Should Osborne go too?

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Behaviours that challenge

It’s taken me a while to finish this but my new book ‘Behaviours that challenge’ is now on sale on The Care Guy website. Only a tenner plus P&P.

Go on, you know you want to

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Often the advice given to social care workers about behaviours that challenge makes their problems worse instead of better. This easy to follow workbook is full of no nonsense tips, techniques and ideas for dealing with the behaviours YOU face at work (and at home).

Contents

Introductory questionnaire
What is Challenging Behaviour?
Legal principles
Theories of behaviour and interaction
Different types of Challenging Behaviours
Its only behavioural
Philosophy and challenging behaviour (rights, paternalism and intervention – people are just people)
Assertiveness – as opposed to aggression, passivity and passive-aggression
Assessing behaviour – ABC, the Pleasure Principle, lessons from research
Basic behavioural management – classical and operant conditioning, reinforcement, gradual progression
Boundaries and the escalation or recession of inappropriate behaviours
The importance of the whole team approach
The problem with punishment
Expectations
Questionnaire
Answers to safeguarding quiz

Petition to prosecute ATOS & the DWP

Yes, I know, some of my readers voted for the callous hyenas who support this ongoing cruelty. But hey – we all make mistakes.

Perhaps a prosecution (or even a large collection of signatures) will send a message

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to ConDem MPs preparing to face the electorate in a little over a year. Either way – this inhuman government and the profiteering ATOS really should be called to account.

Will you sign?

Woohoo! Welcome back, Inspector Brown

Inspector Michael Brown is back!

Within the last hour @MentalHealthCop resumed on Twitter and announced that the Mental Health Cop blog is available for public scrutiny again.

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This is truly fantastic news.

If mental health and/or rights interest you go and have a look. Follow @MentalHealthCop on Twitter too. You won’t be disappointed.

Safeguarding 12: Record, report, communicate

Rachel Baker used to be the manager of Parkfields Residential Care Home in Butleigh, Somerset. In 2010 she was convicted of the manslaughter of 97 year old resident, Lucy Cox who died in November 2006. Baker, a registered nurse was addicted to the controlled substances prescribed for her elderly residents.

Rachel BakerIt is unclear exactly why Baker gave the elderly resident a lethal overdose of medication. It may have been in error due to her own intoxication or it may have been deliberate. The verdict of manslaughter and not murder suggests that there is insufficient evidence to demonstrate deliberate killing although there was evidence given suggesting that Baker had mentioned euthanasia to Lucy Cox a few days earlier.

Her systematic deceit as she lied to inspectors, fellow workers and carers made her crime hard to detect. In fact it was the actions of Parkfield colleagues (arguably the only people in a position to raise the alarm) that led to her discovery. It is her repeated deception that led to Baker also being convicted of perverting the course of justice.

This serious illustration of the need for workers to speak up is an example of why it is so important for workers to speak up. It also shows why the alerter is not the investigator and why there’s no need to collectevidence before speaking out.

Rachel Baker’s coworkers were in no position to establish the facts. That was the task of the police. However, without the courage of those care workers the police would have had no reason to investigate in the first place. A killer would have continued to practice. As it happened two Parkfield workers contacted the Commission for Social Care Inspection (CSCI) and ‘the system’ stepped in.

The principle is clear:

If you suspect abuse – be the alerter.

About the Safeguarding series

This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.

Come back soon Mental Health Cop

I still can’t quite understand this.

Yesterday, along with many others in the online mental health community I learned that the Mental Health Cop (AKA Inspector Michael Brown) had disappeared from the internet. Michael’s multi award winning blog (www.mentalhealthcop.wordpress.com) has been a truly incredible resource for anyone interested in or professionally concerned with the interface between mental health care, law and police intervention.

I really don’t know what has happened except that Michael’s employer (West Midlands Police) appears to have had an issue with something he wrote on line. The upshot is that his blog has gone and his twitter account (@mentalhealthcop) is also inaccessible at present. Up to the minute news will be available via the #mentalhealthcop hashtag on Twitter as literally thousands of subscribers to Michael’s blog follow events.

I sincerely hope that this matter is resolved quickly and that Michael is able to resume his fantastic work very soon. More than that though I’d just like to add my voice to the many who wish Michael well personally. He is very definitely one of the good guys.

Come back soon Mental Health Cop. We miss you.

Safeguarding 11: Neglect

neglectNeglect is a criminal offence linked to the concept of the ‘duty of care’. In fact it is impossible to convict a person of neglect unless they did indeed have a duty of care toward the person whose needs have been neglected.

To make sense of this just imagine how ridiculous it would be to prosecute some random stranger whenever a person’s care needs are neglected. The stranger is not guilty of neglect because the neglect had nothing to do with them. They were not expected to deliver the care in the first place.

Neglect then is the failure to fulfil one’s duty of care.

What then do we mean by ‘duty of care’?

In every job there are specific duties and responsibilities that need to be met. These vary depending upon the job itself but most people are clear about what their responsibilities are. However in terms of safeguarding there are a number of less obvious meanings of the word ‘neglect’.

For example the Protection of Vulnerable Groups Act 2006 and the Adult Support & Protection (Scotland) Act 2007 both reiterate the long-standing duty all health and social care workers have to report abuse. This means that if we are aware of abuse, perhaps by a colleague, and do nothing we also will be guilty of neglect. Employers who fail to deal appropriately with allegations of abuse among their workforce are also guilty of abuse and could face criminal prosecution.

This may seem hard but it is a necessary part of health and social care work for several reasons.

Bullies are attracted to work involving vulnerable adults;
Care staff are often the only people in a position to spot abuse;
Service-users are often dependent upon us for their safety.

When I make this point during training sessions people often object on the grounds that the alerter (the person reporting abuse) may themselves face problems with the rest of their colleagues if they ‘rock the boat’. This is true and I’m not about to pretend that it’s easy to be the alerter. However I would like to make the following points:

The law is what it is and it won’t change just because we might not like it;
Being unpopular for a while is not so bad as prosecution, conviction and a ban from working in social care because we didn’t report what we saw.

It’s also important to realise that there are two distinct roles in adult protection. One is ‘alerter’ and the other ‘investigator’. The alerter is not – indeed cannot be the investigator except in extreme circumstances.

This means that the alerter does not need evidence to report their concerns. Gathering evidence is the job of the investigator. If you have a suspicion, even if you have no proof, your duty is to report it, nothing more. If you wait until you have proof the abuse may go unreported for months or even years. This is not in the best interests of the service-user. In any case, most alerters are not in any position to investigate – that needs management authority or even police powers on occasion. Don’t wait for something you might never get.

You must not discuss your concerns with the alleged abuser. If you do you may increase the risk to the service-user and also interfere with what may become a police investigation. Simply report your concerns and then ‘walk away’ unless you are given a specific task to perform by your manager. This is as much a part of your duty of care as any other element of your work so failing to comply means neglect just as surely as failing to feed, clothe or care for those in our care who need it.

Some acts of parliament such as the Mental Capacity Act 2005 (itself another ‘layer’ of safeguarding for those who lack capacity) create and define their own offence of ‘wilful’ neglect. This is the offence of failing to learn about or comply with the law as it relates to our work. For example since April 1st 2007 it has been an offence to assume a person lacks the capacity to make their own decisions without first helping them to decide. This is just one of many examples where practice has had to change in recent years to avoid ‘wilful neglect’.

Another is the duty of care we all have as care workers to assess a person’s mental capacity before performing care tasks. Failure to do so could result in up to five years imprisonment depending upon the circumstances and the seriousness of the situation. That’s why all members of care staff are expected to understand how to assess mental capacity from the nurse or doctor to the support worker and care assistant.

The law changes. Practice must change too.
If you still do what you did 5 years ago you may be breaking the law.

About the Safeguarding series

This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.

Safeguarding 9: Discrimination

As most people are aware many forms of discrimination are unlawful in British society as they are throughout much of the rest of the world. However the nature of discrimination (what it actually means) isn’t always so clearly understood. The confusion about what is and is not discrimination isn’t helped by the way that certain individuals or groups claim ‘discrimination’ when really they are simply failing to get their own way.

A recent example of this involves the Bristol ‘Healing On The Streets’ (HOTS) team. This faith-based group published materials claiming that any and all ailments from mental disorders to cancer would be cured by the power of prayer. They did not state this as mere opinion but rather they presented it as fact without any reasonable evidence to support the claim. This would be a problem in any organisation, not just a religious ministry.

Hayley Stevens is a paranormal investigator who was ‘leafleted’ by a member of the HOTS team. She was concerned that the published material may offer ‘false hope’ to desperate and vulnerable people. She was also concerned that it might discourage people from seeking medical care and so she contacted the Advertising Standards Authority (ASA) who upheld her complaint and ordered the group to remove such claims from its publications. The HOTS team subsequently issued a statement claiming that Hayley represented a group, generally opposed to Christianity. They have since removed that statement from their website.

Criticising fraudsters for false advertising is fair comment. The reason for criticism of the HOTS team is not their religion, it is their unethical behaviour in making false claims that would be a problem whoever produced the publicity.

We can see then that what does or does not constitute discrimination depends upon relevance. It would be discriminatory to say that all religious people are liars but it is not discriminatory to ask all people, religious or not, for evidence to back up claims of miracle treatments and to expect them to abide by the law and by accepted advertising standards when they cannot.

It is when we make unreasonable distinctions between people that we are guilty of discrimination. For example when we make assumptions about someone based upon characteristics that have nothing to do with the issue at hand. This sort of discrimination, based upon irrelevancies, is what happens when people make judgements based upon skin colour, religious affiliation, nationality, ethnicity, disability, profession or sexual preference. Skin colour for example has nothing to do with trustworthiness and disability does not invalidate a person’s right to be treated with respect. In both cases, colour and disability, the ‘condition’ is irrelevant to the point under consideration.

However the fact that an individual belongs to a group that is regularly discriminated against does not mean that they can do no wrong. A gay man who assaults his neighbour in a dispute about a garden fence will still be prosecuted. But he will be prosecuted because of the assault. His sexuality is irrelevant. He may claim discrimination on the grounds of his sexuality but his claim will not be taken seriously by the courts because his sexuality is not relevant to the case at hand.

On the other hand a gay couple refused accommodation in a hotel or guest house would be supported under anti-discrimination legislation for exactly the same reason. Their sexuality is not relevant to their right to use services.

Similairly if the manager of a residential drug rehabilitation unit were to evict an Asian man because of his use of illicit substances on the premises he could not then claim racial discrimination. The eviction would be because of the rules of the service which are applied equally to all service-users regardless of skin colour or racial type. Colour is simply irrelevant and therefore the decision to evict is not discriminatory – it is simply an appropriate response.

The basic ‘rule of thumb’ then is to ask if the alleged discrimination is relevant. Is your action the result of the individual’s need or behaviour or is it motivated by the fact that they belong to a particular group.

If it’s because of individual circumstances and would be the same whatever subgroup the person belonged to then it’s probably not discrimination. I say probably not because there is the additional aspect of institutional discrimination that we will consider in a later post. If it’s because of the subgroup they belong to (eg religion, LGBT, disabled, Asian etc) then there’s a good chance you really are discriminating.

As ever ‘relevance’ is the key when deciding whether or not you’re being discriminatory.

About the Safeguarding series

This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.

Safeguarding 7: Sexual abuse

It is a fundamental principle of law that people must consent to sexual encounters before they can be considered legal. Sexual contact without consent can constitute a variety of criminal offences, all of which come under the wider definition of ‘abuse’.

This idea of ‘consent’ is very clear when we consider ‘forced’ offences such as a violent rape or sex with a minor who is not yet sufficiently mature to give informed consent. Even with adults who might usually be deemed to have the capacity to consent situations can arise that might invalidate that capacity such as drug-assisted rape. Even ‘taking advantage’ of a drunken partner can constitute an offence because their ability to consent (and therefore to withhold consent) is impaired.

Other situations that can impair consent involve the relative status of those involved. This is why, even between adults, sex involving someone who is in ‘a position of trust’ can be unlawful. For example a teacher who seduces a sixteen year old pupil might face prosecution even though his or her pupil is old enough to consent. The relationship they share breaches the trust normally expected in such a situation.

Workers in health and social care are also in a position of trust and the dynamics of the care relationship can distort consent just as the relationship between teacher and pupil can. This means that even if the service-user appears to consent there is likely to be a problem.

The Safeguarding Vulnerable Groups Act 2007 builds upon the legal definitions laid down in the ‘No Secrets’ document and emphasises the issue as does the Sexual Offences Act 2003. Sexual encounters that abuse a position of trust are likely to result in prosecution. This is also true of offences that are not physical but still come under the sexual abuse umbrella of offences as we shall see later.

Some service-users have such impaired understanding that they can’t really consent to sex at all with anyone in any circumstances whether involving someone in a position of trust or not. In these circumstances the superficial solution would be to prevent all sexual experiences and often this is precisely what happens but not always.

To simply prevent all sexual activity would be to ignore the need for a full quality of life, including the need for sexual fulfilment. This enforced celibacy might not really be in their best interests. So, even though an individual may not fully understand all the implications of sexual contact that other people might consider, if they express a genuine desire for a ‘full’ relationship this may be supported by ‘the system’ if other circumstances are ‘right’.

Such decisions should be taken in consultation with the local Adult Protection or Safeguarding team. It’s too big a decision for care providers themselves. Remember that safeguarding vulnerable adults is a concern for the whole of society and so society has put in place a system to manage it.

For workers in the ‘front line’ then, if you have any doubts about a service-user’s ability to consent you must inform the Local Authority (LA) Safeguarding team straight away.

Of course not all sexual abuse involves penetration or even physical contact at all. Inappropriate suggestion, comment or innuendo is also sexual abuse. Most people understand the idea of sexual harassment as it applies to people who are not in our care. The same principles apply for service-users but with even more emphasis than for the rest of us. Basically, the less able an individual is to protect themselves the more they are protected in law.

Comments that embarrass or demean the individual can fairly be described as psychological/emotional abuse but if they are of a sexual nature then they might also be sexual abuse. It doesn’t matter how inoffensive the carer or worker might consider their comments to be. Once we know that the service-user is at all uncomfortable with our words we need to reconsider them.

It is particularly important to take care how we may be perceived when delivering ‘intimate’ care. As well as the obvious considerations about who delivers that care, the sex of the worker for example, the conversation between carers and service-users or even between carers themselves can be humiliating for the vulnerable adult in our care. There is no excuse for knowingly humiliating, embarrassing or otherwise distressing service-users in these situations. I have heard tales of care workers discussing intimate details of their own sexual encounters whilst ‘intimately’ assisting elderly ladies who were offered no choice about whether or not they wanted to listen. Quite apart from the fact that the care staff were ignoring the people they were employed to care for (and presumably to care about) this is hardly the time or the place for such discussions.

Unfortunately it is this area of sexual abuse – the embarrassing or degrading comment – that is most misunderstood. There are many reasons why people involved in intimate care develop a sense of humour that might be misconstrued by their service-users or other interested observers. This does not make them ‘bad’ people or even inappropriate carers. They just may need to stop and think more about how they ‘come across’ to the service-user.

We can see then that sexual abuse might mean a range of different things and also that it depends upon the context of the relationship, the interpretation and the understanding of the service-user.

It’s also vital that we are able to understand and acknowledge cultural and religious differences between carers and the vulnerable adults they care for. This is more than the well-publicised concerns that particular religious groups might have, for example the inappropriateness of male carers bathing Islamic women. There is a relatively marked cultural divide between the generations and although there are exceptions it is a general principle that elderly ladies will have different values from the young adults who care for them.

If we assume that the majority of sexual abuse is unintended (and, with the exception of physical assaults, I think that’s probably true) then it’s worth taking the time to learn a bit about the values and culture of our service-users.

References and further reading

Department of Health (2000) No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse, London, Department of Health.

Sexual Offences Act 2003:

http://www.opsi.gov.uk/acts/acts2003/ukpga_20030042_en_1

Sexual Offences Act 2003 sentencing guidelines:

http://www.sentencing-guidelines.gov.uk/docs/0000_SexualOffencesAct1.pdf

About the Safeguarding series

This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.

Safeguarding 6: Physical abuse

The definition of physical abuse may seem obvious and to many I’m sure it will be but it still warrants some description. The process of outlining what we mean by physical abuse will also allow me to make another point about abuse definitions in general:

Although different forms of abuse can be categorised separately there is considerable ‘crossover’ between types of abuse in practice. This means that a single abusive event can fall into several different categories.

The basic illustration of physical abuse (and the one that springs most readily to mind for most people) is physical violence. This is understandable. It is obvious, for the most part unambiguous and the effects of violence upon the physical body are often very easy to spot. However it’s not the only example.

Failure to provide adequate nutrition is also a form of physical abuse because it has a detrimental effect upon the physical body. Failure to administer medication or deliberately withholding medication is also a form of physical abuse for the same reason. These are also examples of neglect and very possibly would result in psychological/emotional harm as well. Particular abuses can fall into several different categories.

Consider the practice of withholding meds, food or any other need as a form of punishment or ‘behaviour modification’. If you are deliberately trying to ‘teach a person a lesson’ by withholding something to which they are legally entitled this is a form of punishment. The European Convention on Human Rights is very clear about this sort of practice – the significant phrase is:

“No punishment without law”

At the opposite end of the scale is more active abuse such as the over use of tranquilisation (prescribed or otherwise) which could also be physical abuse. The use of physical restraints or barriers to contain people or to prohibit movement may also represent physical abuse. This is not always the case as on occasions it is appropriate and justifiable to restrict a person’s freedom of movement, for example with the use of safety harnesses when transporting them in a wheelchair or in certain circumstances the use of door locks to prevent people from leaving unattended.

However such restrictions need to be proportionate and in the individual’s best interests to be lawful.

This is not the same as saying that the family demand it or staffing levels mean we need to lock the door.

If any such restriction crosses the line to become an actual deprivation of liberty then formal authorisation must be sought via the Deprivation of Liberty Safeguards process.

Other forms of physical abuse might involve inappropriate temperature regulation (seasonally inappropriate clothing or maintaining the environment at an unreasonably high or low temperature), overly rough physical care. Insensitive/inadequate provision of food as well as hurried or unreasonable practice whilst assisting people to eat are also good examples.

One excellent ‘rule of thumb’ when thinking about abusive practice of all kinds, including physical abuse, is to consider how you might react if this happened to you. If you would be affronted by it there’s a reasonable chance that the experience would be a breach of your rights. This isn’t 100% reliable as a guide to abuse but it’s a pretty good starting place.

Bear in mind that your service-user has exactly the same rights as you have unless there is a legally justifiable way to say otherwise. Simply being a service-user/resident/patient or whatever isn’t sufficient to remove a person’s rights. If it was then anyone who is registered with a family doctor (GP) would give up their rights too. We’re all service-users but we still have rights.

This notion of rights and the fact that we all begin with the same rights is essential to understanding the reality of abuse and safeguarding in health and social care. These rights are our legal entitlements and liberties and as such they can only be taken away if the law says so. To put it another way:

The law giveth – the law taketh away.

If you are considering physical restraint or any other form of physical intervention ask yourself this question:

If I had to explain this to a court would the judge be satisfied?

Of course very often the judge would be completely satisfied. Circumstances count for a great deal but if the intervention seems in any way like neglect or punishment then you might find it harder to justify.

About the Safeguarding series

This blog series first appeared on Stuart’s personal blog early in 2010. It has been reposted here as part of a process of ‘rationalisation’ in which work from several blogs has been removed and reposted on only two.

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