Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Policy and procedure

Care home safeguarding policy and procedure

1.1.1 Care homes and care home providers must have a safeguarding policy and procedure in place, to meet the requirements of the Care Act 2014 and the Care Act 2014 statutory guidance and to follow local safeguarding arrangements (overseen by the local Safeguarding Adults Board). Providers that operate across more than one area must ensure that each care home follows the local safeguarding arrangements in their area.

1.1.2 Care home and care home provider safeguarding policies should:

  • be clearly written and in line with Accessible Information Standard requirements to meet the communication support needs of individual residents

  • be easy to find, so that all residents, staff, visitors and service providers can request and read it when they need to

  • include clear and transparent arrangements for identifying, responding to and managing safeguarding concerns, and involve residents (and their families and carers) in designing and reviewing these arrangements

  • explain how to respond to safeguarding concerns, and how to report suspected abuse or neglect

  • be based on the principle of collaborative working, because safeguarding is everyone's responsibility.

1.1.3 Care homes and care home providers should have systems in place to track and monitor incidents, accidents, disciplinary action, complaints and safeguarding concerns, to identify patterns of potential harm.

1.1.4 Care homes should have systems in place 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.

1.1.5 Care homes should have a procedure for recording and sharing information (in line with data protection laws) about safeguarding concerns.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care home safeguarding policy and procedure.

Full details of the evidence and the committee's discussion are in:

Care home whistleblowing policy and procedure

1.1.6 Care homes and care home providers should have a whistleblowing policy and procedure, and make sure that staff and volunteers are aware of these.

1.1.7 Care home providers should have a clear procedure setting out how staff and volunteers can report a whistleblowing concern. This process must specify who people can contact, and how (for example a senior contact within a care home group, and the local authority or the Care Quality Commission). For more information, see the Care Quality Commission guidance on whistleblowing.

1.1.8 Care home providers should consider using an external whistleblowing service. If they do, they should make sure that staff know how to contact the service.

1.1.9 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. Be aware that whistleblowers are protected by law.

1.1.10 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 a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care home whistleblowing policy and procedure.

Full details of the evidence and the committee's discussion are in evidence review B: barriers and facilitators to identifying abuse and neglect and evidence review C: tools to support recognition and reporting of safeguarding concerns.

Care home and care home provider roles and responsibilities

1.1.11 Care homes should:

  • have a safeguarding lead and

  • make sure everyone knows who this is, what they do, how to contact them, and who to speak to if they are unavailable.

1.1.12 Care homes and care home providers should make it clear who is accountable for different aspects of safeguarding within the home, in addition to the roles and responsibilities of the safeguarding lead.

1.1.13 Safeguarding responsibilities should be included in the job description of all care home staff, including at board level.

1.1.14 Care homes and care home providers should ensure that all staff understand how to meet their safeguarding responsibilities in their day‑to‑day work within the care home (see the recommendations on induction and training for more information).

1.1.15 Care homes should maintain and regularly audit care records (in addition to external checks, such as audits or Care Quality Commission inspections) and ensure that they are complete and available, in case they are needed if a safeguarding concern is raised.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care home and care home provider roles and responsibilities.

Full details of the evidence and the committee's discussion are in evidence review B: barriers and facilitators to identifying abuse and neglect and evidence review F: barriers and facilitators to effective strategic partnership working.

Local authorities, clinical commissioning groups, and other commissioners

1.1.16 Local authorities and other commissioners should ensure that all care homes they work with are fulfilling their statutory and contractual safeguarding responsibilities.

1.1.17 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.

1.1.18 Commissioners should:

  • ensure that care homes are maintaining records about safeguarding

  • make record-keeping responsibilities clear as part of contract management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on local authorities, clinical commissioning groups, and other commissioners.

Full details of the evidence and the committee's discussion are in evidence review B: barriers and facilitators to identifying abuse and neglect and evidence review F: barriers and facilitators to effective strategic partnership working.

Safeguarding Adults Boards

1.1.19 Safeguarding Adults Boards should be assured that local authorities and clinical commissioning groups have clear lines of communication in place with safeguarding leads in care homes.

1.1.20 Safeguarding Adults Boards should include specific objectives about safeguarding in care homes as part of their strategic planning.

1.1.21 Safeguarding Adults Boards should cover issues relevant to safeguarding in care homes as part of their annual report.

1.1.22 Safeguarding Adults Boards should share recommendations and key learning from Safeguarding Adults Reviews with key stakeholders (including care home providers, staff, residents and their families and carers).

1.1.23 Safeguarding Adults Boards should be assured that partner organisations are working together to support residents during safeguarding enquiries.

1.1.24 Safeguarding Adults Boards should ensure that their escalation procedures for resolving safeguarding disputes are applicable to care homes.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on Safeguarding Adults Boards.

Full details of the evidence and the committee's discussion are in evidence review E: support and information needs and evidence review F: barriers and facilitators to effective strategic partnership working.

1.2 Induction and training in care homes

1.2.1 All directly employed staff working in care homes should:

  • read and understand the safeguarding policy and procedure during their induction

  • complete mandatory training on safeguarding as soon as possible, and no later than 6 weeks after they start.

1.2.2 Care home managers must ensure that agency staff working at the home have completed the necessary safeguarding training for their role, and that they understand the local safeguarding policy and procedure.

1.2.3 Care home managers should assess staff safeguarding knowledge annually, and run refresher training if needed.

1.2.4 Safeguarding Adults Boards, their subgroups and partnership members should work with partner organisations to:

  • ensure that mandatory safeguarding training includes elements of multi-agency working

  • ensure that mandatory training reflects the safeguarding responsibilities of each member of staff (so staff with more responsibilities receive more comprehensive training)

  • encourage care home providers to arrange opportunities for staff and residents to learn together from recent Safeguarding Adults Reviews and other experiences of safeguarding.

1.2.5 Care homes should give staff protected time for induction and mandatory safeguarding training. They should ensure that staff have enough time to read and understand the induction and training materials and improve their knowledge and confidence about safeguarding.

1.2.6 Care home managers should:

  • assess staff understanding of safeguarding after induction and mandatory safeguarding training, to identify areas for improvement

  • request feedback on induction and training

  • help staff to understand the indicators of abuse and neglect, so they can identify safeguarding concerns more accurately

  • help staff increase their confidence in managing safeguarding concerns.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on induction and training in care homes.

Full details of the evidence and the committee's discussion are in:

What mandatory training should cover

1.2.7 At a minimum, mandatory safeguarding training should include:

  • safeguarding and legal principles under the Care Act 2014

  • the 6 core principles of safeguarding and the Making Safeguarding Personal framework

  • specific responsibilities and accountabilities for safeguarding in the care home

  • how to recognise different forms of abuse and neglect, including organisational abuse and neglect

  • how to understand the differences between poor practice and abuse and neglect

  • the care homes whistleblowing policy and procedure, including what support and information is available in this situation

  • how to act on and report suspected abuse or neglect

  • how to deal with and preserve evidence

  • how to raise safeguarding concerns within the care home and how the care home should respond

  • how to escalate concerns (for example, to appropriate helplines or the local authority) if staff feel that the response taken was not appropriate or effective, or if the concern relates to the actions of the care home manager

  • confidentiality and data protection

  • the importance of being open and honest when things go wrong (the duty of candour)

  • duties under the Public Interest Disclosure Act 1998

  • other training that is needed, based on the staff member's role and their specific safeguarding responsibilities.

1.2.8 Mandatory safeguarding training should include reflective learning at the individual, team and organisational level, and include opportunities for problem-solving.

1.2.9 Mandatory safeguarding training should include an explanation of safeguarding concepts and terminology, including translations of specific terminology if needed (to ensure that training is accessible to all staff).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on what mandatory training should cover.

Full details of the evidence and the committee's discussion are in:

Further training

1.2.10 Further training could cover:

  • how to ask about abuse and neglect in a sensitive and non-judgemental manner

  • how frequently to assess and ask about abuse and neglect

  • the wide range of situations and circumstances in which abuse and neglect can potentially occur

  • less obvious indicators of abuse and neglect, and more complex safeguarding concerns (for example organisational abuse and neglect)

  • risk assessments and their relationship to safeguarding

  • the skills needed to support a resident through a safeguarding enquiry.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on further training.

Full details of the evidence and the committee's discussion are in evidence review E: support and information needs and evidence review H: the effectiveness and acceptability of safeguarding training.

How to conduct training

1.2.11 Provide mandatory safeguarding training face-to-face whenever possible. This can be delivered either in person or remotely. It should be live and interactive, and e-learning should only be used when face-to-face training is not possible.

1.2.12 Include case studies and reflective practice in training and learning at the team and organisational level (for example, at team meetings and handovers).

1.2.13 Use case studies and examples to teach staff how safeguarding relates to personalised care and the human rights of residents.

1.2.14 Incorporate recommendations and other learning from Safeguarding Adults Reviews into training as quickly as possible after they are available.

1.2.15 Training should be directly applicable to the responsibilities and daily practices of the person being trained, and to the care and support needs of the residents they are working with.

1.2.16 Tailor training to reflect the safeguarding responsibilities of each member of staff, so staff with more responsibilities receive more comprehensive training.

1.2.17 If using e-learning, be aware of the limitations (for example, the lack of opportunity for discussion and asking questions, and the difficulty in ensuring that people have understood the training).

1.2.18 If using e-learning, care home managers should assess staff literacy levels and IT skills to ensure the training is appropriate. If staff cannot use it, find an alternative e-learning programme or another way to conduct training.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on how to conduct training.

Full details of the evidence and the committee's discussion are in evidence review H: the effectiveness and acceptability of safeguarding training.

Evaluating training

1.2.19 Care home managers and safeguarding leads should ensure that staff are learning from training and using it to improve their practice. This could be done by:

  • checking that training is completed, and that this is done within an agreed timeframe

  • follow-up conversations with staff

  • periodic checks that staff are adhering to safeguarding procedures.

1.2.20 Care home managers should evaluate changes in understanding and confidence before and after training. Assess this:

  • immediately after the training

  • annually

  • in regular long-term evaluations (for example, as part of supervision sessions).

1.2.21 Line managers should encourage staff to complete and apply learning from their training, for example during staff appraisals. This could include recognising and acknowledging new skills and competences, and changes in attitudes and behaviours.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on evaluating training.

Full details of the evidence and the committee's discussion are in evidence review H: the effectiveness and acceptability of safeguarding training and evidence review I: embedding organisational learning about safeguarding.

1.3 Care home culture, learning and management

Management skills and competence

1.3.1 Registered managers and providers of regulated care must comply with all safeguarding requirements in regulations 12 and 13 of the Health and Social Care Act 2008 (regulated activities) Regulations 2014.

1.3.2 Care home managers and safeguarding leads should lead by example in maintaining up-to-date knowledge on safeguarding.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management skills and competence.

Full details of the evidence and the committee's discussion are in evidence review I: embedding organisational learning about safeguarding.

Line management and supervision

1.3.3 Be aware that staff may be reluctant to challenge poor practice or raise concerns about potential abuse or neglect, particularly if they feel isolated or unsupported.

1.3.4 Care home managers and supervisors should promote reflective supervision to help staff understand how to identify and respond to potential abuse and neglect in care homes. Consider making this independent of line management.

1.3.5 Line managers should provide feedback (through supervision and appraisals) acknowledging how staff have learned from their experience of identifying, reporting and managing safeguarding concerns.

1.3.6 Care home managers should encourage staff to discuss care home culture, learning and management in relation to safeguarding (e.g. in exit interviews) when leaving employment with the care home.

1.3.7 Be aware of the potential for under-reporting of safeguarding concerns by staff who may be afraid of losing their job (for example staff who have their housing or work permit linked specifically to their current role).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on line management and supervision.

Full details of the evidence and the committee's discussion are in evidence review B: barriers and facilitators to identifying abuse and neglect and evidence review I: embedding organisational learning about safeguarding.

Care home culture

1.3.8 Care home providers (including trustees and company directors) and managers should:

  • promote a culture in which safeguarding is openly discussed and abuse and neglect can be readily reported

  • ensure that support is readily available for people raising concerns, for example, by appointing safeguarding champions.

1.3.9 Staff should be encouraged to watch out for changes in the mood and behaviour of residents, because this might indicate abuse or neglect (see indicators of individual abuse and neglect).

1.3.10 Staff should record and share relevant and important information about changes in mood or behaviour or other issues of concern in a timely manner (for example, at every shift handover or transfer of care). In cases of possible abuse or neglect, see the recommendations on immediate actions to take if you consider or suspect abuse or neglect.

1.3.11 Care home managers should make sure there are regular opportunities (for example in team meetings or one-to-one supervision) for all staff to:

  • share best practice in safeguarding, including learning from Safeguarding Adults Reviews

  • challenge poor practice or discuss uncertainty around practice

  • discuss the differences between poor practice (which is not necessarily a safeguarding issue) and abuse or neglect (which are safeguarding issues).

    Care home managers should make particular efforts to involve staff who work alone or who get very little direct oversight (for example night staff).

1.3.12 Care home managers should ask for feedback about safeguarding from residents (and their families, friends and carers) and other people working in care homes. They should:

  • ask them about their experience of safeguarding concerns and how these have been identified, reported, managed and resolved

  • respond to feedback and tell people about any changes made in response to their comments.

    This could be done using surveys, meetings and where appropriate, other community engagement (such as open days and visits).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care home culture.

Full details of the evidence and the committee's discussion are in evidence review B: barriers and facilitators to identifying abuse and neglect and evidence review I: embedding organisational learning about safeguarding.

Multi-agency working and shared learning with other organisations

1.3.13 Care homes, local authorities, clinical commissioning groups and other local agencies should work together to establish local strategic partnership arrangements that cover safeguarding adults in care homes, and that specifically include:

  • information sharing and communication protocols

  • roles, responsibilities and accountability for safeguarding within each organisation

  • procedures for raising and managing a safeguarding concern, the decision-making process and the procedure for enquiries

  • definitions of good practice and poor practice

  • the indicators of abuse and neglect that should result in safeguarding action (based on the indicators in sections 1.4 and 1.12 of this guideline).

1.3.14 Local health, social care and other practitioners working with care homes should use a multi-agency approach to safeguarding, bringing together a wide range of skills and expertise to keep residents safe.

1.3.15 Care home managers and providers should be aware that some staff may be apprehensive about external oversight, and may need time to build relationships with external agencies before effective multi-agency working and shared learning can take place.

1.3.16 Care home managers and providers should participate in local Safeguarding Adults Board arrangements for sharing experiences about managing safeguarding concerns in care homes.

1.3.17 Care home managers and providers should share relevant information from Safeguarding Adults Board meeting minutes and reports with their staff.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on multi-agency working and shared learning with other organisations.

Full details of the evidence and the committee's discussion are in:

Record-keeping

1.3.18 Care home managers should ensure that actions taken to safeguard residents are recorded, and shared with other staff as necessary.

1.3.19 Care home managers should ensure that all safeguarding records are focused on the wellbeing of the individual resident. Records should be clear and easily accessible for purposes such as performance management, audits, court proceedings, Care Quality Commission inspections, or learning and development.

1.3.20 Care home managers should regularly review safeguarding records for accuracy, quality and appropriateness.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on record-keeping.

Full details of the evidence and the committee's discussion are in evidence review I: embedding organisational learning about safeguarding.

1.4 Indicators of individual abuse and neglect

This section describes indicators that should alert people to the possibility of abuse or neglect of individuals within a care home. This section (and the sections on immediate actions to take if you consider or suspect abuse or neglect) applies to anyone in contact with care home residents. This includes staff, volunteers, visiting health and social care practitioners, other residents, family and friends, and any other visitors to the care home. Local authorities may wish to adapt and incorporate these indicators as part of their referral guidance or criteria.

The terms 'consider' and 'suspect' are used to define the extent to which an indicator suggests abuse or neglect, with 'suspect' indicating a stronger likelihood of abuse or neglect.

  • To 'consider' abuse or neglect means that this is one possible explanation for the indicator.

  • To 'suspect' abuse or neglect means a serious level of concern about the possibility of abuse or neglect.

None of the indicators are proof of abuse or neglect on their own. Instead, they are signs that the pathway set out between sections 1.4 and 1.11 of this guideline should be followed. See the indicators of individual abuse and neglect visual summary for a summarised view of this pathway.

This process is in line with the Department of Health and Social Care statutory guidance on adult safeguarding.

Some behavioural and emotional indicators of abuse and neglect may be due to past trauma, including non-recent incidents such as adverse childhood experiences, or past experience of domestic violence or modern slavery.

Some indicators of abuse and neglect can be similar to signs of distress or behaviours arising from other causes. In particular, there can be similarities with behaviours that may be associated with dementia, autism, learning disability or acute mental distress. However, the possibility of abuse or neglect should always be considered as a cause of behavioural and emotional indicators, even if they are seemingly explained by something else. This is particularly important for residents who do not communicate using speech.

Physical, sexual, psychological and financial abuse may be perpetrated by volunteers, visitors, and family members and carers, as well as by care home staff. When it is perpetrated by someone who is personally connected to the resident, this is considered to be domestic abuse. In some cases, this can be a continuation of past relationships of domestic violence or abuse.

1.4.1 Health and social care practitioners should provide information to residents and their families and carers, covering what abuse and neglect look like and how to recognise warning signs.

1.4.2 When responding to all indicators of abuse and neglect:

1.4.3 If a resident is in immediate danger or if there is a risk to other residents (for example if the alleged abuser is a person in a position of trust):

1.4.4 If a resident does not want any safeguarding actions to be taken, but you suspect abuse or neglect:

1.4.5 If there are multiple indicators, and at least one is a 'suspect' indicator, you should suspect abuse or neglect (see immediate actions to take if you suspect abuse or neglect).

1.4.6 If you are not sure if an indicator is a 'consider' or a 'suspect' indicator, speak to your safeguarding lead and/or seek further advice from the local authority about whether to make a safeguarding referral (see also recommendation 1.7.3 for guidance on what safeguarding leads should do if they suspect abuse or neglect).

Neglect

1.4.7 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 (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.

1.4.8 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.

1.4.9 Be aware that some indicators of neglect may result from self-neglect. When deciding how to respond to self-neglect:

  • think about why the resident may be refusing support

  • think about whether the resident has capacity to understand the possible impact of their self-neglect on themselves and others (see the NICE guideline on decision making and mental capacity)

  • if the resident is refusing support, ask them why, and ask if they would like a different kind of support

  • make an assessment based on the risks and needs specific to the resident, in line with the Care Act 2014 statutory guidance.

Physical abuse

1.4.10 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).

1.4.11 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.

1.4.12 Act immediately to safeguard residents and contact the police if you witness an assault or are told that a resident has been assaulted (see making sure people are safe).

1.4.13 Be aware that injuries can be caused by other residents.

Sexual abuse

1.4.14 Be aware that residents have the right to engage in sexual activity if they have the mental capacity to consent. For more information, see:

1.4.15 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).

1.4.16 Suspect sexual abuse if a resident has an intimate relationship with a member of staff.

1.4.17 Suspect sexual abuse 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.

Psychological abuse

1.4.18 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.

1.4.19 Suspect psychological abuse when residents:

  • are repeatedly addressed rudely or inappropriately (verbally or non-verbally)

  • are shouted at or verbally threatened

  • are repeatedly humiliated, belittled, or have their opinions or beliefs undermined

  • are getting married or entering a civil partnership, if you are concerned that they have not consented or lack capacity to consent to this.

  • are denied access to independent advocacy

  • are repeatedly denied choices (for example, around their activities of daily living or freedom of movement).

Financial and material abuse

1.4.20 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.

1.4.21 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.

1.4.22 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.

Discriminatory abuse

1.4.23 Consider discriminatory abuse when residents:

1.4.24 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

  • 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 in recommendation 1.4.19, if these are associated with protected characteristics.

1.5 Immediate actions to take if you consider abuse or neglect

1.5.1 If you 'consider' abuse or neglect:

  • Seek medical attention for the resident at risk if needed.

  • Record what you have found.

  • Seek advice from a safeguarding lead (unless they are implicated in the alleged abuse or neglect).

  • Check whether other indicators have previously been recorded.

  • Discuss the welfare of the resident at risk with a manager or supervisor and:

    • if you work in the care home, address the problem yourself

    • if you cannot address the problem yourself or you do not work in the care home, ask the manager or supervisor to address the problem.

  • Monitor to see if the problem persists or is repeated, and to check for any other indicators. Think whether new information gives cause for your level of concern to rise from 'consider' to 'suspect'.

  • After taking these steps, decide whether there is now a serious concern about the possibility of abuse or neglect. If there is, and if you 'suspect' abuse and neglect, see immediate actions to take if you suspect abuse or neglect.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on indicators of individual abuse and neglect and immediate actions to take if you consider abuse and neglect.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

1.6 Immediate actions to take if you suspect abuse or neglect

Making sure people are safe

1.6.1 If you suspect abuse or neglect, you must act on it. Do not assume that someone else will.

1.6.2 If you suspect abuse or neglect, make sure that no one is in immediate danger. If there is immediate danger, call 999 and stay with the resident at risk until help arrives.

1.6.3 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.

1.6.4 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

  • a healthcare professional or the NHS 111 service if there is a serious medical issue

  • the police or other emergency services if the resident is in immediate danger or you suspect a crime.

For a short explanation of why the committee made these recommendations, see the rationale and impact section on making sure people are safe.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

Gathering information

1.6.5 As soon as the resident is safe, start gathering information about the suspected abuse or neglect. Write down:

  • what happened

  • when it happened

  • where it happened

  • who was involved (the resident at risk, any other person who has told you about the abuse or neglect, and the alleged abuser).

1.6.6 When talking to the resident (or any other person who has told you about the abuse or neglect):

1.6.7 Explain the safeguarding process to the resident (or to any other person who has told you about the abuse or neglect) and discuss the next steps.

1.6.8 Provide emotional support to the resident (or to any other person who has told you about the abuse or neglect).

1.6.9 Do not contact the alleged abuser about the incident yourself, unless this is essential (for example, if a manager needs to immediately suspend a member of staff).

1.6.10 Do not investigate the situation yourself, because this could cause problems for police or other investigations and enquiries. Preserve any physical evidence as far as possible (for example, ask the resident to not wash or bathe), and gather information as specified in recommendations 1.6.5 and 1.6.6.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on gathering information.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

Confidentiality and discussing suspected abuse and neglect

1.6.11 If someone discloses abuse or neglect, tell them that you have a responsibility to report your concerns. Tell them who you will report to, why, and when.

1.6.12 If someone discloses abuse or neglect, do not agree to keep secrets or make promises you cannot keep.

Reporting suspected abuse and neglect

1.6.13 If you suspect abuse or neglect, tell a senior member of staff and the safeguarding lead as soon as is practical (unless the alleged abuser is the only senior member of staff or the safeguarding lead). If you do not feel confident reporting within your organisation, contact:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on confidentiality, and discussing and reporting suspected abuse and neglect.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

1.7 Responding to reports of abuse or neglect

Care home safeguarding leads

1.7.1 When abuse or neglect is reported, the safeguarding lead should treat it as a safeguarding concern and:

  • ask the resident at risk what they would like to happen next

  • ensure that they have access to communication support

  • explain that you have a responsibility to report your concerns to the local authority, and tell them who you will report to, why, and when.

1.7.2 When a safeguarding concern has been reported, the safeguarding lead should look at the broader context rather than assessing the concern in isolation. Take into account:

  • if any other people (including children) are at risk as well as the resident you are concerned about

  • if there have been repeat allegations

  • if there could be a criminal offence

  • if there is a current or past power imbalance in the relationship between the resident and alleged abuser.

1.7.3 If the safeguarding lead suspects abuse or neglect, they should make a safeguarding referral to the local authority, in line with the Care Act 2014 and Care Act 2014 statutory guidance.

1.7.4 If the safeguarding lead is not sure whether to make a safeguarding referral to the local authority (because they are not sure whether they suspect abuse or neglect), they should discuss it with the local authority first.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on care home safeguarding leads.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

Local authorities

1.7.5 Local authorities should ensure that there is a process for care homes to discuss safeguarding concerns with social workers or other qualified safeguarding practitioners without formally making a safeguarding referral.

1.7.6 Local authorities should consider providing a single point of contact for care homes, local agencies and practitioners, so they can seek expert advice on safeguarding in care homes (for example, to help decide whether a referral should be made).

1.7.7 Local authorities should be aware that safeguarding referrals may come from a care home's openness and awareness of the safeguarding policy, as well as being possible signs of poor care.

1.7.8 Local authorities and other organisations involved in assessing safeguarding referrals should use professional judgement, supported by the recommendations on indicators of individual abuse and neglect. They should not be limited in their view of what abuse or neglect is, and should always consider the circumstances of the individual case.

1.7.9 When a safeguarding referral is made, the local authority should decide as quickly as possible whether this meets the legal criteria for a section 42 safeguarding enquiry (as defined in the Care Act). As soon as this is done, they should tell the resident and the care home safeguarding lead what they have decided.

1.7.10 If a section 42 safeguarding enquiry is not needed, the local authority should:

  • discuss what other support is needed with the care home and the resident

  • provide advice and support to help improve outcomes for the resident (for example, by reviewing the care and support plan and risk management procedures).

1.7.11 If a section 42 safeguarding enquiry is needed, the local authority should decide who needs to be informed or consulted, depending on the individual context. This might include:

  • 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 (for financial abuse).

1.7.12 The local authority should set up an initial planning discussion about the safeguarding enquiry with relevant people, and (if appropriate) involve staff from the care home or care home provider.

1.7.13 The local authority should appoint an enquiry lead to coordinate the work of the enquiry and act as a main point of contact.

1.7.14 For more information about conducting a section 42 safeguarding enquiry see Making Safeguarding Personal.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on local authorities.

Full details of the evidence and the committee's discussion are in:

1.8 Working with and supporting the resident at risk during a safeguarding enquiry

1.8.1 At the start of the safeguarding enquiry, the enquiry lead should ask the resident at risk what they would like the enquiry to achieve and how they would like to be involved.

1.8.2 The enquiry lead should ensure that the resident at risk has the chance to review and revise their desired outcomes throughout the process (if needed using speech and language therapy, non-instructed advocacy or other communication and decision-making aids).

1.8.3 Involve the resident at risk (and their family or an appropriate advocate) throughout the enquiry process, in line with their wishes and mental capacity, unless there are exceptional circumstances that justify their exclusion.

1.8.4 For more guidance about supporting decision making for residents who may lack capacity, see the NICE guideline on decision making and mental capacity.

1.8.5 Make reasonable adjustments to enable residents to fully participate in the safeguarding enquiry, in line with the Equality Act 2010.

1.8.6 Safeguarding Adults Boards should be assured that local authorities have auditing processes in place to monitor how residents and their advocates are included in safeguarding enquiries.

Sharing information

1.8.7 The enquiry lead should ask the resident at risk:

  • if they would like to be kept up to date during the enquiry

  • how much detail they want

  • what format they would prefer this in

  • who they would like to contact them.

1.8.8 If the police are involved in a safeguarding enquiry, the enquiry lead should hold early discussions with the case officer on the rules of communication and information recording.

1.8.9 When safeguarding enquiries finish, the enquiry lead should provide feedback for the resident (and their family and advocates) that:

  • summarises the enquiry, and includes the relevant outcomes and recommendations

  • gives them the information needed to decide whether they wish to take any further action (for example, informing the Care Quality Commission or making a complaint to the Local Government and Social Care Ombudsman).

Working with advocates

1.8.10 For guidance on finding out how residents want to be supported in decision making, see recommendation 1.2.1 in the NICE guideline on decision making and mental capacity.

1.8.11 All organisations involved with safeguarding adults in care homes should:

  • understand the role of advocacy in relation to safeguarding, and that the advocate is the only person who acts solely according to instructions from the resident

  • think about the resident's needs and know when to refer people for advocacy

  • involve an independent advocate for the resident, when this is required by the Care Act 2014 and Care Act 2014 statutory guidance or the Mental Capacity Act 2005

  • ensure that anyone supporting the resident as an informal or independent advocate has been identified in line with the resident's statutory rights to advocacy under the Care Act and the Mental Capacity Act.

1.8.12 Care homes should tell residents:

  • how advocates can help them with safeguarding enquiries

  • that they may have a legal right to an advocate, and what the criteria for this are.

1.8.13 Practitioners involved in managing safeguarding concerns should build effective working relationships with advocates and other people supporting the resident.

1.8.14 Local authorities and commissioners should monitor:

  • whether care homes are telling residents about advocacy and the criteria for accessing this and

  • how advocates are involved in the management of safeguarding concerns.

Support during a safeguarding enquiry

1.8.15 Ask the resident at risk who they would like to support them through the enquiry (in addition to any legal rights to advocacy).

1.8.16 Provide practical and emotional support to the resident at risk:

  • while the enquiry is taking place

  • when the enquiry has finished, to help deliver the outcomes the person wishes to achieve

  • as needed after the enquiry (for example, by updating the care and support plan or protection plan, conducting risk assessments, or through future reviews).

1.8.17 Consider referring the resident for other specialist support (such as psychological support) after the enquiry.

1.8.18 Provide information and support to informal advocates chosen by the resident at risk (for example, family and friends).

1.8.19 Everyone involved with a safeguarding enquiry should remember that the resident is entitled to and may benefit from support (regardless of their mental capacity).

1.8.20 Ensure that the same level of support is offered to residents who self-fund their care and to residents whose care is publicly funded.

1.8.21 Be aware that when the alleged abuser is another resident, they may also need support (including advocacy). Manage the risks between residents while any enquiry takes place and work with relevant commissioners.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on working with and supporting the resident at risk during a safeguarding enquiry.

Full details of the evidence and the committee's discussion are in evidence review D: responding to and managing safeguarding concerns and evidence review E: support and information needs.

1.9 How care home providers and managers should support care home staff during an enquiry

Supporting staff who are subject to a safeguarding enquiry

1.9.1 Care home providers and managers should:

  • be aware of how safeguarding allegations can affect the way other staff and residents view a person subject to a safeguarding enquiry

  • take steps to protect the person from victimisation or discriminatory behaviour.

1.9.2 When a member of staff is subject to a safeguarding enquiry, care home providers and managers should:

  • tell them about any available Employee Assistance Programme

  • tell them about professional counselling and occupational health services (if available)

  • nominate someone to keep in touch with them throughout the enquiry (if they are suspended from work).

1.9.3 Staff who are subject to a safeguarding enquiry should be able to request that the nominated person be replaced, if they think there is a conflict of interest.

1.9.4 The nominated person should not be directly involved with the enquiry.

1.9.5 If the police are involved, care home providers and managers should tell them who the nominated person is.

1.9.6 For members of staff who return to work after being suspended, care home providers and managers should:

  • arrange a return-to-work meeting when the enquiry is finished, to give them a chance to discuss and resolve any problems

  • agree a programme of guidance and support with them.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting care home staff who are subject to a safeguarding enquiry.

Full details of the evidence and the committee's discussion are in evidence review E: support and information needs.

Supporting care home staff

1.9.7 Unless they are subject to the safeguarding enquiry themselves, care home managers should:

  • find out from the local authority what they can share with staff at each stage of the enquiry

  • communicate as much as possible with all staff about the enquiry, and be open to answering questions.

1.9.8 During safeguarding enquiries, care home managers should:

  • acknowledge that enquiries are stressful and that morale may be low

  • think of ways to support staff (such as one-to-one supervision and team meetings)

  • provide extra support to cover absences as part of the enquiry, and to help staff continue providing consistent and high-quality care.

1.9.9 If a care home manager is subject to a safeguarding enquiry, the care home or care home provider should put an acting manager in their place.

1.9.10 If staff are concerned about working with a resident who has made allegations, care home managers should:

  • provide support, additional training and supervision to address these concerns

  • ensure that the resident is not victimised by staff.

1.9.11 Care home managers should direct staff to sources of external support or advice if needed.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting care home staff.

Full details of the evidence and the committee's discussion are in evidence review E: support and information needs.

1.10 How local authorities should support care homes during an enquiry

1.10.1 Local authorities should ensure that there is a single point of contact to keep the care home informed about the progress of the safeguarding enquiry.

1.10.2 Local authorities should be aware of the reputational impact on the care home's business (for example, on recruitment, resourcing and financial losses), and ensure that their actions are timely and proportionate.

1.10.3 Local authorities should be aware that care home staff may be anxious about their job security because of a safeguarding enquiry.

1.10.4 Local authorities should offer:

  • positive feedback to care homes when they handle safeguarding concerns well

  • practical support to care home staff, to help with safeguarding enquiries.

1.10.5 Local authorities should share the outcomes of safeguarding enquiries with commissioners, so that they can incorporate the findings into their own decisions (for example, whether to lift a placement embargo).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on how local authorities should support care homes during an enquiry.

Full details of the evidence and the committee's discussion are in evidence review E: support and information needs.

1.11 Meetings during a safeguarding enquiry

1.11.1 Only exclude people from a safeguarding meeting if this is in accordance with the safeguarding policy. If people have to be excluded from a meeting, explain why and give them a chance to share their views in another way.

1.11.2 If the care home manager and the care home provider safeguarding leads are not at a safeguarding meeting, the chair of the meeting should ensure they are informed of the outcome and the reasons behind it.

1.11.3 Keep the resident at risk informed about the outcome of the meetings. If the outcome is not what the resident was expecting, the chair of the meeting should take particular care to explain the reasons behind it.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on meetings during a safeguarding enquiry.

Full details of the evidence and the committee's discussion are in evidence review D: responding to and managing safeguarding concerns and evidence review G: multi-agency working at the operational level in the context of safeguarding.

1.12 Indicators of organisational abuse and neglect

This section describes indicators that should alert people to the possibility of organisational abuse or neglect within a care home, and immediate actions that should be taken. It does not go into detail about the process for raising a concern, making a referral or conducting an enquiry. This process will vary depending on the nature of the allegations, and the local arrangements in place for responding to such allegations.

This section is for anyone in contact with care home residents, including staff, volunteers, visiting health and social care practitioners, other residents, family and friends, and any other visitors to the care home.

Local authorities and others involved in care home quality assurance may wish to adapt and incorporate these indicators into notification and safeguarding referral guidance or quality assurance frameworks.

There is no one size fits all approach for managing and responding to organisational abuse. This is because of the huge range of actions and inactions that may contribute to organisational abuse, at all managerial and financial levels within organisations. Organisational abuse can also be caused by a single act of neglect or omission. However, commissioners should be alert to any allegations of organisational abuse within care homes, as part of their responsibility for monitoring standards of care against contractual requirements.

Organisational abuse (also known as institutional abuse) is distinct from other forms of abuse or neglect, because it is not directly caused by individual action or inaction. Instead, it is a cumulative consequence of how services are managed, led and funded. Some aspects of organisational abuse may be hidden (closed cultures), and staff may act differently when visitors are there (disguised compliance). Organisational abuse can affect one person or many residents. Therefore, it is important to consider each unique case, and the impact on individual residents as well as the whole care home.

The terms 'consider' and 'suspect' are used to define the extent to which an indicator suggests abuse or neglect, with 'suspect' indicating a stronger likelihood of abuse or neglect.

None of the indicators are proof of abuse or neglect on their own. Instead, they are signs that the recommendations on actions to take if you consider or suspect organisational abuse should be followed. See the indicators of organisational abuse and neglect visual summary for a summarised view of this pathway.

When to consider abuse or neglect

Lack of safeguarding policy, procedure, accountability or governance

1.12.1 Consider organisational abuse when:

  • 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

    • complaints

  • the care home has policies and procedures covering safeguarding, whistleblowing and complaints, but does not use them

  • the care home policy and procedure on safeguarding is inconsistent with the Care Act 2014 or this guideline

  • residents, visitors, staff and other people working in care homes do not have access to policies and procedures covering safeguarding, whistleblowing and complaints

  • the care homes 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 are not involved in how the care home is run.

Not meeting contractual or regulatory requirements.

1.12.2 Consider organisational abuse when care homes:

  • do not meet contractual safeguarding requirements

  • do not meet national regulations, including the fundamental standards of quality and safety monitored by the Care Quality Commission

  • fail 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)

  • fail to sustain improvements

  • do 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.

Mismanagement of safeguarding concerns and poor record-keeping

1.12.3 Consider organisational abuse when:

  • 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).

Staffing

1.12.4 Consider organisational abuse when:

  • 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.

Quality of care and service provision

1.12.5 Consider organisational abuse when:

  • there is evidence of poor medicines management (for example, excessive use of 'as needed' medicines)

  • restrictive practice is used:

    • 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

    • 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.

Failure to refer for appropriate care or support

1.12.6 Consider organisational abuse when:

  • residents miss appointments or are not referred to other professionals or services (such as GPs or dentists)

  • people who require independent advocacy are denied access to it.

Financial mismanagement and lack of investment

1.12.7 Consider organisational abuse when:

  • there are not enough staff on each shift to meet the needs of residents

  • there are problems with care home equipment:

    • it does not meet the needs of residents

    • it is poorly maintained

    • 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).

Physical signs and lack of openness to visitors

1.12.8 Consider organisational abuse when:

  • the care home is dirty or smelly, or is not compliant with basic infection control (for more information about infection control see the NICE quick guide on helping to prevent infection)

  • 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.

Actions to take if you consider abuse or neglect

1.12.9 For indicators starting with 'consider'

  • raise the matter with the care home manager, in writing if possible

  • explain the impact on residents, or the likely impact if the situation continues

  • ask for a response within a specified period of time (for example 2 weeks)

  • if the manager agrees to make changes, make sure these happen

  • after taking these steps, if the situation does not improve, raise your level of concern to 'suspect'.

When to suspect organisational abuse or neglect

1.12.10 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.

Actions to take if you suspect abuse or neglect

1.12.11 If you 'suspect' abuse or neglect:

  • Contact your local authority and tell them that you want to make an adult safeguarding referral.

  • When local authorities receive adult safeguarding referrals:

    • they should gather information, under section 4 of the Care Act

    • they must decide if there is reasonable cause to suspect that an adult with care and support needs is experiencing abuse or neglect and is unable to protect themselves from harm

    • if this criteria is met, they must conduct a section 42 enquiry.

  • If many residents of a care home are affected, local authorities may conduct a large-scale enquiry, following their own local procedures.

  • If you are not satisfied with the response from your local authority, you can make a complaint to the Local Government and Social Care Ombudsman and give feedback to the Care Quality Commission.

1.12.12 When organisational abuse or neglect is identified, plan what individual or collective support is needed for residents, staff, and other people who might be affected.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on indicators of organisational abuse and neglect.

Full details of the evidence and the committee's discussion are in evidence review C: tools to support recognition and reporting of safeguarding concerns.

1.13 How care homes should learn from safeguarding concerns, referrals and enquiries

1.13.1 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.

1.13.2 Care home managers should incorporate learning from safeguarding concerns, referrals and enquiries into the care home culture at all levels:

  • individual staff, for example through changes to support, supervision, retraining, and performance management)

  • care home, for example through:

    • observations of practice, discussion and watching people work across the home

    • changing practices, procedures, policy and learning, and group training (including training from other health and social care practitioners)

  • care home provider, for example through policy changes).

    In addition, see the recommendations on care home culture, learning and management.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on how care homes should learn from safeguarding concerns, referrals and enquiries.

Full details of the evidence and the committee's discussion are in evidence review I: embedding organisational learning about safeguarding.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Care homes

Residential care homes (with or without nursing care) that are registered with and regulated by the Care Quality Commission.

Care home providers

Companies that own and operate one or more care homes that are regulated by the Care Quality Commission.

Commissioners

Local authorities, clinical commissioning groups and other public sector commissioners who oversee contracts for care and support services provided by care homes that pay for care home residents who are eligible for public funding. The term 'commissioner' does not apply to individuals who pay privately for their care.

e-learning

Induction, training and assessment that people undertake on a computer or mobile device, without interacting with other people.

Enquiry lead

Sometimes referred to as the lead enquiry officer or enquiry officer. This person is appointed by the local authority when a safeguarding enquiry begins. They may be a local authority social worker or a designated member of staff from the care home or care home provider. They are responsible for coordinating responses to the enquiry, coordinating decision making and acting as the main point of contact. They make sure that enquiry actions are undertaken in accordance with Care Act duties, related statutory guidance and the recommendations in this guideline.

Face-to-face learning

Induction, training and assessment that is undertaken one-to-one, or in groups led by either in-house staff experts, managers or external trainers. It may take place with participants all in the same room, or using video or telephone conferencing. It may include online materials, but participants are able to ask questions, discuss, reflect on current practice and use case studies and examples. This type of training looks at how safeguarding relates to the particular role of the person being trained, and to the personalised care and support needs of residents.

Multi-agency

Organisations working together in the context of safeguarding adults in care homes. Relevant organisations include:

  • local authorities and health and social care services

  • the police and other organisations in the criminal justice system

  • education and learning services

  • advocacy services

  • local voluntary and community groups.

National organisations or complaints services can also be included (such as the Local Government and Social Care Ombudsman).

Reflective practice and reflective supervision

Opportunities for staff to:

  • reflect on previous practice

  • talk about why they made the decisions they made, and why they acted or behaved in particular ways

  • talk about their emotional responses to their actions and the actions of others

  • engage in continuous learning.

Reflective practice and supervision may also provide insight into personal values and beliefs, and help staff understand how these influence action and decision making within the care home.

Registered managers

Care homes registered with the Care Quality Commission must have a registered manager, in line with the Health and Social Care Act 2008. The registered manager is responsible for leading and running the care home and making sure that standards are upheld. Note that other managers may also work within care homes and have responsibilities for staff supervision, line management, or other aspects of running the home. However, the registered manager is the person accountable to the Care Quality Commission for the standards of care and safeguarding within the home.

Residents

Adults aged 18 and over who live in and receive care and support in care homes, or who use care homes to access care and support from time to time (for example respite care, including day care).

Resident at risk

The resident at the centre of a safeguarding concern, when:

  • abuse or neglect is considered or suspected or

  • a safeguarding referral has been made to a local authority or

  • a section 42 safeguarding enquiry is taking place.

Safeguarding adults reviews

Must be arranged by Safeguarding Adults Boards if:

  • there is reasonable cause for concern that partner agencies could have worked more effectively to protect an adult and

  • when serious abuse or neglect is known or suspected and

  • if certain conditions are met, in line with section 44 of the Care Act 2014 and related statutory guidance.

Safeguarding champions

Safeguarding champions are staff already working within the care home, with good knowledge of safeguarding policy and procedure, who help ensure that procedures are followed and are available for discussion. They also ensure reflective learning about best practice in preventing abuse and neglect. Champions may also offer practical and emotional support to those worried about the impact of raising concerns. They are not a replacement or alternative to the safeguarding lead.

Safeguarding concern

For the purposes of this guideline, a safeguarding concern is defined as a consideration, suspicion or indication of abuse or neglect of a resident, or residents within a care home. Anybody who works in, lives in or visits the home may have a safeguarding concern, either because of something they have seen or because of something they were told. All safeguarding concerns should be responded to in line with this guideline. Note that this definition relates to concerns in care home settings. For a more general definition, see the Local Government Association and ADASS definition in their report on understanding what constitutes a safeguarding concern.

Safeguarding enquiry

If the local authority agrees that the safeguarding referral falls within the duty set out within section 42 of the Care Act 2014 and related statutory guidance, they must undertake an enquiry into the suspected abuse or neglect. Note that this definition relates to enquiries about abuse and neglect in care homes. For a more general definition, see the Local Government Association and ADASS definition in their report on understanding what constitutes a safeguarding concern.

Safeguarding lead

This may be the care home registered manager or someone with delegated responsibility for safeguarding within the care home. It is a statutory requirement for care homes to have a designated safeguarding lead. Safeguarding leads should have had training in safeguarding, and should have the relevant skills and competencies to ensure the safety and protection of residents, in line with Care Quality Commission guidance.

Safeguarding referral

As outlined in this guideline, if abuse or neglect is suspected this must be reported to the local authority. This is called making a safeguarding referral.

Service providers

Other organisations providing services within care homes or contracted by care homes to provide services. These include health and social care services (for example, GP services, clinical psychology and occupational therapy), and other services such as cleaning, catering, gardening, transport, education, learning or activities.

Staff

Anyone paid to work in a care home and involved either directly or indirectly in the care and support of residents. This includes care workers, nurses, managers, administrative staff, cleaners, caterers, gardeners or anyone else who the care home employs directly or via agencies or contractors, on a casual, part-time, full-time, temporary or permanent basis.

Contract or temporary staff

Staff who are not employed on a permanent contract with the care home, who may be supplied by an employment agency on a short-term basis, or who might be employed on a zero hours contract or on a casual labour basis.