well and not slip off;
sandals with little support and shoes with high heels should be avoided;
slippers should have a good grip and stay on properly;
people should always wear shoes or slippers and not walk in bare feet, socks or tights.

2.1.7 Eating well

Having food that is nutritious, as well as tasty, helps people stay well. If people do not have a good appetite, it is better to eat little and often instead of three main meals, if they prefer. Having enough energy is important in keeping up strength and preventing falls.

2.1.8 Drinking fluids

As well as eating well, people should make sure they are drinking plenty. Not having enough fluids may result in someone feeling light-headed, which will increase their risk of a fall. People should drink about six to eight glasses of fluid (non-alcoholic) a day.

2.1.9 Bone health

Bones can become weaker as people get older and weak bones are more likely to break if someone falls. Bones can be kept healthier and stronger by eating food rich in calcium, getting enough vitamin D from sunlight and doing some weight-bearing exercises, as mentioned above.

2.2 Environment Issues

Tips for preventing falls in the home include:

wiping up anything that has been spilt on the floor;
removing clutter, trailing wires and repairing or replacing frayed carpet;
using non-slip mats and rugs;
making sure all rooms, passages and stairs are well lit, especially when it is dark. A night light near the bed so people can see where they are going if they wake up in the night – including motion-activated light that come on as needed – are useful;
organising the home so that climbing, stretching and bending are kept to a minimum, and avoid bumping into things so drawers and cupboards are shut immediately after use;
the adult getting help from other people to do things they cannot safely by themselves;
not wearing loose-fitting, trailing clothes that might catch on door handles or trip the person up

Mobile phones or alarms should always be carried, even around the house.

Personal alarms and telecare allow people to call for help, if they are unwell or have a fall and cannot reach the phone. People can wear a button on a pendant or wristband all the time, or have other technology aids, which will alert a 24-hour response centre. The staff at the centre call friends and family on the adult’s pre-decided list of contacts, or contact the emergency services.

2.2.2 Avoiding a fall outside

Falls do not just happen in the home, they can occur in the garden, in the street and on outings, particularly if places are not familiar. The following should be considered to reduce risk:

if people are wearing a mask or face covering, they should be extra careful about moving about as it can make it harder to see. They may need to slow down to reduce their risk of falling;
people should use a walking stick, walking frame or walk with others for support if this helps them feel more confident;
walking on uneven ground in gardens may make some people more vulnerable to losing their balance, as can reaching and stretching to do gardening jobs. Mobile phones should always be carried, especially in the garden;
walking dogs who may pull, even if they are small dogs, can cause people to lose balance as can dogs jumping up onto people;
take extra care in icy, snowy and wet weather – wet leaves and mud can also be very slippery; see also What to do when the weather’s particularly bad (Age UK).

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