3.1 Categories of abuse

1. Physical Abuse

This includes assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions.

Possible indicators include:

• Unexplained or inappropriately explained injuries;
• Person exhibiting untypical self-harm;
• Unexplained cuts or scratches to mouth, lips, gums, eyes or external genitalia;
• Unexplained bruising to the face, torso, arms, back, buttocks, thighs, in various stages of healing. Collections of bruises that form regular patterns which correspond to the shape of an object or which appear on several areas of the body;
• Unexplained burns on unlikely areas of the body (for example: soles of the feet, palms of the hands, back), immersion burns (from scalding in hot water / liquid), rope burns, burns from an electrical appliance;
• Unexplained or inappropriately explained fractures at various stages of healing to any part of the body;
• Medical problems that go unattended;
• Sudden and unexplained urinary and/or faecal incontinence'
• Evidence of over / under medication;
• Person flinches at physical contact;
• Person appears frightened or subdued in the presence of particular people;
• Person asks not to be hurt;
• Person may repeat what the alleged abuser has said (for example: ‘Shut up or I’ll hit you’);
• Reluctance to undress or uncover parts of the body;
• Person wears clothes that cover all parts of their body or specific parts of their body;
• A person without Capacity not being allowed to go out of a care home when they ask to;
• A person without Capacity not being allowed to be discharged at the request of an unpaid carer/family member.

2. Domestic Abuse

In the context of this policy, Domestic Abuse is included with reference to individuals who are considered to be adults at risk.

The cross-government definition of domestic violence and abuse is: any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:

• Psychological;
• Sexual;
• Financial;
• Emotional;
• Honour-based violence;
• Female genital mutilation (FGM).

A new offence of coercive and controlling behaviour in intimate and familial relationships was introduced into the Serious Crime Act 2015. The offence will impose a maximum 5 years imprisonment, a fine or both. The offence closes a gap in the law around patterns of coercive and controlling behaviour during a relationship between intimate partners, former partners who still live together, or family members, sending a clear message that it is wrong to violate the trust of those closest to you, providing better protection to victims experiencing continuous abuse and allowing for earlier identification, intervention and prevention.

The offence criminalising coercive or controlling behaviour was commenced on 29 December 2015. See: Statutory guidance framework: controlling or coercive behaviour in an intimate or family relationship.

2.1 Honour-Based Violence

Honour -based violence is a crime, and referral to the police must always be considered. It has or may have been committed when families feel that dishonour has been brought to them. Women are predominantly (but not exclusively) the victims, and the violence is often committed with a degree of collusion from family members and/or members of the community. Many of these victims are so isolated and controlled that they are unable to seek help. Safeguarding concerns that may indicate honour based violence include domestic violence, concerns about forced marriage, enforced house arrest and missing persons’ reports. If a concern is raised through a Safeguarding Adults Referral, and there is a suspicion that the adult is the victim of honour-based violence, a police referral is required. When dealing with victims, do not speak with them in the presence of their relatives. Women who return to their families should be offered support including, escape plans, the option to deposit DNA samples, finger prints and photograph with the police.

2.2 Female Genital Mutilation (FGM)

Female Genital Mutilation (FGM) is a collective term for procedures which include the removal of part or all of the external female genitalia for cultural or other non-therapeutic reasons. The practice is medically unnecessary, extremely painful and has serious health consequences, both at the time when the mutilation is carried out and in later life. The procedure is typically performed on girls aged between 4 and 13, but in some cases it is performed on young women before marriage or pregnancy.

FGM is a criminal offence in the UK; under the FGM Act 2003 it is also an offence for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where the practice is legal.

Multi-agency statutory guidance on female genital mutilation

Female Genital Mutilation Risk and Safeguarding

2.3 Forced Marriage

Forced marriage is where one or both of the parties is married without their Consent or against their will. A forced marriage differs from an arranged marriage, in which both parties Consent to the assistance of their parents or a third party in identifying a spouse.

Anyone threatened with forced marriage or forced to marry against their will can apply for a Forced Marriage Protection Order. Third parties, such as relatives, friends, voluntary workers and police officers, can also apply for a protection order with the leave of the court. Local authorities can seek a protection order for Adults at Risk and children without leave of the court. Guidance published by the Ministry of Justice explains how local authorities can apply for protection orders and provides information for other agencies. This is available on the Justice website).

The Anti-social Behaviour, Crime and Policing Act 2014 made it a criminal offence, with effect from 16 June 2014, to force someone to marry. This includes:

• Taking someone overseas to force them to marry (whether or not the forced marriage takes place);
• Marrying someone who lacks the mental Capacity to consent to the marriage (whether they’re pressured to or not).

Breaching a Forced Marriage Protection Order is also now a criminal offence. The civil remedy of obtaining a Forced Marriage Protection Order through the family courts, as set out above, continues to exist alongside the criminal offence, so victims can choose how they wish to be assisted.

Forcing someone to marry can result in a sentence of up to 7 years in prison.

Disobeying a Forced Marriage Protection Order can result in a sentence of up to 5 years in prison.

In a situation where there is concern that an Adult at Risk is being forced into a marriage they do not or cannot Consent to, there will be an overlap between action taken under the forced marriage provisions and the Safeguarding Adults Process. In this case action will be coordinated with the police and other relevant organisations.

Predatory Marriage is generally understood as a situation when a younger person marries an older person in order to receive an inheritance. The older person may have been groomed over a period of time and/or be someone who lacks capacity to marry, thus making such a marriage also a forced marriage under the Anti-social Behaviour, Crime and Policing Act of 2014 and so unlawful. Predatory marriage of adults who lack capacity to consent is a safeguarding issue. In addition to being a forced marriage, it can be linked to a range of abuses and so falls within the remit of the Care Act 2014.

Much of the work in this new field of safeguarding has been completed by Daphne Franks who founded Justice for Joan.

My Marriage, My Choice is a project for people with a learning disability.

See also:

Handling Cases of Forced Marriage: Multi-Agency Practice Guidelines.

Forced Marriage and Learning Disabilities: Multi-Agency Practice Guidelines

3. Sexual Abuse

Including 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 consenting.

Any sexual relationship that develops between adults where one is in a position of trust, power or authority in relation to the other (for example, day centre worker / social worker / residential worker / health worker etc.) may also constitute Sexual Abuse.

Possible indicators include:

• Person has urinary tract infections, vaginal infections or sexually transmitted diseases that are not otherwise explained;
• Person appears unusually subdued, withdrawn or has poor concentration;
• Person exhibits significant changes in sexual behaviour or outlook;
• Person experiences pain, itching or bleeding in the genital/anal area;
• Person’s underclothing is torn, stained or bloody;
• A woman who lacks the mental Capacity to Consent to sexual intercourse becomes pregnant.

Sexual exploitation: The sexual exploitation of Adults at Risk involves exploitative situations, contexts and relationships where Adults at Risk (or a third person or persons) receive ‘something’ (for example: food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of performing, and / or others performing on them, sexual activities.

Sexual exploitation can occur through the use of technology without the person’s immediate recognition, this can include being persuaded to post sexual images on the internet or via mobile phone with no immediate payment or gain or being sent such an image by the person alleged to be causing Harm.

In all cases those exploiting the Adult at Risk have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources.

4. Psychological Abuse

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

Psychological abuse is the denial of a person’s human and civil rights including choice and opinion, privacy and dignity and being able to follow one’s own spiritual and cultural beliefs or sexual orientation.

Possible indicators include:

• Untypical ambivalence, deference, passivity, resignation;
• Person appears anxious or withdrawn, especially in the presence of the alleged abuser;
• Person exhibits low self-esteem;
• Untypical changes in behaviour (for example: continence problems, sleep disturbance);
• Person is not allowed visitors / phone calls;
• Person is locked in a room / in their home;
• Person is denied access to aids or equipment, (for example: glasses, dentures, hearing aid, crutches, etc.);
• Person’s access to personal hygiene and toilet is restricted;
• Person’s movement is restricted by use of furniture or other equipment;
• Bullying via social networking internet sites and persistent texting.

4.1 Exploitation by Radicalisers who Promote Violence

Radicalisation is defined as the process by which people come to support extremism that can lead to terrorism, and, in some cases to then participate in terrorist groups. If there are concerns related to an Adult at Risk being targeted for radicalisation, a concern should be raised and a referral to Channel made.

• Prevent Guidance;
• Channel Guidance.

5. Financial or Material Abuse

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

It includes the withholding of money or the unauthorised or improper use of a person’s money or property, usually to the disadvantage of the person to whom it belongs.

Staff borrowing money or objects from a service user is also considered financial abuse.

Possible indicators include:

• Lack of money, especially after receipt of benefits;
• Inadequately explained withdrawals from accounts;
• Disparity between assets / income and living conditions;
• Power of Attorney obtained when the person lacks the Capacity to make this decision;
• Concerns about management by a Department of Work and Pensions appointee;
• Recent changes of deeds / title of house;
• Recent acquaintances expressing sudden or disproportionate interest in the person and their money;
• Service user not in control of their direct payment or individualised budget;
• Mis-selling / selling by door-to-door traders / cold calling;
• Illegal money-lending;
• Internet scams, postal scams and doorstep crime are more often than not, targeted at adults at risk and all are forms of financial abuse. These scams are becoming ever more sophisticated and elaborate.
  For example:
  • Internet scammers with very convincing websites;
  • People can be referred to a website to check the caller’s legitimacy but this may be a copy of a legitimate website;
  • Postal scams are massed-produced letters which are made to look like personal letters or important documents;
  • Doorstep criminals call unannounced at the adult’s home under the guise of legitimate business and offering to fix an often non-existent problem with their property. sometimes they pose as police officers or someone in a position of authority.
• In all cases this is financial abuse and the adult at risk can be persuaded to part with large sums of money and in some cases their life savings. These instances should always be reported to the local police service and local authority Trading Standards Services for enquiry;
• These scans and crimes can seriously affect the health, including mental health, of an adult at risk. Agencies working together cab better protect adults at risk. Failure to do so can result in an increased cost to the state, especially if the adult at risk loses their income and independence;
• Where the abuse is perpetrated by someone who has the authority to manage an adult’s money, the relevant body should be informed - for example, the Office of the Public Guardian for deputies or attorneys and Department for Work and Pensions (DWP) in relation to appointees;

​Report on The Financial Abuse of Older People [PDF, 471KB]

Think Jessica Campaign

6. Modern Slavery

• Modern slavery encompasses slavery, human trafficking, 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;
• Human trafficking involves acts of recruiting, transporting, transferring, harbouring or receiving a person through a use of force, coercion or other means, for the purpose of exploiting them. If an identified victim of human trafficking is also an Adult at Risk, the response will be coordinated under the Safeguarding Framework;
• The police are the lead agency in managing responses to adults who are the victims of human trafficking;
• There is a national framework to assist in the formal identification and help to coordinate the referral of victims to appropriate services, known as the National Referral Mechanism. N.B.: This has recently been reviewed by the Home Office and the evaluation of the pilot response is awaited.

Modern Slavery: how to identify and support victims

Modern Slavery Act

Modern Slavery Awareness and Victim Identification Guidance (Home Office)

Modern slavery: how the UK is leading the fight (Home Office)

Home - Unseen

Stop the Traffik

7. Discriminatory Abuse

This includes forms of harassment, slurs or similar treatment; because of race, gender and gender identity, age, disability, sexual orientation or religion.

This type of Abuse is motivated by discriminatory and oppressive attitudes towards people on the grounds of disability, gender reassignment, age, race, religion or belief, sex and sexual orientation, and political beliefs. It may be a features of any form of Abuse of an Adult at Risk, and manifests itself as Physical Abuse / assault, Sexual Abuse / assault, Financial Abuse / theft and the like, Neglect and Psychological Abuse/harassment, including verbal abuse and racist, sexist, homophobic or ageist comments, jokes or any other form of harassment. It also includes not responding to dietary needs and not providing appropriate spiritual support.

Definitions of Protected Characteristics

Possible indicators include:

• Indicators for Discriminatory Abuse may not always be obvious and may also be linked to acts of Physical Abuse and assault, Sexual Abuse and assault, Financial Abuse, Neglect, Psychological Abuse and harassment, so all the indicators listed above may apply to discriminatory abuse;

• A person may reject their own cultural background and/or racial origin or other personal beliefs, sexual practices or lifestyle choices;
• A person making complaints about the service not meeting their needs.

7.1 Hate crime

A hate crime is any criminal offence that is motivated by hostility or prejudice based upon the victim's:

• Disability;
• Race;
• Religion or belief;
• Sexual orientation;
• Transgender identity, and as such should be reported to the police.

If the victim of hate crime is an Adult at Risk, Part 2: Safeguarding Framework - should be followed, with appropriate referrals made for early Police involvement.

7.2 Disability Hate Crime

‘Disability’ means any physical or mental impairment. There is no statutory definition of a disability-related incident. However, the Crown Prosecution Service definition is: ‘Any incident, which is perceived to be based upon prejudice towards or hatred of the victim because of their disability or so perceived by the victim or any other person’. It also applies to relevant cases where the offender has assumed a person is disabled, whether or not that assumption is correct. For further information for regarding disability hate crimes, visit the CPS website.

8. Organisational Abuse

This includes neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’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.

This may take the form of isolated incidents of Neglect, and poor or unsatisfactory professional practice at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other.

Repeated instances of poor care may be an indication of more serious problems, and this is sometimes referred to as Institutional Abuse.

It may be a result of regimes, routines, practices and behaviours that occur in services that Adults at Risk live in or use and which violate their Human Rights. This may be part of the culture of a service to which staff are accustomed and may pass by unremarked upon. They may be subtle, small and apparently insignificant, yet together may amount to a service culture that denies, restricts or curtails the dignity, privacy, choice, independence or fulfilment of Adults at Risk. It can occur in any setting providing health or social care.

 A number of inquiries into care in residential settings have highlighted that Institutional Abuse is most likely to occur when staff:

• Receive little support from management;
• Are inadequately trained;
• Are poorly supervised and poorly supported in their work;
• Receive inadequate guidance.

It is also more likely to occur where there are inadequate quality assurance and monitoring systems in place.

Possible indicators include:

• Unnecessary or inappropriate rules and regulations;
• Lack of stimulation or the development of individual interests;
• Inappropriate staff behaviour, such as the development of factions, misuse of drugs or alcohol, failure to respond to leadership;
• Restriction of external contacts or opportunities to socialise;
• Staff attitudes, where staff may view clients negatively, treating them like children, not involving them in making choices as they seem too confused or disabled. Staff may think that if clients do not appear to understand then they can talk in front of them as if they are not there.

8.1 Staffing Issues

Staffing levels are insufficient to provide appropriate and timely intervention required to meet the complete range of physical and social needs:

• Routines: Routines can become too set and rigid and may be fixed around the needs of staff, for example, bathing routines, bedtimes set around the staff rotas and not around the individual;
• Lack of choice and consultation: About social needs, personal care needs, activities etc;
• Lack of personal belongings: Lack of personal care items, shared toiletries, bulk-buying of personal care items, lack of personal clothing;
• Task-focused: Where staff are focused on getting the job done rather than spending time with clients. Lack of staff training, staff do not have the required knowledge/skills to provide care. No training has been provided;
• Staff Morale: Staff can feel undervalued, can lack supervision or training. Staff conditions can be poor. Staff can experience work-place stress which is not being addressed by colleagues and their manager. Low staff self-esteem can lead to an environment in which Abuse becomes the norm;
• Policies and procedures: Care Plans do not reflect the needs and wishes of the service users. Care Plan evaluation and record keeping do not contain evidence of implementation of care. Poor recruitment procedures leading to inappropriate appointments, for example appointing staff with convictions for theft.

8.2 Environment

The care environment is not suited to care is unsafe, that is during building works rendering the area not compliant with Health and Safety legislation.

The environment is dirty and does not comply with hygiene /control and infection standards.

9. Neglect or Acts of Omission

This includes 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.

Neglect also includes a failure to intervene in situations that are dangerous to the person concerned or to others, particularly when the person lacks the mental Capacity to assess risk for themselves.

Neglect and poor professional practice may take the form of isolated incidents or pervasive ill treatment and gross misconduct. Repeated instances of poor care may be an indication of more serious problems.

Neglect can be intentional or unintentional.

Possible indicators include:

• Person has inadequate heating and/or lighting;
• Person’s physical condition/appearance is poor (for example ulcers, pressure ulcers, soiled or wet clothing);
• Person is malnourished, has sudden or continuous weight loss and/or is dehydrated;
• Person cannot access appropriate medication or medical care;
• Person is not afforded appropriate privacy or dignity;
• Person and/or a carer has inconsistent or reluctant contact with health and social services;
• Callers/visitors are refused access to the person;
• Person is exposed to unacceptable risk.

New Criminal Offence of Willful Neglect

From 13 April 2015, section 20 of the Criminal Justice and Courts Act 2015 applies to individuals such as doctors, dentists, nurses and care staff, and it states: "It is an offence for an individual who has the care of another individual by virtue of being a care worker to ill-treat or willfully to neglect that individual."

The offence focuses on the conduct of the individual, not the outcome. It is to do with what the worker actually did (or failed to do) to the patient, rather than any harm that resulted.

Section 21 sets out the circumstances where a care provider commits an offence; organisations and individuals face different thresholds for the offence. For organisations the offence focuses on the way their activities are managed and organised, and whether an incident amounts to a gross breach of a relevant duty of care owed to the patient.

The Department of Health has given examples to show what the offence is not meant to do, and these include:

• Penalising genuine accidents or errors;
• Hindering the free exercise of clinical judgement;
• Hindering organisations from making considered decisions on selection criteria for particular treatments.

10. Self Neglect

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

It should be noted that self-neglect may not prompt a section 42 safeguarding enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.