Wellbeing Principles

The wellbeing principles from Section 1 of the Care Act [3] are:

Personal dignity
Physical and mental health and emotional wellbeing
Protection from abuse and neglect
Control by the individual over their day-to-day life
Participation in work, education, training or recreation
Suitability of living accommodation
Domestic, family and personal relationships
Social and economic wellbeing
Contribution to society

All work with adults related to care and support has to adhere to these principles.

Health Inequalities

Health is determined by a complex interaction between individual characteristics, lifestyle and the physical, social and economic environment. Health inequalities are avoidable, unfair and systematic differences in health between different groups of people.

Health inequalities affect people grouped by a range of factors:

Socio-economic factors, for example, income
Geography, for example, region or whether urban or rural
Specific characteristics including those protected in law, such as sex, ethnicity or disability
Socially excluded groups, for example, people experiencing homelessness [4]

These differences have a huge impact because they result in people who are worse off experiencing poorer health and shorter lives [5].

Taking action to reduce health inequalities is a key aim of the NHS Long Term Plan, published in 2019 [6].

Safeguarding Case Study Example

There are many forms of slavery and trafficking including sexual exploitation, domestic servitude, criminal exploitation and forced labour. In this case study we look at a scenario where modern slavery in the form of forced labour may be occurring. Individuals seeking better employment prospects are being manipulated into exploitative labour practices under false claims. Industries that commonly exploit for labour include agriculture, warehouse and distribution, manufacturing and food processing – sectors that require shift work and can hire through agencies that offer zero-hour contracts.

Anton is a 28-year-old Polish man, he attends the Emergency Department, he does not speak much English and is accompanied by another man who speaks English well and calls himself a friend although he is unable to provide an address for Anton. Anton is very thin, dirty and very subdued with poor eye contact. He is wearing very dirty clothes and cannot weight bear on his right foot. His friend says they work together on a construction site and that Anton got his foot trapped under some heavy equipment and now cannot walk properly.

On examination, Anton is wearing trainers not work boots, his foot is badly damaged, and you note a number of other injuries on his body and can smell alcohol on him.

This scenario should trigger professional curiosity about what is happening to this man.

What are the concerns? What actions could you take?

Concerns

Anton appears in a poor state of general health as well as the acute foot injury.

He appears weak and confused with a smell of alcohol despite arriving from a construction site yet is not wearing any protective clothing including work boots.

He cannot speak for himself due to the language barrier and his non-verbal interaction is also poor, his friend is speaking for him.

Actions

Anton must be given a chance to speak to health professionals to ensure he gets the correct medical treatment and support and his wishes are known. Do not use any accompanying person as interpreter for the potential victim; if safe to do so, access an independent interpreter, see your local area protocol for access to interpreting.

Anton is showing signs of being a victim of modern slavery which must be explored further. He may be part of a group of people being abused in this way.

If Anton shares information that suggests he is being abused and exploited, a trauma informed approach must be used, and his responses and injuries carefully documented. The usual principles of consent apply to any referrals considered.

Usual principles of mental capacity apply as set out in the Capacity section; individuals should be presumed to have the capacity to make decisions, including about their care and decisions on whether to agree to, or refuse, an examination, investigation or treatment, unless it is established that they lack capacity. Speak to your safeguarding lead for advice. You can also contact:

The Police on 999 if an emergency or 101 if no immediate danger
The Modern Slavery Helpline on 08000 121 700 providing confidential advice and support whether you are sure or not that someone is a victim
The Gangmasters and Labour Abuse Authority to report concerns about the mistreatment of workers on 0800 432 0804, or by email intelligence@glaa.gsi.gov.uk
Report to local authority safeguarding adults and/or children team depending on the ages suspected

Victims may have had limited or poor access to healthcare services which may exacerbate any medical conditions.

Healthcare professionals are in a unique position to help identify victims and to make a difference to their lives by…

Healthcare professionals are in a unique position to help identify victims and to make a difference to their lives by treating their injuries from physical violence or from occupational hazards, their illnesses from poor environmental conditions or from infectious diseases, their sexual health conditions linked to sexual abuse and exploitation, as well as helping to manage the psychological effects of their traumas.

Making Safeguarding Personal

Making Safeguarding Personal (MSP) requires a shift in culture and practice in a response to what we know about what makes safeguarding more or less effective from the perspective of the person being safeguarded. It's about having a conversation with people about how we might respond in safeguarding situations in a way that enables their involvement, choice and control as well as improving quality of life, well-being and safety. It is:

A personalised approach that enables safeguarding to be done with, not to, people
A practice that focuses on achieving meaningful improvement to people's circumstances rather than just on ‘enquiry' and ‘conclusion’
An approach that utilises social work skills rather than just ‘putting people through a process’
An approach that enables practitioners, families, teams and SABs to know what difference has been made

''Unless people's lives are improved, then all the safeguarding work, systems, procedures and partnerships are purposeless.

Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services ADASS; LGA, 2013.

The safeguarding process should be set out in your local multi-agency safeguarding adults with care and support needs procedures.

This will include the local authority’s assessments that inform the safeguarding plan. For further information please see your local multi-agency safeguarding plan and the national guidance in resources.

The Adult Safeguarding Duty

The adult safeguarding duty applies to an adult, aged 18 or over, who:

Has needs for care and support (whether or not the local authority is meeting any of those needs)
Is experiencing, or at risk of, abuse or neglect
As a result of those care and support needs is unable to protect themselves from either the risk, or the experience, of abuse and neglect
The person’s inability to protect themselves must be the result of their care and support needs

What about the local authority’s role in carrying out enquiries?

Local authorities must make enquiries, or cause others to do so, if they reasonably suspect an adult who meets the above criteria is at risk of being abused or neglected.

In many cases, a health professional who already knows the adult, or if the enquiry is clinical in nature, may be best placed to begin the enquiry, following discussion with the local authority.

An enquiry could range from a conversation with the adult, representative or advocate (if they lack capacity or have substantial difficulty in understanding the enquiry) prior to initiating a formal enquiry under Section 42, right through to a much more formal multi-agency plan or course of action.

What about the Safeguarding Adults Section 42 enquiry?

A Section 42 enquiry will:

Protect the adult from abuse and/or neglect in accordance with their views and wishes (discovered in consultation with relatives, friends or advocate where needed) about the level of risk
Establish the facts
Assess the level of risk and needs of the adult for protection, support and redress and consider how they might be met
Make decisions about what follow-up actions should take place with regards to the person or organisation causing harm
Enable the adult to achieve resolution and recovery

When should an enquiry be undertaken without consent?

An enquiry should be undertaken without consent when:

The adult lacks the mental capacity to consent even after all practicable measures to maximise capacity have been carried out
It would be in the best interests of an adult lacking capacity to carry out enquiries
There is an overriding public interest due to others being at risk

What should an enquiry take into account?

Providing individuals with information about options for resolution
The individual's wishes and outcomes
The individual's need for care and support, the risk of abuse or neglect, and the impact they may have on that individual
The ability of the individual to safeguard themselves or the ability of their informal networks to increase the support they offer to safeguard the person (asset based)
The potential impact on important relationships and the potential that action could increase the risk of harm
Risk of repeated/increasingly serious acts including risks to others (adults/children)
Supporting the individual to identify and manage risks
Safeguarding enquiries and interventions must be undertaken within a framework of respect for the person's rights such as the right to liberty, autonomy and rights to private family life

Safeguarding adults is everybody’s business if you identify a concern you have a responsibility to raise and document it. You should be familiar with your organisation's policy and procedures for safeguarding adults which will align to the multi-agency policies and procedures for safeguarding adults that your local Safeguarding Adults Board oversee, facilitate and define the relationships between agencies to safeguard adults appropriately. The local authority is the lead accountable agency for safeguarding adults’ enquiries while the police lead on any criminal element. Health services and staff have a key role to play in identifying, recording, and raising concerns and then working in partnership with the local authorities (and police where necessary) to achieve the best outcome for the adult(s) involved.

The Mental Capacity Act

The Mental Capacity Act (MCA) [7] is the law which must be followed to assist and support people who may lack capacity and to discourage anyone who is involved in caring for them from being overly restrictive or controlling.

It also aims to balance people’s right to make decisions for themselves, and live as they choose, with their right to be protected from harm if they lack capacity to make decisions to protect themselves.

Anyone paid to work with, or on behalf of, someone who lacks capacity must ‘have regard to’ the MCA statutory code of practice.

In order to assess an individual's capacity, functional and diagnostic tests need to be carried out. Chapter 4 of the MCA code of practice describes how and when assessments of capacity should be carried out.

The MCA set up Independent Mental Capacity Advocates (IMCA) who MUST be instructed, and then consulted, for people lacking capacity who have no one else to support them in situations set out in Chapter 10 of the MCA Code of Practice.

The MCA [7] is based on five statutory principles, which must form the basis of decision making whenever someone aged 16 or above might lack mental capacity for a specific decision at the time it needs to be made. The MCA is fundamental to the Safeguarding Adults agenda.

There are five principles to the Mental Capacity Act [7]. Watch the video to find out more.

1. Assumption of capacity

This means that nobody has to prove that they have capacity for a certain decision. The responsibility lies with someone who wishes to act under the MCA to show, on the balance of probability, that the person does lack capacity to make the decision.

2. Take all practical steps to support a person to make a decision

This means a person-centred search for what will help this individual to make their own decisions: this could be finding the best time of day, or a quiet place, or the best way to communicate with this individual. Chapter 3 of the MCA code of practice outlines ways to achieve the necessary best practice.

3. Unwise decisions

A series of unwise decisions, or a particularly risky, uncharacteristic decision, may alert you to a possible lack of capacity. If this happens, apply the two-stage test of capacity (see MCA code of practice, chapter 4). But remember that we all make, with capacity, what other people might think ‘unwise or eccentric’

4.Best interests

The MCA lays out a statutory checklist of factors that must be considered in working out what is in the best interests of the person. Crucial among these factors are the wishes and feelings of the person. These wishes and feelings must sometimes be overruled in their best interests, but they should be honoured wherever possible. See MCA code of practice, chapter 5 [4]. When to instruct an Independent Mental Capacity Advocate (IMCA) An IMCA must be instructed, via the local authority, and then consulted when a person has no one other than paid staff to support them and: An NHS body is proposing serious medical treatment An NHS body or local authority is proposing to arrange accommodation or a change of accommodation, in a hospital or a care home and - the person will stay in the hospital more than 28 days or - they will stay in the care home longer than 8 weeks. An IMCA may be instructed to support someone who lacks capacity to make decisions concerning care reviews where there is no one else to consult - or adult protection cases where family and friends are involved

5. Least restrictive option

This is the ‘golden thread’ that runs through the MCA [4]. Always look for the option, among those available, that is the least restrictive of the person’s freedom of choice, and the closest to what they want.

Advocacy

Advocacy means getting support from another person to help a person express their views and wishes, and help stand up for their rights. There are many types of advocacy available where a person requires this support or has no-one to represent them. An advocate is truly independent and is there to support rights wishes and feelings of the person involved and not to offer their own opinion or persuade a person to a particular decision.

Statutory Advocacy services that support people in relation to the Care Act, Mental Capacity Act or Mental Health Act, are provided through the local authority who can advise on which type of advocate a person may need.

An advocate can

An advocate can:

Listen to the person's views and concerns
Help the person explore their options and rights (without pressuring them)
Provide information to help the person make informed decisions
Help the person contact relevant people, or contact them on their behalf
Accompany and support the person in meetings or appointments

An advocate will not

An advocate will not:

Give their personal opinion
Solve problems and make decisions for a person
Make judgements about a person

Deprivation of Liberty Safeguards (DoLS)

The Deprivation of Liberty Safeguards (DoLS) protect the rights of people aged 18 or over who lack capacity to consent to treatment in care homes, or hospitals, in England in Wales. A DoLS authorisation is required when the way they are cared for, in order to be given necessary care or treatment, deprives them of their liberty. DoLS provide this protection by ensuring that the deprivation of liberty cannot be arbitrary but must follow a process laid down in law, so that anyone can understand it, and the person has a right to challenge the deprivation of liberty in a court.

In settings other than care homes and hospitals, such as supported living or shared lives settings, or for people aged 16 or 17, the commissioner (or, if the care is privately funded, the local authority) must apply directly to the Court of Protection for authority to deprive the person of their liberty.

You can also contact the DoLS team in the adult care department ur local authority.

What is the ‘acid test’?

A Supreme Court ruling in 2014 widened the understanding of what constituted deprivation of liberty in the so-called ‘acid test'. It applies wherever a person lacks capacity to consent to the arrangements needed to provide necessary care or treatment and is not free to leave the care or treatment setting and is under continuous supervision and control in that setting.

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