Adult abuse – advice for all

At first, you might not recognise the signs of abuse. They may appear to be symptoms of dementia or signs of the elderly person’s frailty.

Some examples of adult abuse include the following.

General signs of abuse:

• Frequent arguments between the carer and the elderly person.
• Changes in personality or behaviour in the person being abused.

Physical abuse:

• Unexplained signs of injury such as bruises, burns or scars, or more serious unexplained injuries such as broken bones.
• Report of a person taking too much of their medicines or not taking their medicines regularly (a prescription has more remaining than it should).
• Broken eye glasses or frames.
• Signs of being restrained, such as bruises on the wrists.
• Staff in a care home refusing to allow you to see the elderly person alone.

Emotional abuse:

• Threatening, belittling, or controlling behaviour by the abuser.
• Behaviour from the abused person that seems like dementia, such as rocking, sucking, or mumbling to themself.

Sexual abuse:

• Bruises around the breasts or genitals.
• Unexplained genital infections.
• Unexplained bleeding from the vagina or from the back passage.
• Torn, stained or bloody underwear.

Neglect by caregivers or self-neglect:

• Unusual weight loss because of not eating enough food or drinking enough fluids.
• Untreated physical problems, such as bedsores.
• Dirty living conditions: dirt, bugs, soiled bedding and clothes.
• Being left dirty or unbathed.
• Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards).

Financial exploitation – this may include:

• Significant withdrawals from the vulnerable person’s bank account.
• Items or cash missing.
• Suspicious changes in wills, power of attorney, policies or other documents.
• Suspicious addition of names to the person’s signature card.
• Unnecessary services, goods or subscriptions.

For more details see the sections below or the more detailed resources in our resource hub

Who are ‘Adults at Risk of harm’?
The safeguarding duties apply to an adult who:

• is 18 and over
• has needs for care and support (whether or not the local authority is meeting any of those needs)
•  is experiencing, or at risk of harm of, abuse or neglect and as a result of those care and support needs is unable to protect themselves from either the risk of harm of, or experience of abuse or neglect.

Who may have ‘Care and Support Needs’?
This may be a person who:

• is elderly and frail due to ill health, physical disability or cognitive impairment
• has a learning disability and or a sensory impairment
• has mental health needs including dementia or a personality disorder
• has a long term illness/condition
• misuses substances or alcohol.

Why might a person be vulnerable?
There are many factors that could increase the risk of abuse. Some of these are listed below:

• People dependent on others for assistance, especially with finances and personal care
• Mental incapacity, communication difficulties, decreased mobility
• Those without visitors
• Those subjected to hate crimes
• People having care in their own homes
• Not knowing where to turn to for help
• People might also think that the standard of care they are receiving is all they can expect.

Everyone is a potential victim of crime or abuse but the following conditions can increase that vulnerability:

• a learning disability
• mental health issues
• a physical or sensory impairment
• is frail or an older person.

Abuse does not have to be deliberate, malicious or planned. It sometimes happens when people are trying to do their best but do not know the right thing to do. Sometimes the person who causes harm does so because of frustration even in the caring context.

However, irrespective of why the abuse might happen, any abuse is harmful. This makes it vitally important to ensure that those involved with the care and wellbeing of adults  have a clear sense of what signifies abuse and what must happen should abuse be suspected or discovered.

Abuse can occur anywhere and is not confined to any one setting. Just because there are no records of abuse having occurred does not mean it has not happened or is happening now. It is important to remain alert for the signs at all times, for example abuse can occur:

• In a nursing, residential or day care setting
• In a persons’ own home
• In another place previously assumed safe for example: prison
• In a hospital or public place In education, training or a work place setting.

An abuser can be a spouse, partner, relative, a friend or neighbour, a volunteer worker, paid worker, practitioner, solicitor, or any other individual with the intent to deprive a vulnerable person of their resources.

Relatives include adult children and their spouses or partners, their offspring and other extended family members. Children and living relatives who have a history of substance misuse or have had other life troubles are of particular concern.

Perpetrators of adult abuse can include anyone in a position of trust, control or authority over the individual. Family relationships, neighbours and friends, are all socially considered as relationships of trust, whether or not the older adult actually thinks of the people as ‘trustworthy’.

Some perpetrators may ‘groom’ a vulnerable adult (befriend or build a relationship with them) in order to establish a relationship of trust. Older people living alone who have no adult children living nearby are particularly vulnerable to grooming by neighbours and friends who would hope to gain control of their assets.

The majority of abusers are relatives, typically an older adult’s spouse/partner or schildren; although the type of abuse differs according to the relationship, for example:

• the abuse is ‘domestic violence grown old’ – a situation in which the abusive behaviour of a spouse or partner continues into old age
• an older couple may be attempting to care and support each other and failing, in the absence of external support
• with children it tends to be financial abuse, justified by a belief that it is nothing more than the ‘advance inheritance’ of property, valuables and money.

Within paid care environments, abuse can occur for a variety of reasons. Some abuse is the wilful act of cruelty inflicted by a single individual upon an older person.

More commonly, institutional abuses or neglect may reflect lack of knowledge, lack of training, lack of support, or insufficient resourcing. Institutional abuse may be the consequence of common practices or processes that are part of the running of a care institution or service. Sometimes this type of abuse is referred to as ‘poor practice’, although this term reflects the motive of the perpetrator (the causation) rather than the impact upon the older person.

Types of abuser:

• Domineering or bullying perpetrators feel justified in abusing others; these people usually know where and when they can get away with abusive behaviour.
• Narcissistic (means inflated sense of own importance and lack of empathy for others) people are motivated by anticipated personal gain and meeting their own needs; and do this by using other people and their assets – this could include inheriting an elderly person’s home, gaining access to benefits or stealing other valuables.
• Impaired perpetrators are well-intentioned care givers who have problems that mean they are unable to adequately care for dependent adults; this includes advanced age and frailty; physical and mental illness; and developmental disabilities.
• Overwhelmed perpetrators are well intentioned care givers; however, when pressure mounts for them to provide more than they are capable of, they lash out verbally or physically and/or the quality of their care may degrade to the point of neglect. Risk factors include:
  • stress & depression
  • social isolation. See Carers…
• Sadistic perpetrators derive feelings of power and importance by humiliating, terrifying and harming others. They take pleasure in their victims’ fear and don’t feel guilt, shame or remorse (sadistic means getting pleasure from inflicting pain, suffering or humiliation).

What is the definition of abuse?
Whilst neither the Care Act 2014 nor its statutory guidance specifically defines abuse, it does state that professionals should not limit their view of what constitutes abuse or neglect as it can take many forms and the circumstances of the individual case should always be considered.

The Care Act statutory guidance goes on to provide a detailed definition of each of the ten types of abuse which is listed below. Further to this, the guidance highlights that incidents of abuse may be one-off or multiple, and affect one person or more. Therefore professionals should look beyond single incidents or individuals to identify patterns of harm.

There are many different types of abuse and they all result in behaviour towards a person that deliberately or intentionally cause harm.

It is a violation of an individual’s human and civil rights and in the worst cases can result in death.

Victims may suffer severe neglect, injury, distress and/or depression and people without capacity, such as those people with severe dementia, are particularly vulnerable.

There is additional legal protection for such people under the Mental Capacity Act 2005.

Cases of abuse can result in criminal prosecution and action being taken by the courts.

The types of abuse have been categorised and placed under ten headings, you will find that on occasions the actual behaviour you might observe or be told about could fit under more than one heading, do not worry about this, others will make a decision later in the process as to the most appropriate category under which to record the event.

Discriminatory abuse includes forms of harassment, slurs or similar treatment because of:

• race
• gender
• gender identity
• age
• disability
• sexual orientation
• religion.

Discriminatory abuse can take the form of:

• derogatory comments
• harassment
• being made to move to a different resource/service based on age
• being denied medical treatment on grounds of age or mental health
• not providing access.

Hate crimes are any crimes that are targeted at a person because of hostility or prejudice towards that person’s:

• disability – including physical impairments, Mental Health problems, learning disabilities, hearing and visual impairment
• race or ethnicity – skin colour, nationality, ethnicity or heritage
• religion or belief – faith or belief including people without a religious belief
• sexual orientation – people who are lesbian, gay, bisexual or heterosexual
• gender identity – includes people who are transgender, transsexual or transvestite.

Disability Hate Crime – targeting a person because of their disability, for example by laughing or shouting at them or physically assaulting them is classed as a hate crime.

Hate crimes can be committed against a person or property and could include:

• Physical attacks – such as physical assault, damage to property, offensive graffiti, neighbour disputes and arson
• Threat of attack – including offensive letters, abusive or obscene telephone calls or text messages, groups hanging around to intimidate and unfounded, malicious complaints
• Verbal abuse or insults – offensive leaflets and posters, abusive gestures, offensive comments and/or name calling, dumping of rubbish outside homes or through letterboxes and bullying at school or in the workplace.

A victim does not have to be a member of the group at which the hostility is targeted. In fact, anyone could be a victim of a hate crime.

A victim is also someone who witnesses another person being subjected to a hate motivated incident or crime.

A perpetrator or offender is any person who commits acts of hatred against other people because of their race, colour, ethnic origin, nationality, faith or religion, age, gender, sexuality or disability.

For more information on the different forms of hate crime can be found on the True Vision website www.report-it.org.uk

To report a hate crime
Even if you are unsure if you have been a victim of a hate crime it is important to speak to someone:

• Call Greater Manchester Police on 101 or at www.gmp.police.uk
• Call the Manchester City Council’s Hate Crime Report Line on 08000 830 007
• Report it to True Vision anonymously.

If you don’t want to call the Police you can report online or download a reporting form (which can be sent to your local police station) on the True Vision website

The Safety Net project launched aims to prevent the exploitation of people with learning disabilities by those claiming to be their friends. More information and resources can be found on their website at arcuk.org.uk/safetynet

There is an  Easy Read guide to the harassment of disabled people (March 2018)

Further easy read information about disability hate crime can be found on the Action Against Cruelty website.

For more local information visit the Making Manchester Safer pages on hate crime.

Domestic abuse is a pattern of coercive control, which includes combinations of physical, sexual, psychological and financial abuse and isolation by a current or former partner, or family member.

Family members are defined as mother, father, son, daughter, brother, sister, and grandparents, whether directly related, in laws or step-family.

Domestic abuse includes:

• psychological abuse
• physical abuse
• sexual abuse
• financial abuse
• emotional abuse
• so called ‘honour’ based violence.

Other definitions include:

• Female Genital Mutilation (FGM)
• Forced marriage (FM)
• Honour based violence (HBV)
• Prostitution and trafficking
• Sexual Violence including rape
• Sexual exploitation
• Sexual harassment
• Stalking.

More information can be found on our domestic violence and abuse resource.

Financial or material abuse includes:

• theft
• fraud
• internet scamming
• coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions
• the misuse or misappropriation of property, possessions or benefits.

Potential indicators of financial or material abuse
It is important not to jump to the wrong conclusions too quickly but the following is a list of possible indicators of financial abuse:

• sudden inability to pay bills
• sudden withdrawal of money from an account
• person lacks belongings that they can clearly afford
• lack of receptivity by the person’s relatives to necessary expenditure
• power of attorney obtained when the person is unable to understand what they are signing
• extraordinary interest by family members in the vulnerable person’s assets
• recent change of deeds of the house or property
• the main interest of the carer is financial with little regard for the health and welfare of the vulnerable adult
• the person managing the vulnerable adults’ finances is evasive and uncooperative
• reluctance to accept care services
• purchase of items that individual does not require or use
• personal items going missing
• unreasonable or inappropriate gifts.

Scams are schemes to cheat people out of their money. They come in a variety of ways; by post, phone, email, online and sometimes by a knock on the door. For more information  see our fraud, scams and safety resource and mate crime resource

Modern slavery encompasses:

• slavery
• human trafficking
• debt bondage
• sexual exploitation
• forced labour and domestic servitude.

Traffickers and slave masters use whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment.

This might mean being forced to work long hours for little or no pay; being forced into a life of abuse, exploitation and inhumane treatment; or people being trafficked or moved around.

Slavery is closer than you think – watch the new Modern Slavery advert on YouTube

Neglect and acts of omission include:

• ignoring medical, emotional or physical care needs
• failure to provide access to appropriate health care and support or educational services
• the withholding of the necessities of life, such as medication, adequate nutrition and heating.

Potential indicators of neglect and acts of omission
It is important not to jump to conclusions too quickly but the following list may be indications of many different problems:

• poor environmental conditions
• inadequate heating and lighting
• poor physical condition of the vulnerable adult
• clothing is ill-fitting, unclean and in poor condition
• malnutrition
• failure to give prescribed medication properly
• failure to provide appropriate privacy and dignity
• inconsistent or reluctant contact with health and social care agencies
• isolation – denying access to callers or visitors.

Organisational abuse includes:

• neglect
• poor care practice within an institution or specific care setting such as a hospital or care home
• poor practice in relation to care provided in a person’s own home.

This may range from one off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation.

Potential indicators of organisational abuse
It is important not to jump to the wrong conclusions too quickly but the following list may be possible indicators of organisational abuse:

• no flexibility in bedtime routine and/or deliberate waking
• people left on a commode or toilet for long periods of time
• inappropriate care of possessions, clothing and living area
• lack of personal clothes and belongings
• un-homely or stark living environments
• deprived environmental conditions and lack of stimulation
• inappropriate use of medical procedures such as enemas, catheterisation
• batch care – lack of individual care programmes
• illegal confinement or restrictions
• inappropriate use of power or control
• people referred to, or spoken to, with disrespect
• inflexible services based on convenience for the provider rather than the person receiving services
• inappropriate physical intervention
• service user removed from the home or establishment, without discussion with other appropriate people or agencies because staff are unable to manage the behaviour.

Physical abuse includes:

• assault
• hitting
• slapping
• pushing
• misuse of medication
• restraint or inappropriate physical sanctions.

Potential indicators of physical abuse
It is important not to jump to the wrong conclusion too quickly, but the list below may be indicators of potential physical abuse:

• history of unexplained falls
• unexplained bruising in well protected areas or soft parts of the body
• bruising in different stages of healing
• unexplained burns in unusual locations
• unexplained fractures to any part of the body
• unexplained lacerations or abrasions
• slap, kick, punch of finger marks
• injury shape similar to an object
• untreated medical problems
• weight loss due to malnutrition or dehydration.

Psychological abuse includes:

• emotional abuse
• threats of harm or abandonment
• deprivation of contact
• humiliation
• blaming
• controlling
• intimidation
• coercion
• harassment
• verbal abuse
• cyber bullying
• isolation
• unreasonable and unjustified withdrawal of services or supportive networks.

Potential indicators of psychological abuse
It is important not to jump to the wrong conclusions too quickly, but the following may be indicators of many different problems:

• ambivalence about carer
• fearfulness, avoiding eye contact, flinching on approach
• deference
• insomnia or the need for excessive sleep
• change in appetite
• unusual weight loss/gain
• tearfulness
• unexplained paranoia
• low self-esteem
• confusion, agitation
• coercion
• possible violation of human and/or civil rights
• distress caused by being locked in a home or car
• isolation – no visitors or phone calls allowed
• inappropriate clothing
• sensory deprivation
• restricted access to hygiene facilities
• lack of personal respect
• lack of recognition of individual rights
• carer does not offer personal hygiene, medical care or regular food or drinks
• use of furniture to restrict movement.

Self neglect covers a wide range of behaviour including neglecting to care for one’s personal hygiene, health or surroundings; and includes behaviour such as hoarding.

Types of self-neglect:

• lack of self-care to an extent that it threatens personal health and safety
• neglecting to care for one’s personal hygiene, health or surrounding
• inability to avoid self-harm
• failure to seek help or access services to meet health and social care needs
• inability or unwillingness to manage one’s personal affairs.

Indicators of self-neglect:

• very poor personal hygiene
• unkempt appearance
• lack of essential food, clothing or shelter
• malnutrition and/or dehydration
• living in squalid or unsanitary conditions
• neglecting household maintenance
• hoarding
• collecting a large number of animals in inappropriate conditions
• non-compliance with health or care services
• inability or unwillingness to take medication or treat illness or injury.

There is more information about hoarding in our hoarding resource.

Is self-neglect a safeguarding issue?
Self neglect can be a complex and challenging issue for practitioners to address, because of the need to find the right balance between respecting a person’s autonomy and fulfilling their duty to protect the adult’s health and wellbeing. Both perspectives can be supported by human rights arguments.

The statutory guidance includes self neglect in the categories of abuse or neglect relevant to safeguarding adults with care and support needs. In some circumstances, where there is a serious risk to the health and wellbeing of an individual, it may be appropriate to raise self neglect as a safeguarding concern.

However, interventions on self neglect are usually more appropriate under the parts of the Care Act dealing with assessment, planning, information and advice, and prevention.

It is vital to establish whether the person has capacity to make decisions about their own wellbeing, and whether or not they are able or willing to care for themselves. An adult who is able to make choices may make decisions that others think of as self-neglect.

If the person does not want any safeguarding action to be taken, it may be reasonable not to intervene further, as long as:

• no-one else is at risk
• their ‘vital interests’ are not compromised – that is, there is no immediate risk of death or major harm
• all decisions are fully explained and recorded
• other agencies have been informed and involved as necessary.

Risk and capacity assessments are likely to be useful. The legislation makes clear that adult safeguarding responses should be guided by the adult themselves, to achieve the outcomes that they want to achieve.

Carrying out an assessment may be difficult, if the person is reluctant. The Department of Health advises (in statutory guidance on the implementation of the Care Act 2014) that adult social care departments should record all the steps they have taken to complete an assessment of the things that a person wants to achieve and the care and support that they need. Research indicates that intervening successfully depends on practitioners taking time to gain the person’s trust and build a relationship, and going at the person’s own pace.

If it is impossible to complete the assessment, or if the person refuses to accept care and support services, you should be able to show that you have tried, and that information and advice have been made available to the person on how to access care and support and how to raise any safeguarding concerns. All your decisions, and the considerations that have led to them, should be recorded in light of the person’s wishes and their particular circumstances. You should be able to show that whatever action you have taken is reasonable and proportionate.

For more information:

• Safeguarding practice questions
• SCIE Report – 46: self neglect and adult safeguarding
• Briefing: Care Act implications for safeguarding adults

Sexual abuse includes:

• rape
• indecent exposure
• sexual harassment
• inappropriate looking or touching
• sexual teasing or innuendo
• sexual photography
• subjection to pornography or witnessing sexual acts
• indecent exposure and sexual assault or sexual acts to which the adult has not consented or was pressured into.

Potential indicators of sexual abuse
The following list may be indicators of many different problems so it is important not to jump to conclusions too quickly. Some of the indicators of sexual abuse could be as follows:

• sudden change in behaviour
• sudden onset of confusion
• incontinence
• withdrawal
• overtly sexual behaviour/language by the vulnerable adult
• self-inflicted injury
• disturbed sleep pattern/poor concentration
• difficulty in walking
• torn, stained underwear
• love bites
• pain or itching, bruising or bleeding in the genital area
• sexually transmitted disease/urinary tract/vaginal infection
• bruising to upper thighs and arms
• frequent infection
• severe upset or agitation when being bathed etc
• pregnancy in a person unable to consent.

Sexual Abuse Helpline
The Rape Crisis National Freephone is tele: 0808 802 999 or visit their website: www.rapecrisis.org.uk/