Awareness

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Adult Support and Protection (Scotland) Act 2007
Awareness of Risks and Responsibilities
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• Fire exits and alarms
• Breaks
• Refreshments
• Toilet facilities
• No Smoking

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Course Content

1. Introduction
2. Definitions -- Adult at Risk and Harm
3. Risks
4. Responses
5. Information Roles and Responsibilities
6. Difficulties and Dilemmas
7. Procedures and Practice
8. Key Messages

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Course Material

• Much of the course has been drawn from training
  material developed by social work, health and
  police service staff in Edinburgh, the Lothians,
  Scottish Borders, and Perth Kinross, with
  contributions from staff from the Scottish
  Governments Adult Support and Protection Team
  concerning legislation and particularly the Adult
  Support and Protection (Scotland) Act 2007. All
  of the material can be customised for local use.
• The course is intended initially for staff who
  will have key roles in relation to the
  legislation, including Council Officers, and
  specialist NHS and Police staff, and within this
  context to complement training on the legislation
  and its practice implications.
• The wider workforce in social care, health and
  housing support services, and the police, as well
  as in a wide variety of other agencies, will also
  require to have knowledge and awareness of adult
  support and protection, and this half day
  awareness course is also designed for them.

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1. Introduction
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Learning outcomesAt the end of this session
participants will have an understanding of

1. What is meant by the term adult at risk.
2. What is meant by the term harm.
3. What are the signs of harm.
4. What should be the response to concerns that an
   adult is at risk of harm.
5. What are the responsibilities for sharing
   information.
6. What principles should be followed and ethical
   dilemmas faced.
7. What local interagency Adult Support And
   Protection Guidelines exist .

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Session Rules

• We will be discussing harm of adults in this
  session.
• This can be an emotive and difficult subject.
• It is therefore essential to create a safe
  learning environment for all participants.
• Everyones comments will be respected.
• All personal information shared within the room
  is confidential unless it raises concerns about
  an adult at risk.

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Background

• In 1997 the Scottish Law Commission published
  recommendations and a draft Bill in respect of
  vulnerable adults.
• Since then there have been several formal
  enquiries, where there have been failings in
  local services in individual cases. Local
  experience and practice has also developed
  considerably.
• National policy to protect people has also moved
  forwards, with new laws for adults with
  incapacity, mental health care and treatment, and
  most recently the Adult Support and Protection
  (Scotland) Act 2007.

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The Law

• Many laws are relevant to the support and
  protection of adults at risk, including
• Adult Support and Protection (Scotland) Act 2007
• Protection of Vulnerable Groups (Scotland) Act
  2007
• Vulnerable Witnesses (Scotland) Act 2004
• The Mental Health (Care Treatment) (Scotland)
  Act 2003
• Regulation of Care (Scotland) Act 2001
• Protection from Abuse (Scotland) Act 2001
• Adults with Incapacity (Scotland) Act 2000
• The Data Protection Act 1998
• Human Rights Act 1998
• Public Disclosure Act 1990
• NHS and Community Care Act 1990
• The Social Work (Scotland) Act 1968
• The National Assistance Act 1948

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Group exercise 1

• Attitudes
• The aim of the exercise is to see what your
  initial feelings or perceptions are and to
  discuss the differences in your multi-agency
  groups.
• Individually
• Take 5 minutes to read the scenarios. Rate them
  on the scale from 1 to10.
• Each case must have a different rating attached
  to it, so that you have a list from 1 to 10 and
  from those you think are the least harmful to
  those you think are the most harmful.
• In your groups
• Compare results. Discuss the choices you have
  made, and if you have rated them differently why
  that might be so. What personal and professional
  values may have influenced your ratings?

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Attitudes Exercise
Least Harm Least Harm Least Harm Most Harm Most Harm Most Harm
1 2 3 4 5 6 7 8 9 10
Case Rank Place

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

• Consider the following scenarios and number
  according to level of harm
• There are no right or wrong answers. This
  activity works best if you answer the questions
  spontaneously.
• Every day, Samuel, who was a refugee and was
  imprisoned and beaten in his country of origin,
  is visited by his 16 year old grandson. The
  grandson likes to sneak up behind his grandfather
  and shout The prison guards are coming.
• George has severe emphysema and lives with his
  family. They all smoke inside the house.
• Carer Eric gives his wife extra medication so he
  can get a good nights sleep.
• John visits his mother every week on pension day.
  After his visits, his mother never has any money.
  
• Peter arranges for his mothers pension to be
  paid into his own bank account and says he is
  saving for her funeral. She would like to spend a
  week by the seaside but Peter says she cannot
  afford it.
• Phillip watches pornographic DVDs on TV in front
  of his mother, aged 74, every day.
• A district nurse and carer talk about Edith and
  her condition in front of her and do not include
  her in the conversation.
• Rosemary is very weak and unsteady on her feet,
  but would love to try to walk around the garden
  with her zimmer frame to look at the flowers. Her
  daughter says she must remain in the house.

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2. DefinitionsAdult at RiskandHarm
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• What is meant by the term adult at risk?

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Who is an Adult at Risk?

• The Adult Support and Protection (Scotland) Act
  2007 defines Adults at Risk, through a
  three-point test, as adults, aged 16 years or
  over, who
• are unable to safeguard their own well-being,
  property, rights or other interests
• are at risk of harm and
• because they are affected by disability, mental
  disorder, illness or physical or mental
  infirmity, are more vulnerable to being harmed
  than adults who are not so affected.

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The Three-Point Test

• Can you think of people you have worked with, who
  would
• Meet the three-point test, and be considered as
  adults at risk
• Meet only one or two elements of the three-point
  test, and not be considered as adults at risk.
• Three-point test -- unable to safeguard
  well-being, property etc at risk of harm and
  because they are affected by disability, etc are
  more vulnerable ......

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• What is meant by the term harm?

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Types of harm

• The following are the main forms of harm that
  have been identified
• Physical
• Sexual
• Psychological/emotional
• Financial or material
• Neglect and Acts of Omission
• Discriminatory
• Information
• Human Rights

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Examples of types of harm

• Neglect Acts of Omission - withholding adequate
  nutrition, clothing, heating failing to provide
  for medical or physical care needs failure to
  give privacy and dignity neglect of
  accommodation self-neglect.
• Financial harm/exploitation theft fraud use or
  misuse of money or property without the adults
  consent preventing access to money or property
  pressure in connection with wills, property,
  inheritance or financial transactions.
• Psychological harm intimidation by word or act
  bullying verbal abuse threats of harm or
  abandonment deprivation of contact with others,
  or of something important to the adult
  humiliation blaming controlling coercion
  taking away privacy constant criticism.
• Physical Harm hitting, slapping, pinching,
  pushing, biting, burning, scalding, shaking
  forcible feeding inappropriate restraint and/or
  sanctions improper use of medication
  rough-handling inappropriate sanctions
  restriction of freedom of movement (e.g. locking
  the adult in a room, tying him/her to a bed or
  chair)
• Sexual harm contact unwanted/non-consensual
  touching/kissing/sexual activity non-contact
  photographing exposure to pornographic
  materials being made to listen to sexual
  comments indecent exposure sexual harassment
  voyeurism.
• Discriminatory harm actions (or omissions) of a
  prejudicial nature focusing on a persons age,
  gender, disability, race, colour, cultural
  background, sexual/religious orientation.
• Human Rights denial of a liberty, fair hearing,
  freedom of speech or religion slavery.

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What is harm?

• The Adult Support and Protection (Scotland) Act
  2007 says
• harm includes all harmful conduct and, in
  particular, includes
• conduct which causes physical harm
• conduct which causes psychological harm (e.g. by
  causing fear, alarm or distress)
• unlawful conduct which appropriates or adversely
  affects property, rights or interests (e.g.
  theft, fraud, embezzlement or extortion)
• conduct which causes self-harm.
• N.B - conduct includes neglect and other
  failures to act, which includes actions which are
  not planned or deliberate, but have harmful
  consequences.

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Group exercise 2

• Place in order of the most prevalent form of harm
  to older people
• Sexual
• Psychological
• Physical
• Neglect
• Financial

Rank Place Type of Harm

1.
2.
3.
4.
5.
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Exercise 2 Survey Finding

• Answer (UK Figs) percentage of the population
• UK Study of Abuse and Neglect of Older People -
  National Centre for Social Research, Kings
  College London - June 2007
• Note The prevalence estimates are almost
  certainly lower than the actual level of
  mistreatment
• More men (5.2) than women (3.6) in
  Scotland different from other UK countries

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Patterns of harm

• Patterns of harm vary and reflect very different
  dynamics. These include
• Neglect of a persons needs because those around
  him or her are not able to be responsible for the
  persons care or with deliberate intent
• Situational harm which arises because pressures
  have built up and/or because of difficult or
  challenging behaviour
• Long term harm in the context of an ongoing
  family relationships e.g. between siblings,
  generations
• Unacceptable treatments or programmes which
  include sanctions or punishment such as
  withholding of food drink, seclusion,
  unnecessary or unauthorised use of control
  restraint
• Opportunistic harm such as theft occurring
  because money has been left around
• Institutional harm which features poor care
  standards, lack of positive responses to complex
  needs, rigid routines, inadequate staffing and an
  insufficient knowledge base within the service
• Serial abusing in which the perpetrator seeks out
  and grooms vulnerable individuals. Sexual abuse
  usually falls into this pattern as do some forms
  of financial harm.
• Department of Health No Secrets (2000)

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3. Risks
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• What are the signs of harm?

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People who are harmed

• People who are harmed very often have or are
• Socially isolated
• Communication difficulties
• Impaired intellect, memory or physical function
• Behavioural problems
• History of poor quality long term relationships
• Pattern of family violence

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Risk factors

• People have been shown to be more at risk if
  their carer
• Has mental illness
• Has drug /or alcohol misuse
• Has a past history of offending
• Is financially dependent on client
• Is socially isolated
• Suffers from external stress mainly associated
  with house sharing not work
• But anyone can end up harming!
• The harm may be perpetrated with or without
  deliberate intent.

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Signs of harm

• Staff and others should look out for the signs of
  abuse and harm, including
• Unusual or suspicious behaviour by client or
  carer
• Delay in seeking advice for injuries
• Over frequent / inappropriate referrals to
  outside agencies
• Misuse of medication
• Sudden increase in confusion
• Unexplained physical deterioration
• Difficulty in interviewing adult
• Demonstration of fear
• Anxious, disturbed or rejecting behaviour
• Carer /or client showing apathy, depression and
  withdrawal
• Diagnosis of sexually transmitted disease
• Serious or persistent failure to meet needs

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Who harms?

• People who abuse and harm others include
• Family/Informal carers
• Spouses/partners or ex-spouses/ex-partners
• Relatives
• Volunteers
• Neighbours
• Friends and associates
• Professional staff care workers
• People who deliberately exploit adults at risk
• Strangers
• Service users
• Other adults at Risk

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Group exercise 3

• Place in order of the most prevalent source of
  harm to older people
• Care workers
• Partner
• Close Friend
• Other Family Member

Rank Place Source of Harm

1.
2.
3.
4.
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Exercise 3 Survey Finding

• Answer (UK Figs) percentage of the population
• UK Study of Abuse and Neglect of Older People
  National Centre for Social Research, Kings
  College London - June 2007
• Note Respondents could mention more than one
  person

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Group Exercise 4

• Place in order of the most prevalent places where
  harm to older people occurs
• Care home
• Hospital
• Own house
• Sheltered housing
• Other

Rank Place Place where Harmed

1.
2.
3.
4.
5.
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Exercise 4 Survey Finding

• Answer (UK Figs) percentage of the survey
  population
• Source Audit of calls to the AEA help line
• House of Commons Health Committee. Elder Abuse.
  Session 200304

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4. Responses
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• What should be the response to concerns
• that an adult is at risk of harm?

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Group exercise 5
It is common for an adult who is being harmed to
deny this. Why?
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Group exercise 6

• Place in order of the most prevalent reactions of
  responses to disclosure of abuse to them by older
  people
• No reaction
• Reacted verbally, physically, or confronted the
  perpetrator
• Emotional reaction
• Ignored it or walked away

Rank Place Response to Disclosure

1.
2.
3.
4.
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Exercise 6 Survey Finding

• Answer (UK Figs) percentage of the population
• UK Study of Abuse and Neglect of Older People -
  National Centre for Social Research, Kings
  College London - June 2007
• Note Respondents could give more than one
  answer Reaction questions were not asked for
  neglect

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Barriers to disclosure

• Barriers to disclosure commonly include
• Pride not wanting to be viewed as stupid or
  vulnerable
• Loyalty when family is involved, or towards
  friends or care/support staff
• Culture generation which does not complain
• Fear may make things worse, may have to go into
  care.

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Handling disclosures

• When someone discloses harm, then you should
• Ask client what happened listen
• Ask person who, what, where, when why obtain
  relevant information
• Remember this may be the only opportunity (e.g.
  clients poor memory)
• Restrict your questions to one interview
• Take a note of points to remember
• Try and avoid leading questions -- possible open
  questions include
• do you want to talk about what happened? what
  has happened today? are you hurt anywhere?
  has this happened before? where were you?
  what do you think about this? who was around?
  what can de done to help just now? what do
  you want to happen now?

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Disclosure do / dont

• Do
• Stay calm and listen carefully
• Reassure person, show sympathy concern
• Explain what you are going to do
• Report to your line manager
• Write the facts of what you have been told
• Dont
• Make judgements, appear shocked, horrified or
  angry
• Give assurances, promises keep secrets
• Confront or contact alleged perpetrator
• Press the individual for details
• Remove forensic evidence

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Immediate help required

• If the adult at risk appears to be in immediate
  physical danger or urgent medical attention is
  needed
• Contact appropriate emergency service (police,
  ambulance)
• Consent capacity is not an issue when in
  life and limb situation
• Medical care must be sought provided if
  needed
• Staff must be aware of the preservation of
  evidence
• Staff members should not put themselves at
  risk
• Staff should always discuss and record action
  taken.

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Consult supervisor / manager

• Discuss with line manager, supervisor or suitable
  alternative manager as soon as possible about
• Suspected or actual harm, and the full facts
  and circumstances of the case
• An agreed action plan
• Whether there is a need to obtain more
  information
• Whether a referral to the local Social Work
  Team office is appropriate
• Consent and capacity issues, and duty to
  inform under the Act
• If a medical examination needs to take place
  and whether delay may jeopardise securing vital
  evidence
• Whether the adult at risk needs to be removed
  to a place of safety
• Whether immediate action would cause more
  distress and/or pose greater risks to the adult.
• All actions and decisions to be recorded.

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Who can help?

• Senior staff member
• Manager
• Social Work
• Care Commission / Mental Welfare Commission
• Police
• Family Protection Unit
• Adult Protection Unit
• Never hesitate to ask or phone for advice if you
  are unsure about anything!

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Group exercise 7

• In your groups discuss and assess the risk in one
  case scenario.
• What factors influence and inform your
  assessment?
• What factors hinder your assessment?

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Group exercise case scenarios

• SCENARIO 1
•  Tom (19 )
•  Tom is a young Asian man who suffers from
  paranoid schizophrenia. His community health
  Nurse visits fortnightly. He lives alone in a
  second floor supported tenancy In a council
  estate. Children call him names and people throw
  stones at his window and kick his door. His
  girlfriend, who is 8 months pregnant and has a
  mild learning disability has her own tenancy down
  the road. She provides informal support for Tom
  and called the police on the last few occasions.
  Last week, a gang stuffed lit papers through his
  letter box. The police attended. Tom is
  frightened to go out and lives in fear of his
  neighbours. Yesterday, Toms community health
  nurse visited. She saw he was in a distressed
  state and seemed eager to tell her something. He
  repeatedly said to her If I tell you, you wont
  tell
• anyone else will you ?
• What are the main concerns / risks ?
•  
•  SCENARIO 2
•  Rachael ( 75)
• Rachael, 75, was admitted to hospital having
  sustained a head injury. The meals on wheels
  person found her unconscious and called an
  ambulance. Over the past 6 months, Rachael has
  had numerous admissions with falls, fractures and
  unexplained major bruising. Rachael states she
  has become clumsy lately, no physical evidence
  has yet been established as a cause. At present,
  Rachaels support includes an allocated care
  manager, meals on wheels and district nurse
  input. After being discharged, as the nurse was
  assisting Rachael to bath, she disclosed to her
  that her son had actually caused the injury as
  well as the previous injuries. Rachael went on to
  say her son had an alcohol problem and became
  physically violent towards her on pension days,
  when she refused to give him more money. She
  insisted the nurse keep this information
  confidential as she did not wish her son to get
  into trouble.
•  1. What are your main concerns ? 2. What
  action would you take ?
•  
•  SCENARIO 3
•  Ivy ( 51 )
•  Ivy lives alone in a ground floor flat. She has
  learning difficulties and cannot read or write.
  A couple of years ago her health deteriorated
• And now she cannot walk very far. The only time
  Ivy goes out is when she attends a luncheon club
  twice a week. Both a care manager and a home care
  worker have been involved with Ivy for some time.
  There have been concerns in the past when Ivy has
  said she has not got any money left. She has
  never said where the money has gone. Only on one
  occasion did she say she had given some money to
  her 25 year old daughter, Tracey. This weekend
  the police have been called out by a neighbour,
  who had heard Ivy shouting for help through the
  wall. When the neighbour went in she found Ivy
  crying and saying she was starving. It seems
  Tracey has come to visit and whilst Ivy was on
  the toilet she took all the money out of her
  purse and left the flat. Ivy had not eaten for
  three days. The home care worker arrives on
  Monday to find the neighbour with Ivy. They
  explain what has happened over the weekend and
  then Ivy says it has happened before.
• 1. What are your main concerns ? 2. What
  action would you take ?

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5. Information Roles and Responsibilities
47

• What responsibilities are there
• to share information?

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Group exercise 8
What may stop us from sharing concerns when
witnessing practices or incidents that may have a
negative effect on the welfare of an adult at
risk?
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Information sharing the law

• Various laws protect information. The rights to
  privacy and seeking consent should always be
  considered, but various laws also allow
  information sharing without consent
• The Human Rights Act 1998
• The Common Law Duty of Confidentiality
• The Data Protection Act 1998
• These existing laws allow information to be
  disclosed without consent
• where such disclosure is required by law (either
  a court order or statute)
• where such disclosure is for crime prevention,
  detection and prosecution
• where such disclosure is in the public interest
  (including the best interests of adults, who are
  or may be being harmed).
• The Adult Support and Protection (Scotland) Act
  2007 supports information sharing without consent
  when it is necessary to protect adults at risk.

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Information sharing duties
The Adult Support and Protection (Scotland) Act
2007 says that where a public body or
office-holder knows or believes that a person is
an adult at risk, and that action needs to be
taken (under this Part or otherwise) in order to
protect that person from harm, the public body or
office-holder must report the facts and
circumstances of the case to the council for the
area where the person is. Section 10 also
provides for the examination of records and says
that a council officer may require any person
to give her/him health, financial or other
records relating to an individual whom the
officer knows or believes to be an adult at risk.
Only a health professional can then inspect the
health records (other than to determine whether
they are health records). These requirements
conform with the Caldicott Principles that staff
must understand and comply with the law. The
other Caldicott Principles are that staff must
understand their responsibilities justify the
purpose(s) for using confidential information
only use when absolutely necessary use the
minimum that is required and provide access on a
strict need to know basis. Local authorities,
NHS Boards, Police Forces, the Care Commission,
the Mental Welfare Commission for Scotland, the
Public Guardian
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Capacity and decision-making

• In common law, we all, as adults, have a right to
  make our own decisions. Others must assume that
  we have capacity to act and make decisions unless
  there is evidence otherwise. No one should be
  regarded as lacking capacity just because they
  make unwise, unusual decisions, or because they
  have a particular diagnosis, illness or
  condition.
• In relation to adult protection inquiries and any
  interventions, for example through guardianship
  or protection orders, it will be for Council
  Officers and others involved to consider whether
  the adult has capacity or may be under undue
  pressure, and for the courts to decide this.
• The Adults with Incapacity (Scotland) Act 2000
  offers ways to protect adults who lack capacity
  and are unable to secure their own safety and
  welfare.
• However, the Adult Support and Protection
  (Scotland) Act 2007 also requires specific bodies
  and their staff to communicate about adults at
  risk whether or not they have capacity, when the
  bodies or staff thinks that action needs to be
  taken in order to protect that person from harm.

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What is your role?

• You have a Duty Of Care, therefore you have a
  duty to report and record any concerns,
  suspicions or disclosures made by or about any
  adults who may need protection.
• If an adult at risk does not consent to you
  reporting concerns that he/she is being harmed,
  it is necessary to go against his/her wishes
  when
• a person is, or may be, an adult at risk, and
  action needs to be taken in order to protect that
  person from harm
• there is an issue of public safety.
• the person is/may be a service provider, and
  other people may also be at risk.
• Never dismiss your information as being
  unimportant or trivial.it is very important and
  may be the crucial part of the full picture.

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Recording

• Good practice in case recording and record
  keeping is that staff
• record adequate, relevant personal data, which is
  not excessive for the purpose for which it is
  processed, and which clearly distinguishes fact
  and opinion
• record information following procedures at each
  stage of the process including public information
  to service users and their representatives, and
  about consents
• ensure limitations on information sharing
  identified by service users are flagged both on
  the consent form and documented in relevant case
  notes
• keep accurate records of what information has
  been disclosed to whom, the source of the data
  disclosed, and the date on which it was
  disclosed
• record full details about information disclosed
  without consent, the reasons for the decision to
  disclose , the person who authorised the
  disclosure, if different than the staff member
  concerned, and the person(s) to whom it was
  disclosed
• record requests by other professionals that
  information supplied by them be kept confidential
  from the service user, the outcome of this
  request and the reasons for taking the decision.

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Referral to the council

• The referral to the Social Work Team should
  include (as far as possible) the following
• personal details name, address, date of birth,
  ethnic origin, gender, religion, GP, type of
  accommodation, family circumstances, support
  networks, physical and mental health, any
  communication difficulties.
• the referrers name, job title, agency, contact
  details and reason for involvement.
• the nature/substance of the allegation.
• details of care givers/significant others.
• details of alleged person inflicting the
  harm/current whereabouts and likely movements
  within the next 24 hours, if known.
• details of any specific incidents, e.g. dates,
  times, injuries, witnesses, evidence such as
  bruising.
• what was said and by whom where possible in the
  words used by the adult.
• background of any previous concerns.
• whether the adult is aware/has consented or not
  to the referral being made.
• actions already taken, if any.
• information given to the adult, expectations and
  wishes of the adult if known.
• Person responsible staff member / line manager

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Cooperation
The Adult Support and Protection Act says that
certain public bodies and their office-holders
must, so far as consistent with the proper
exercise of their functions, co-operate with a
council making adult protection inquiries, and
with each other. The same sort of co-operation
would also be a matter of good agency and
professional practice for other agencies and
service providers and their staff in relation to
adult protection, and would be an expectation
under national care and practice standards.
Local authorities, NHS Boards, Police Forces,
the Care Commission, the Mental Welfare
Commission for Scotland, the Public Guardian
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Key Messages

• Communicate
• Record
• Co-operate

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6. Difficulties and Dilemmas
58

• What principles should be followed
• and ethical dilemmas faced?

59
Adult protection dilemmas

• Rights/self-determination
• Risk taking
• Consent/confidentiality/Duty to report suspicion
  / witness
• Disclosure
• Challenging behaviour restraint
• Whistle blowing
• Allegations against staff
• Capacity
• Domestic abuse
• Feelings of carers and stress
• Impact on family of allegations

60
Group exercise 9

• In your multi-agency group, discuss the 3
  statements provided.
• You may wish to make notes in the space provided.
  
• Feedback in plenary after approximately 10
  minutes.

61
Group Exercise dilemmas



It is a fundamental human right to choose to
remain in an harmful situation.
Multi-agency personnel must always adhere to the
individuals right to confidentiality.
Whistle-blowing should only happen once all
other options have been discounted.
62
7. Procedures and Practice
63

• What local interagency guidelines exist
• for
• adult support and protection?

64

• Local interagency procedures

65
Local contact details
66
8. Key Messages
67
Key messages

• For the system to work we need
• Trust
• Communication
• Information sharing
• Knowledge of procedure
• Clarity of role
• Awareness that no one agency has all duties
• The messages for individual staff are
• Be alert for possible harm
• Do not go it alone
• Recognise peoples rights
• Make clear decisions
• Avoidance of hesitancy recognise duty to
  report
• Talk to other agencies
• Write it all down

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ADULT SUPPORT AND PROTECTION Half Day Awareness
Course

• Date August 2008
• Your assistance in completing this evaluation is
  important, as it will provide an indication of
  the effectiveness of this training.
• Evaluate the degree to which the training has
  been effective in enabling you to achieve the
  following learning objectives.
• Understand what is meant by the term adult at
  risk.
• Understand what is meant by the term harm.
• Understand what are the signs of harm.
• Understand what should be the response to
  concerns that an adult is at risk of harm.
• Understand what are the responsibilities about
  sharing information.
• Understand what principles should be followed and
  ethical dilemmas faced.
• Understand what local interagency Adult Support
  And Protection Guidelines exist.
• Please rate the value of the training overall

Poor Poor Poor Poor Poor Excellent Excellent Excellent Excellent Excellent
1 2 3 4 5 6 7 8 9 10
69
Adult Support and Protection
70
Possible indicators of harm

• Additional information for reference

71
Possible indicators of neglect and acts of
omission

• Unkempt appearance
• Inappropriate or inadequate clothing (e.g. adult
  is kept in nightclothes during the day)
• Medication is withheld and/or not given as
  prescribed
• Failure to seek medical attention or appropriate
  medical care
• Lack of food
• Malnourishment
• Dehydration
• Unexplained weight loss
• Poor personal hygiene
• Poor physical condition
• Urine sores or pressure sores
• Carers reluctant to accept contact/support from
  services
• Sensory deprivation (e.g. adult has no access to
  hearing aids, glasses etc)
• The adult is denied / doesnt have access to
  necessary aids e.g. mobility aids
• Hazardous or unsafe living conditions (e.g.
  inadequate heating or lighting)
• Unsanitary or unclean living conditions (e.g.
  dirty bedding)

72
Possible indicators of financial harm /
exploitation

• Unpaid bills
• Unexplained inability to pay for household
  shopping or bills
• Disparity between the adults assets and living
  conditions
• The adult has insufficient food / essential items
• Sudden changes in the adults bank account or
  banking practice
• Unauthorised withdrawal of the adults funds
• Unexplained disappearance of funds or valuable
  possessions
• Signature on cheques that do not resemble the
  adults
• The inclusion of additional names on the adults
  bank account
• Abrupt changes to or sudden establishment of
  wills
• The sudden appearance of previously uninvolved
  relatives claiming their rights to an adults
  affairs or possessions
• The unexplained sudden transfer of assets from
  the adult to another person
• Visitors whose only visits and interest in the
  adult always coincide with the day that the adult
  cashes his/her benefits
• Unusual and extraordinary interest, knowledge and
  involvement in the adult's assets
• Missing items from the adults home

73
Possible indicators of psychological harm

• An allegation of harm made by an adult at risk
• Denial that anything is amiss or wrong
• Changes in the adults mental state (e.g.
  confusion, anxiety, paranoia)
• Changes in the adults behaviour (e.g. agitated,
  aggressive, withdrawn, fearful, challenging
  behaviour, anger and verbal or physical
  outbursts)
• Feelings of worthlessness / hopelessness
• Low mood / depression
• Insomnia or excessive sleep
• Changes in appetite
• Unusual bouts of crying / tearfulness
• Resignation (the adult accepts that being
  ill-treated is to be expected and is part of
  his/her life)
• Low self esteem
• Poor confidence
• Difficulty making decisions
• Silence or restricted communication when the
  perpetrator is present
• Subdued personality when the perpetrator is
  present
• Lack of interest / concern / consideration for
  the needs of the adult
• Denial of choices
• The adult is not allowed to express his/her views
  or opinions
• The adult is denied privacy

74
Possible indicators of physical harm

• An allegation of harm made by an adult at risk
• Denial that anything is amiss or wrong
• Changes in behaviour e.g. fearful, anxious,
  withdrawn, seeking attention and/or protection
  from others, anger and verbal or physical
  outbursts
• The adults liberty or freedom of movement is
  denied or restricted (e.g. being locked in a
  room, being tied up, inappropriate restraint)
• Unexplained, unusual or suspicious injuries (e.g.
  multiple bruising and/or fractures, not
  consistent with a fall)
• Unusual or unexplained behaviour of carers (e.g.
  delay in seeking advice dubious or inconsistent
  explanations for injuries)
• A delay between an injury and seeking medical
  care
• Difficulty in interviewing the adult (e.g.
  another adult unreasonably insists on being
  present)
• Difficulty moving (because of hidden or
  undisclosed physical injury)
• Over-medication / Under-medication (e.g. apathy,
  slurring of speech, excessive sleep, lack of
  sleep, continual pain/distress)
• Medication is not given as prescribed or is being
  given against the adults will or without the
  adult knowing e.g. being hidden in food
• unless there is legislation in place
  for this to happen Adults with Incapacity
  (Scotland) Act 2007 or Mental Health (Care
  Treatment) (Scotland) Act 2005

75
Possible indicators of sexual harm

• An allegation of harm made by an adult at risk
• Denial that anything is amiss or wrong
• Unexplained difficulty walking / sitting
• Stained undergarments/bed linen
• Changes in behaviour / mental state (e.g.
  fearful, anxious, withdrawn, seeking attention
  and/or protection from others, sleep disturbance,
  nightmares, poor eye contact, anger and verbal or
  physical outbursts)
• Bruising/injury to genital/rectal area or inner
  thighs etc
• Infections (e.g. urinary tract infections,
  sexually transmitted infections)
• Complaints of pain/discomfort from genital/rectal
  areas
• Fearful of or retreating from any form of
  physical touch or contact
• Sexualised behaviour / language
• Inappropriate attachments (e.g. if adult is being
  groomed he/she may want to spend time with
  perpetrator)
• Attempts to avoid contact with perpetrator
• Perpetrator engineering time alone with the adult
• Enforced pregnancy / withdrawal of contraception
• Signs of Grooming

76
What is grooming?

• Grooming is when a perpetrator tries to set up
  and prepare another person to be the victim of
  harm, often sexual abuse.
• Grooming can be used by those known to the adult
  or by strangers.
• A grooming process can last for months or even
  years.
• It can be very subtle those who are being
  groomed often do not realise that they are being
  manipulated, nor do their relatives or carers.
• A perpetrator of sexual abuse may use many
  techniques to groom and prepare an adult for
  abuse, such as
• Giving an inappropriate level of attention to
  the adult
• Telling the adult that he/she is special
• Giving the adult special treatment, favours
  and privileges
• Offering, promising and/or giving gifts
• Offering to help family/carers to gain access to
  the adult
• Manipulating the adult through threats or
  coercion
• Openly or accidentally exposing the adult to
  nudity / sexual material
• Sexualising physical contact
• Having inappropriate boundaries (e.g. sharing
  problems)

77
Possible indicators of discriminatory harm

• Offensive remarks/slurs/harassment/ based on the
  adults age, gender, disability, race, colour,
  cultural background sexual or religious
  orientation
• Changes to the adults mental state and behaviour
  ( e.g. fearful, anxious, withdrawn, angry,
  frustrated)
• Loss of self-esteem
• Bullying
• Degradation
• Providing unacceptable food/diet
• Failure to provide for cultural needs
• Lack of sensitivity, care or interest to cultural
  diversity
• Isolation (e.g. due to barriers to communication)
• Verbal abuse
• Hate crime
• Lack of opportunities and equity
• Not allowing for individual choice or difference
• Social isolation and exclusion
• The adult is refused access to services or is
  excluded inappropriately