New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2021.

HTAs (Health Technology Assessments)

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Economic Appraisals

No new economic appraisals relevant to England since 1 October 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 October 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2021.

New policies

No new national policies or guidelines since 1 October 2021.

New safety alerts

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Changes in product availability

No changes in product availability since 1 October 2021.

Who is involved in safeguarding adults in care homes?

Safeguarding is ‘everybody’s business’ - effective safeguarding relies on individuals and organisations working together including:

• Local authorities
  • The local authority is the lead agency for adult safeguarding and should be notified whenever abuse or neglect is suspected. They will decide whether a safeguarding enquiry is necessary, and if so who will conduct it.
• Safeguarding Adults Boards
  • The Care Act 2014 requires that each local authority must set up a Safeguarding Adults Board.
  • The Safeguarding Adults Board must:
    • Include the local authority, the NHS and the police — these agencies should meet regularly to discuss and act upon local safeguarding issues.
    • Develop shared plans for safeguarding working with local people to decide how best to protect adults in vulnerable situations.
    • Publish this safeguarding plan and report to the public annually on progress, to help ensure all organisations are working together in the best way.
• Care Quality Commission (CQC)
  • In England, care homes are regulated and inspected by the Care Quality Commission (CQC) to ensure that they meet fundamental standards of quality and safety.
  • Latest inspection reports and ratings for each care home can be found on the CQC website. 
• Care homes and care home providers
  • There are around 10,500 residential care homes and 4,200 nursing homes in England — these provide support to around 410,000 older people (as estimated by the 2017 Competition and Markets Authority care homes market study), and to many younger adults with disabilities, mental health issues or complex support needs.
  • In addition to long term residential care, care homes may also provide services, sometimes known as ‘respite care’, for people who stay for shorter periods of time, including day visitors.
  • It is a statutory requirement for care homes to have a designated safeguarding lead who has had training in safeguarding, and has the relevant skills and competencies to ensure the safety and protection of residents, in line with CQC guidance.
• Health and social care staff
  • All staff working within health and social care services (for example in hospitals, primary care, dental practices, and pharmacies) should be fully aware of their safeguarding roles and responsibilities.
  • Primary care staff often have regular contact with care home residents and are therefore well-placed to identify abuse and neglect. Each practice should have a GP Safeguarding Lead who is available to offer advice and guidance to colleagues on safeguarding concerns and support staff involved in safeguarding cases.
• Volunteers, residents, family, friends and any other visitors to the care home
  • All care home staff, residents and members of the public have a vital role in safeguarding and should be supported to remain vigilant for and report any concerns about abuse or neglect.
  • Information should be provided in easily accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult.
• Police services
  • The police are a key safeguarding partner.
  • In emergency situations (if there are concerns that an adult is at immediate risk of serious harm) they have powers to intervene to provide immediate assistance due to a health condition, injury or other life-threatening situation.
  • In non-emergency situations, decisions on when to involve the police depend on a number of factors including:
    • The views and wishes of the adult at risk.
    • Whether a criminal offence as defined by law has been disclosed.
    • The exact circumstances surrounding each individual case of suspected abuse or neglect.

[Social Care Institute for Excellence, 2015 (updated 2018); Department of Health and Social Care, 2016; Manthorpe, 2017; NHS, 2017,; Royal College of General Practitioners (RCGP), 2017; AgeUK, 2020; CQC, 2021b; Dept. of Health and Social Care, 2021; NICE, 2021]

What is a safeguarding enquiry?

• A safeguarding enquiry is any action taken (or instigated) by a local authority (under Section 42 of the Care Act 2014) when there is reasonable cause to suspect that an adult at risk is experiencing, or at risk of, abuse or neglect.
  • The particular circumstances of each individual case determine the scope of each enquiry, as well as who leads it and the form it takes.
  • Enquiries can range from a conversation with the adult concerned (or with their representative or advocate) through to a formal multi-agency plan to ensure the wellbeing of the adult concerned.
  • The local authority will decide which individuals and organisations need to be informed or consulted during the safeguarding enquiry for example:
    • The resident.
    • Their family and carers.
    • Anyone holding lasting power of attorney for the resident.
    • The care home and care home provider.
    • Advocacy organisations.
    • Voluntary organisations.
    • The police.
    • The organisation commissioning care.
    • The Office of the Public Guardian — if the safeguarding concern relates to lasting power of attorney.
    • The Department for Work and Pensions — if the safeguarding concern relates to an appointee for the resident's benefits.
    • Specialist helplines or online support, for advice and information.
    • GPs or other healthcare professionals.
    • The Care Quality Commission or other regulators.
    • Banks — if the safeguarding concern relates to financial abuse. 
• For more information about conducting a section 42 safeguarding enquiry see the Making Safeguarding Personal framework.

[Social Care Institute for Excellence, 2015 (updated 2018); Gibson, 2016; Johnson, 2019; NICE, 2021]

What is a Safeguarding Adults Review?

• Safeguarding Adults Reviews (SARs) are a statutory requirement for Safeguarding Adults Boards with the purpose of promoting learning and improving safeguarding practice.
• A Safeguarding Adults review must be arranged by a Safeguarding Adults Board if:
  • There is reasonable cause for concern that partner agencies could have worked more effectively to protect an adult and,
  • Serious abuse or neglect is known or suspected and,
  • Certain conditions are met, in line with section 44 of the Care Act 2014 and related statutory guidance.

[NICE, 2021]

What is a Safeguarding Adults Board?

• The Care Act 2014 requires that each local authority must set up a Safeguarding Adults Board.
• The Safeguarding Adults Board must:
  • Include the local authority, the NHS and the police — these agencies should meet regularly to discuss and act upon local safeguarding issues.
  • Develop shared plans for safeguarding working with local people to decide how best to protect adults in vulnerable situations.
  • Publish this safeguarding plan and report to the public annually on progress, to help ensure all organisations are working together in the best way.

[Department of Health and Social Care, 2016; AgeUK, 2020]

What legislation relates to adult safeguarding in the UK?

Safeguarding law and practice differs across the UK — primary care clinicians should be familiar with local procedures and always work within the framework of the relevant local authorities safeguarding policy and procedure.

• England — all adult safeguarding in England, including safeguarding in care homes, should be underpinned by:
  • The Care Act 2014.
  • The Care Act 2014 statutory guidance — any actions taken in relation to a safeguarding concern should be based on the 6 principles set out in the Care Act statutory guidance. These principles should be known and understood by everyone working in care homes and should be part of their everyday practice:
    • Empowerment: People being supported and encouraged to make their own decisions and informed consent.
    • Prevention: It is better to take action before harm occurs.
    • Proportionality: The least intrusive response appropriate to the risk presented.
    • Protection: Support and representation for those in greatest need.
    • Partnerships: Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.
    • Accountability: Accountability and transparency in delivering safeguarding.
  • The Making Safeguarding Personal framework.
    • Making Safeguarding Personal (MSP), is a sector-led safeguarding initiative focused on taking into account the needs, goals and wishes of the adult at risk when taking safeguarding actions.
  • Other legislation and guidance relevant to adult safeguarding includes the Mental Health Acts 1983 and 2007, the Health and Social Care Act 2008, the Human Rights Act 1998, the Mental Capacity Act 2005 and the Mental Capacity (Amendment) Act 2019.
• Wales
  • In Wales, legislation and guidance related to adult safeguarding includes the Social Services and Wellbeing (Wales) Act 2014.
• Scotland
  • In Scotland legislation relating to adult safeguarding includes the Adult Support and Protection (Scotland) Act 2007.  
• Northern Ireland
  • In Northern Ireland, policy related to adult safeguarding includes Adult Safeguarding: Prevention and Protection in Partnership, 2015. 

[Dept. of Health and Social Care, 2021; GMC, 2021; NICE, 2021]

What is individual abuse or neglect?

Individual abuse or neglect includes:

• Physical abuse:
  • Includes assault, hitting, slapping, pushing, misuse of medication, restraint, and inappropriate physical sanctions.
• Sexual abuse:
  • Includes rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, indecent exposure, sexual assault, sexual acts to which the adult has not consented or was pressured into consenting.
• Psychological abuse:
  • Includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, cyber bullying, isolation, unreasonable and unjustified withdrawal of services or supportive networks.
• Financial or material abuse:
  • 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, the misuse or misappropriation of property, possessions or benefits.
• Discriminatory abuse:
  • Includes forms of harassment, slurs or similar treatment: because of race, gender and gender identity, age, disability, sexual orientation or religion.
• Domestic violence:
  • Includes any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between people aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.
  • Includes psychological, physical, sexual, financial, emotional abuse, or so called ‘honour’ based violence and can in some cases be a continuation of past relationships of domestic violence or abuse.
• Neglect and acts of omission:
  • Include the refusal of or failure to fulfil a caregiving obligation for example ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating.
  • May or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the person at risk.
• Self-neglect
  • Self-neglect describes a wide range of behaviours where a person neglects to care for their personal hygiene, health or surroundings.
  • Self-neglect can be challenging to address because of the need to find the right balance between respecting a person's autonomy and fulfilling a duty of care to protect their health and wellbeing.
  • When considering if a safeguarding response is required it is essential to establish if the person has capacity to make decisions about their own wellbeing, and if they are able or willing to care for themselves — adults who are able to make choices may make decisions that others think of as self-neglect.

[Social Care Institute for Excellence, (2015 updated 2021); Storey, 2020; Dept. of Health and Social Care, 2021; NICE, 2021]

What is organisational abuse or neglect?

• Organisational abuse (also known as institutional abuse):
  • Includes acts of neglect or omission and poor care practice within an institution or specific care setting such as a care home.
  • May range from one off incidents to on-going ill-treatment through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation.
  • Some aspects of organisational abuse may be hidden (closed cultures), and staff may act differently when visitors are there (disguised compliance).
  • It can be difficult to differentiate between poor practice and ongoing organisational abuse.

[Social Care Institute for Excellence, 2015 (updated 2018); AgeUK, 2020; Dept. of Health and Social Care, 2021; NICE, 2021]

Safeguarding policy and procedure in care homes

• All care homes and care home providers must:
  • Have clearly written and easily accessible safeguarding policy and procedure that:
    • Meets the requirements of the Care Act 2014 and the Care Act 2014 statutory guidance.
    • Includes clear arrangements for identifying, reporting, responding to and managing safeguarding concerns.
    • Is based on the principle of collaborative working (including residents, staff, visitors and service providers) because safeguarding is everyone's responsibility.
    • Follows local safeguarding arrangements (overseen by the local Safeguarding Adults Board).
  • Have systems in place:
    • To track and monitor incidents, accidents, disciplinary action, complaints and safeguarding concerns, to identify patterns of potential harm.
    • For preserving evidence from reported safeguarding concerns, including care records, as these may be required in future, for example for local authority enquiries or police investigations.
  • Have a procedure for recording and sharing information (in line with data protection laws) about safeguarding concerns.
  • Have a whistleblowing policy and procedure, and make sure that staff and volunteers are aware of how to report a whistleblowing concern.
    • Whistle-blowing is the act of reporting a concern about safety, malpractice or wrongdoing within an organization to formal authorities.
    • The whistleblowing process must specify who people can contact, and how (for example a senior contact within a care home group, the local authority or the Care Quality Commission).
    • Care homes and care home providers must ensure that whistleblowers are not victimised and do not face negative consequences for reporting or disclosing a safeguarding concern — whistleblowers are protected by law.
    • Primary care staff should be aware that care home staff and volunteers may be afraid of the repercussions of whistleblowing, and this can prevent them from identifying and reporting abuse and neglect.
    • For more information, see the Care Quality Commission guidance on whistleblowing.

[NICE, 2021]

Local authorities and commissioning groups

• Local authorities and other commissioners should ensure that all care homes they work with are fulfilling their statutory and contractual safeguarding responsibilities.
• Commissioners should:
  • Contribute to improving safeguarding practice in the care homes they work with, by sharing key messages from Safeguarding Adults Reviews and helping care homes to learn from their own experience of managing safeguarding concerns.
  • Ensure that care homes are maintaining records about safeguarding.
  • Make record-keeping responsibilities clear as part of contract management.

[NICE, 2021]

What are the indicators of  neglect?

• Suspect neglect when residents:
  • Do not have an agreed care and support plan.
  • Are not receiving the care in their agreed care and support plan.
  • Have deteriorating physical or mental health or mental capacity, and there is a lack of response to this from staff.
  • Live in a dirty, unhygienic or smelly environment.
  • Repeatedly have poor personal hygiene or are wearing soiled or dirty clothes.
  • Are malnourished.
  • Are frequently and uncharacteristically not engaging with other people, or in activities that are meaningful for them.
  • Have only inconsistent or reluctant contact with external health and social care organisations.
  • Have restricted access to food or drink, if this is not part of their agreed care and support plan.
  • Are not kept safe from everyday hazards or dangerous situations.
  • Repeatedly do not receive prescribed medication, or medication has been repeatedly administered incorrectly (for example the dose, timing, method, or type of medication).
  • Are denied communication or independence aids (such as hearing aids, glasses or dentures), contrary to their care and support plan.
• Consider neglect when residents:
  • Are not supported to present themselves the way they would like (for example haircuts, makeup, fingernails and oral hygiene and care).
  • Are given someone else's clothes to wear.
  • Occasionally have poor personal hygiene or are wearing dirty clothes.
  • Are wearing clothing that is unsuitable for the temperature or the environment.
  • Have lost or gained weight unintentionally.
  • Do not have access to food and drink in line with their dietary needs.
  • Have repeated urinary tract infections.
  • Are not getting care to protect their skin integrity, potentially leading to pressure ulcers.
    • It can be challenging to identify whether pressure ulcers are caused by poor care or avoidable neglect or the unavoidable result of a person’s current condition.
    • Risk factors for each person should be considered on an individual basis — for more information, see the NICE guideline on pressure ulcers, and the quick guide on preventing pressure ulcers in care homes.
  • Do not have opportunities to spend time with other people, either virtually or in person.
  • Uncharacteristically refuse or are reluctant to engage in social interaction.
  • Do not have opportunities to do activities that are meaningful to them.
  • Do not have access to medical and dental care.
  • Are occasionally denied access to communication and independence aids (such as hearing aids) contrary to their care and support plan.
  • Have not received prescribed medication, or medication has been administered incorrectly (for example, the wrong dose, timing, method, or type of medication).
  • Do not have access to outdoor space, fresh air and sunlight.
  • Are not given first aid when needed.

Self -neglect

• The Care Act 2014 statutory guidance includes self-neglect in the categories of abuse or neglect relevant to safeguarding adults with care and support needs.
  • Self-neglect describes a wide range of behaviour where a person neglects to care for their personal hygiene, health or surroundings.
  • Self-neglect can be complex and challenging to address, because of the need to find the right balance between respecting a person's autonomy and protecting their health and wellbeing.
• When considering if a safeguarding response is required, an assessment should be carried out to determine if the person has capacity to make decisions about their own wellbeing, and if they are able or willing to care for themselves.
  • Be aware that adults who are able to make choices may make decisions that others think of as self-neglect.
• When considering capacity, have a good understanding of the Mental Capacity Act and put into practice its five key principles:
  • Assume that a person has capacity to make decisions, unless there is evidence otherwise.
  • Do all you can to maximise a person’s capacity.
  • Unwise or eccentric decisions do not in themselves prove lack of capacity.
  • If you are making a decision for or about a person who lacks capacity, act in their best interests
  • Look for the least restrictive option that will meet the need.
• Where there is a serious risk to the health and wellbeing of a person, it may be appropriate to raise self-neglect as a safeguarding concern. However, interventions on self-neglect may be more appropriate under the parts of the Care Act which deal with assessment, planning, information and advice, and prevention.

What are the indicators of physical abuse?

• Act immediately to safeguard residents and contact the police if you witness an assault or are told that a resident has been assaulted.
• Be aware that injuries can be caused by other residents.
• Suspect physical abuse when residents:
  • Have multiple or repeated marks or injuries (for example, bruising, cuts, lesions, loss of hair in clumps, bald patches, burns and scalds).
  • Have injuries that are very unlikely to be accidental (for example, grip marks, cigarette burns or strangulation marks).
  • Are being restrained without authorisation (either by direct restraint or by being confined to a particular area).
  • Flinch when approached, or change their behaviour (for example, acting subdued) in the presence of a particular person.
  • Have fractures that cannot be explained.
  • Have their activity limited by misuse of medication, or covert administration when not medically authorised.
• Consider physical abuse when residents:
  • Have unexplained marks or injuries (for example, minor bruising, cuts, abrasions or reddened skin).
  • Tell you or show signs that they are in pain, and the cause is unexplained (for example, the pain is not caused by a pre-existing medical condition).

What are the indicators of sexual abuse?

• Be aware that residents have the right to engage in sexual activity if they have the mental capacity to consent. For more information, see:
  • The Care Quality Commission guidance on relationships and sexuality in adult social care services.
  • The NICE guideline on decision making and mental capacity.
• Suspect sexual abuse:
  • If a resident has an intimate relationship with a member of staff.
  • When residents who lack capacity to consent to intimate or sexual relationships:
    • Report being inappropriately touched or experience unwanted sexualised behaviours.
    • Have unexplainable physical symptoms that may be associated with sexual activity, such as itching, bleeding or bruising to the genitals, anal area or inner thighs.
    • Have unexplained bodily fluids on their underwear, clothing or bedding.
    • Are involved in a sexual act with another person, including their husband, wife, partner or another resident.
    • Have a sexually transmitted infection.
    • Become pregnant.
• Consider sexual abuse when residents:
  • Are spoken to or referred to using sexualised language.
  • Experience any instances of sexualised behaviour or teasing.
  • Show unexplained changes in their behaviour, such as:
    • Resisting being touched.
    • Becoming aggressive or withdrawn.
    • Having trouble sleeping.
    • Using sexualised language.
    • Showing highly sexualised behaviours.
  • Show changes in their relationships (for example, being afraid of or avoiding particular residents, family members or members of staff).

What are the indicators of psychological abuse?

• Suspect psychological abuse when residents are:
  • Repeatedly addressed rudely or inappropriately (verbally or non-verbally).
  • Shouted at or verbally threatened.
  • Repeatedly humiliated, belittled, or have their opinions or beliefs undermined.
  • Getting married or entering a civil partnership, if you are concerned that they have not consented or lack capacity to consent to this.
  • Denied access to independent advocacy.
  • Repeatedly denied choices (for example, around their activities of daily living or freedom of movement).
• Consider psychological abuse when residents:
  • Are addressed rudely or inappropriately on any occasion (verbally or non-verbally).
  • Are prevented from speaking freely.
  • Are deliberately and systematically isolated by other residents and/or staff.
  • Have information about their own care systematically withheld from them by the care home.
  • Are not involved in planning their own care, or when changes are made to their care without discussion or agreement.
  • Are denied a choice on any occasion (for example, around activities of daily living or freedom of movement).
  • Are denied unsupervised access to others.
  • Show significant and otherwise unexplainable changes in their behaviour, including:
    • Becoming withdrawn.
    • Avoiding or being afraid of particular individuals.
    • Being too eager to do anything they are asked.
    • Compulsive behaviour.
    • Not being able to do things they used to be able to do.
    • Not being able to concentrate or focus.

What are the indicators of financial and material abuse?

• Be aware that not having systems to take care of residents' money and possessions is a form of organisational abuse and can lead to financial abuse.
• Suspect financial and material abuse when residents:
  • Have their money spent or their possessions or property used by other people, in a way that does not appear to benefit the resident (for example, their personal allowance being used to fund staff gifts, or misuse of loyalty card points).
  • Have treasured personal items constantly go missing.
  • Get married or enter a civil partnership, if they are likely to lack capacity to consent to this.
  • Change a will under duress or coercion.
  • Sign a lasting power of attorney when they do not have the mental capacity to make this decision.
  • Personal financial information is not kept confidential.
• Consider financial and material abuse when residents:
  • Do not have their money or possessions appropriately recorded by the care home.
  • Lose money or possessions.
  • Do not have access to their money, or to possessions that they want or need.
  • Are not routinely involved in decisions about how their money is spent (for example if they do not get a personal allowance), or how their possessions are used.
  • Appear to have bought things they do not need or invested money in things where they may lack capacity to make informed decisions.
  • Find the person managing their financial affairs to be evasive or uncooperative.
  • Family or others show unusual interest in their assets.
  • Have unusual difficulty with their finances, and are uncharacteristically protective of money and things they own.

What are the indicators of discriminatory abuse?

• Suspect discriminatory abuse when residents:
  • Are not treated equitably and do not have equal access to available services
  • Experience humiliation, violence or threatening behaviour related to protected characteristics:
    • Protected characteristics (Equality Act 2010) include age, disability, gender reassignment, marriage or civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation.
    • For more information see the Equality Act 2010. 
  • Are not provided with the support they need, for example, relating to their religious or cultural beliefs.
  • Are denied access to independent advocacy.
  • Show any of the indicators of psychological abuse, if these are associated with protected characteristics.
• Consider discriminatory abuse when residents:
  • Are denied choices about the care and support that they receive.
  • Are receiving care and support that does not take account of their personal or cultural needs, or other needs associated with protected characteristics.
  • Show any indicators of psychological abuse, if these are associated with protected characteristics.

What are the indicators of organisational abuse or neglect?

• Suspect organisational abuse when:
  • Incidents of abuse or neglect are not reported, or there is evidence of incidents being deliberately not reported.
  • There is evidence of redacted, falsified, missing or incomplete records.
  • There have been multiple hospital admissions of residents, resulting in safeguarding enquiries.
  • There are repeated cases of residents not having access to nursing, medical or dental care.
  • There is frequent, unexplained deterioration in residents' health and wellbeing.
  • Residents' money is being misused by the care home (for example, to purchase gifts for staff or other residents without permission).
  • There is a sudden increase in safeguarding concerns in which abuse or neglect has been identified.
  • Residents are repeatedly evicted or threatened with eviction after making complaints.
  • Repeated instances of residents, families and carers feeling victimised if they raise safeguarding concerns.
  • The care home fails to improve or respond to actions or recommendations in local inspections or audit frameworks from clinical commissioning groups or the local authority, or reviews and inspections by the Care Quality Commission or Healthwatch, and deteriorates over time.
• Consider organisational abuse when:
  • There is a lack of safeguarding policy, procedure, accountability or governance for example:
    • Safeguarding leadership or governance arrangements are unclear (for example, there is no registered manager or delegated safeguarding lead).
    • Managers rarely or never observe their staff at work, or are rarely or never available to speak to residents (or their families and carers), staff, or other professionals.
    • Managers are overly controlling, constantly interfere when staff are working, and stop staff from trying to improve resident safety or care.
    • The care home does not have policies and procedures covering safeguarding, whistleblowing and/or complaints.
    • The care home has policies and procedures covering safeguarding, whistleblowing and complaints, but does not use them or policy and procedure on safeguarding is inconsistent with the Care Act 2014 or this guideline.
    • The care home enforces blanket procedures and decisions, regardless of residents individual needs, wishes and circumstances and which generally conflict with safeguarding policies and procedures.
    • The care home does not explain the concepts of safeguarding, abuse and neglect to residents.
    • Residents, visitors, staff and other people working in care homes do not have access to policies and procedures covering safeguarding, whistleblowing and complaints.
    • Residents are not involved in how the care home is run.
  • Contractual or regulatory requirements are not being met, for example the care home:
    • Does not meet contractual safeguarding requirements.
    • Does not meet national regulations, including the fundamental standards of quality and safety monitored by the Care Quality Commission.
    • Fails to improve or respond to actions or recommendations arising from inspections or audits by professionals, commissioners and regulators (for example clinical commissioning groups, local authorities, the Care Quality Commission and Healthwatch).
    • Fails to sustain improvements.
    • Does not monitor the quality of their care using the Care Quality Commission's key lines of enquiry and prompts to ensure that the service is safe, effective, caring, responsive and well led.
  • Safeguarding concerns are mismanaged and record-keeping is poor, for example:
    • Safeguarding issues are not always reported.
    • No audits or actions are taken after a disclosure.
    • There is no clear safeguarding policy or information about how to raise a safeguarding concern.
    • Serious incidents are not reported (for example, unexplained deaths, serious fires, or infectious disease outbreaks).
    • There is a lack of safeguarding concerns recorded or referrals made.
    • The care home has poor or outdated records.
    • There are inconsistent patterns of safeguarding concerns logged (for example, if all concerns originate from 1 member of staff, then other staff may not be taking enough responsibility for safeguarding).
    • Safeguarding concerns have been reported via complaints procedures rather than through safeguarding procedures.
    • The care home does not comply with Mental Capacity Act requirements on deprivation of liberty and liberty protection safeguards (when enacted).
  • There are concerns about staffing, for example:
    • The care home does not have clear, safe recruitment processes (including reference checks and enhanced Disclosure and Barring Service checks).
    • Staff are not properly supervised and supported, or there is no documentation that this is happening.
    • There is no evidence that safeguarding training or induction is taking place.
    • There are high rates of staff absence.
    • Staff work excessive hours without enough breaks.
    • Staff are working under poor conditions.
    • There is high staff turnover and high dependency on contract or temporary staff.
  • There are concerns about quality of care and service provision for example:
    • There is evidence of poor medicines management (for example, excessive use of 'as needed' medicines).
    • Restrictive practice is used for example residents are prevented from moving around the home freely or independently, staff teams have inflexible and non-negotiable routines that do not take account of what individual residents want or need or staff do not help residents live as independently as they can.
    • Meaningful and structured activities for residents are not available or accessible.
    • Behaviours of concern are mismanaged (for example, overuse of restrictive practices, including misuse of medication).
    • Care and support plans are changed suddenly, without discussion with residents or others involved with their care.
    • Residents do not receive person-centred care, for example care is focused on completing tasks and ignores individual circumstances and preferences (including cultural preferences).
    • Staff routinely make assumptions about residents or their needs, and miss hidden needs or disabilities.
    • Staff do not respond to requests from residents, or interfere with residents' preferences and choices.
    • Residents are reluctant to ask for changes or to make complaints.
    • Certain residents routinely receive preferential treatment over others.
    • There are general inconsistencies in the standard of service provision.
  • There is failure to refer for appropriate care or support for example:
    • Residents miss appointments or are not referred to other professionals or services (for example GPs or dentists).
    • People who require independent advocacy are denied access to it.
  • There are concerns about financial mismanagement and lack of investment for example:
    • There are not enough staff on each shift to meet the needs of residents.
    • There are problems with care home equipment, for example it does not meet the needs of residents; it is poorly maintained or there is not enough equipment for all residents.
    • The care home admits or accepts referrals for residents that staff do not have the skills to care for.
    • There is a lack of investment in the services the care home provides, compared with the fees it charges.
    • Resources (such as one-to-one support) for residents with assessed needs are not provided, despite funding being allocated for this.
    • Residents' money is not adequately protected (for example, they do not have personal allowances).
  • There are physical signs and lack of openness to visitors for example:
    • The care home is dirty or smelly, or is not compliant with basic infection control.
    • Call bells have been removed or deactivated, or are routinely overused.
    • There is a lack of engagement with visitors, or places in the care home that visitors are not allowed to see.
    • The care home discourages visitors without justification.
    • There is a lack of engagement with the organisation the care home is part of.

Basis for recommendation

The recommendations on when to consider or suspect abuse or neglect in a care home are from the National Institute of Health and Care Excellence guideline Safeguarding adults in care homes (NG189) [NICE, 2021] with supporting information from the Social Care Institute for Excellence Adult safeguarding practice questions [Social Care Institute for Excellence, 2015 (updated 2018)], Types and indicators of abuse [Social Care Institute for Excellence, (2015 updated 2021)] and Safeguarding adults protocol pressure ulcers and the interface with a safeguarding enquiry [Dept. of Health and Social Care, 2018].

What else might it be?

• The possibility of abuse or neglect should always be considered as a cause of behavioural and emotional indicators – this is particularly important for residents who do not communicate using speech, even if indicators appear to be explained by something else.
• Some indicators of abuse and neglect may be:
  • Similar to signs of distress or behaviours arising from other causes for example there can be similarities with some behaviours associated with dementia, autism, learning disability or acute mental distress.
  • Due to past trauma, including non-recent incidents such as adverse childhood experiences, or past experience of domestic violence or modern slavery.

[NICE, 2021]

Overview

• If unsure if an indicator of abuse or neglect is a 'consider' or a 'suspect' indicator:
  • Discuss with your safeguarding lead about whether to make a safeguarding referral and/or
  • Seek further advice from the local authority.
• If you suspect abuse or neglect, you must act on it.
  • Do not assume that someone else will pass on information which may be critical to the safety and wellbeing of the adult.
• When responding to all indicators of abuse and neglect:
  • Follow the principles of the Making Safeguarding Personal framework.
    • Ensure that any actions are guided by the wishes and feelings of the resident.
    • Be aware that people experiencing abuse or neglect may be influenced, coerced or controlled by someone else.
    • Be aware that duties of care and public interest can over-ride personal preference, for example there is a risk that a perpetrator could abuse again — this needs to be addressed and prevented.
  • Follow the principles of the Mental Capacity Act if a care home resident lacks capacity.
    • For more information see the NICE guideline on Decision making and mental capacity and relevant local guidance.
• If a resident is in immediate danger or if there is a risk to other residents:
  • See the section on Immediate danger.
• If individual abuse or neglect is:
  • Suspected — see the section on Individual abuse - suspected.
  • Considered — see the section on Individual abuse - considered.
• If self-neglect is suspected:
  • See the section on Self-neglect.
• If organisational abuse or neglect is:
  • Considered – see the section on Organisational abuse – suspected.
  • Suspected – see the section on Organisational abuse – considered.
• For information on support during an enquiry:
  • See the section on Support during a safeguarding enquiry.
• For information on how care homes should learn from safeguarding concerns, referrals and enquiries:
  • See the section on Learning from safeguarding enquiries.
• For patient information on adult safeguarding in care homes:
  • See the section on Sources of support and advice for the public.

What should I do if a resident is in immediate danger or if there is a risk to other residents?

• If a resident is in immediate danger or if there is a risk to other residents (for example the alleged abuser is a person in a position of trust):
  • Take immediate action to make sure people are safe:
    • If there is immediate danger, call 999, provide medical attention if needed, and stay with the resident at risk until help arrives.
    • If a crime is suspected but the situation is not an emergency, encourage and support the resident to report the matter to the police. If they cannot or do not wish to report a suspected crime (for example, because they have been coerced or lack capacity), report the situation to the police yourself.
  • Depending on the risks the resident is facing, and who the alleged abuser is, think about who should be immediately notified. For example:
    • The care home manager.
    • Other healthcare professionals or emergency services.
    • The police or other emergency services if the resident is in immediate danger or you suspect a crime
  • As soon as the resident is safe, follow the steps outlined in the section on Suspected abuse or neglect.
    • If a resident does not want any safeguarding actions to be taken, but you suspect abuse or neglect the recommendations outlined should still be followed and a safeguarding referral must still be made.

Individual abuse or neglect

What should I do if I suspect or consider organisational abuse?

How should care homes and local authorities respond to reports of abuse or neglect?

How should residents and care home staff be supported during a safeguarding enquiry?

What should care homes learn from safeguarding concerns and enquiries?

• Care home managers and managers from local agencies should help their organisations to identify key lessons from the outcome of any safeguarding concern, referral, enquiry, or Safeguarding Adults Review.
  • Care home managers should incorporate learning from safeguarding concerns, referrals and enquiries into the care home culture at all levels for example through:
    • Changes to support, supervision, retraining, and performance management for individual staff.
    • Observations of practice, discussion and watching people work across the care home and changes in practices, procedures, policy and learning, and group training.
    • Policy changes for the care home provider.