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The synthesis of art and science is lived by the nurse in the nursing act

Josephine G Paterson

Safeguarding vulnerable adults


Betts V et al (2014) Safeguarding vulnerable adults.
Nursing Standard. 28, 38, 37-41. Date of submission: November 20 2013; date of acceptance: January 27 2014.

Abstract
This article explores some of the issues surrounding safeguarding
vulnerable adults, examines some of the related legislation and
literature, and outlines the responsibilities of those who care for this
patient group. The article describes how one hospital that specialises
in caring for people with early-onset dementia, Huntingdons disease
and alcohol-related brain injury who require additional support, has
provided staff with appropriate evidence-based information about
safeguarding adults.

Authors
Virginia Betts
Formerly staff nurse, Forest Hospital, Nottingham; currently health
visitor student, Derby University, Derby.
Diane Marks-Maran
Honorary professor of nursing, Kingston University, London, and
St Georges, University of London, London.
Trish Morris-Thompson
Director of quality and clinical governance, Barchester Healthcare,
London.
Correspondence to: marksmaran@btopenworld.com

Keywords
Abuse, duty of care, e-learning, patient care, safeguarding adults,
vulnerable patients

Review
All articles are subject to external double-blind peer review and
checked for plagiarism using automated software.

Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive
and search using the keywords above.

NURSING STANDARD / RCN PUBLISHING

ALL HEALTHCARE PROFESSIONALS have


a duty to safeguard patients, particularly those
who are unable to protect themselves from harm
or abuse (Department of Health (DH) 2011).
In 2011, the DH published principles and
practice examples on the role of healthcare
professionals in safeguarding adults. There are
also multi-agency policies and procedures in place
to protect vulnerable adults from neglect, harm
and abuse (DH 2000). The Code (Nursing and
Midwifery Council (NMC) (2008) states that
nurses have a duty to work with others to protect
and promote the health and wellbeing of those
in your care, their families and carers, and the
wider community.
Safeguarding adults is an integral part of patient
care and a legal responsibility of all healthcare
professionals. There are six main principles for
safeguarding adults published by the DH (2011)
(Table 1), which inform government policy in
this area.

Legislation on safeguarding adults


The duty to empower people to make decisions
and to be in control of their care and treatment is
underpinned by the Human Rights Act 1998, the
Equality Act 2010 and the Mental Capacity Act
2005. Empowering adult patients includes respecting
their right to make choices about their care and
treatment, including making decisions about their
safety if they have the capacity to make such
decisions even where those decisions may seem to
others to be unwise. Any actions taken without the
patients full and informed consent must have a clear
justification and be permissible in law (DH 2011).
Mental capacity is a central concept in safeguarding
that needs to be considered at all times. Person-led
safeguarding should not override the duty that
healthcare professionals have to protect others from
harm. In other words, duty of care means taking
may 21 :: vol 28 no 38 :: 2014 37

Art & science safeguarding issues


every reasonable step to identify and reduce risks
to patients, while respecting their rights to make
decisions about care and treatment (DH 2011).
The principles of proportionality and
partnership involve ensuring vulnerable adults are
aware their concerns are being taken seriously and
the degree of risk is being discussed with them,
and that all agencies will work together to protect
them. Accountability is about ensuring the person
understands the roles and responsibilities of all
agencies involved in safeguarding.

Examples of poor care


Despite legislation on safeguarding adults, there is
evidence the care of vulnerable people, including
those with learning disabilities, is inadequate and
safeguarding issues are poorly understood by
healthcare professionals. Heslop et al (2014) found
evidence of health and care disparities between
people with and without learning disabilities.
They identified the need to examine care and
service provision for people with learning

disabilities because premature deaths in this


vulnerable patient group are related to care factors
that can often be prevented.
Safeguarding vulnerable adults is an increasing
concern for healthcare providers, particularly
in light of the findings at Winterbourne View
hospital and Mid Staffordshire NHS Foundation
Trust (Care Quality Commission (CQC) 2011,
Francis 2013). Following a television programme
that exposed abuse of people with learning
disabilities and challenging behaviour by staff at
Winterbourne View, the CQC (2011) undertook
a review of care at the hospital (CQC 2011).
Findings demonstrated a lack of understanding
of the complex needs of people, and care and
treatment that did not ensure the welfare and
safety of those at the hospital. The hospital did
not take reasonable steps to identify the possibility
of abuse and prevent it occurring, and did not
respond appropriately to allegations of abuse.
Similarly, the public inquiry into Mid
Staffordshire NHS Foundation Trust (Francis 2013)
highlighted shortcomings in leadership, management

TABLE 1
Principles of safeguarding and implementation in practice
Principle

Implementation in practice

1 Empowerment.
Presumption of person-led decisions
and consent.

4Giving individuals relevant information about recognising abuse and the choices
available to them to ensure their safety.
4Giving individuals clear information about how to report abuse and crime, and any
necessary support.

2 Protection.
Support and representation for those
in greatest need.

4Providing help and support to individuals to enable them to report abuse.


4Understanding the organisations reporting arrangements for abuse and suspected
criminal offences, and reporting abuse and suspected criminal offences.
4Understanding risk assessments.

3 Prevention.
Prevention of harm and abuse is
a primary objective.

4Understanding what abuse is, how to recognise it and what vulnerable adults can do
to seek help.
4Helping vulnerable adults seek help or informing them about what they can do to
seek help.
4Providing appropriate training and guidance to staff about how to recognise signs of
abuse and take any appropriate action to prevent it.

4 Proportionality.
Proportionality and least intrusive
response appropriate to the risk
presented.

4Helping vulnerable adults to feel confident that healthcare professionals will take into
account their preferred outcomes or best interests.
4Discussing with vulnerable adults and, where appropriate, partner agencies the
proportionality of possible responses to the risk of significant harm before any
decisions are taken.

5 Partnerships.
Local solutions through services
working with communities.

4Enabling vulnerable adults to feel confident that information about them will be
appropriately shared and that agencies will work together to find the most effective
responses for their situation.

6 Accountability.
Accountability and transparency
in delivering safeguarding.

4Ensuring the roles of all agencies and the lines of accountability are clear to vulnerable
adults.
4Ensuring healthcare professionals understand what is expected of them and others.
4Ensuring agencies recognise their responsibilities to each other, act upon them and
accept collective responsibility for safeguarding arrangements.

(Adapted from Department of Health 2011)

38 may 21 :: vol 28 no 38 :: 2014

NURSING STANDARD / RCN PUBLISHING

and care, and exposed neglect and abuse of patients.


Francis (2013) made 260 recommendations,
including ensuring robust safeguarding procedures
were in place to protect vulnerable patients.

Literature review
As well as examining the legislation on
safeguarding adults and findings of independent
inquiries, the authors undertook a literature
search using CINAHL (Cumulative Index to
Nursing and Allied Health Literature). The
following keywords were used: safeguarding,
adults and nursing, and 28 relevant articles
were identified. Inclusion criteria were articles
related to safeguarding adults only, those
involving nurses and nursing, those based in
hospital and/or care home settings, and those that
emphasised awareness training in safeguarding
adults. Of the 28 articles, 16 were excluded from
the literature review because they focused on
news items rather than academic articles, children
and/or young adults, inter-agency training for
safeguarding, staff background checks or nursing
in community settings.
The abuse of adults may take many forms,
including physical abuse, neglect and acts of
omission, sexual abuse, financial abuse, verbal
and psychological abuse, and discriminatory abuse
(DH 2000, Nisbet 2013). Lawrence and Banerjee
(2010) identified several issues associated with the
safe care of older vulnerable people, particularly
in institutional settings, including an increased
incidence of dementia and physical disability, and
that most long-term care is provided in the private
sector, often by staff with minimal training in caring
for people with complex needs. Wang et al (2006)
found that 16% of staff in long-term care facilities
for older people committed acts of significant
psychological abuse, such as blaming people
verbally, ignoring their requests or refusing to accept
their opinions.
Since the independent inquiries into care at
Winterbourne View hospital and Mid Staffordshire
NHS Foundation Trust (CQC 2011, Francis 2013),
there is increased emphasis on ensuring institutions
that provide care for vulnerable adults address
safeguarding issues. The CQC (2011) stated that
such institutions must ensure systems, processes and
practices are in place to allow vulnerable adults to
live a life free from abuse and neglect.
There is a growing emphasis in the literature on
how healthcare institutions are acting to ensure
the safety of vulnerable adults by developing
policies, procedures and safeguarding practices.
Elvidge and MacPhail (2009) described the
Quality in Care model for safeguarding older

NURSING STANDARD / RCN PUBLISHING

adults. This quality assurance initiative was


developed to provide support to residential care
homes for older people in one locality in south east
England, to ensure the safety of older residents
and to improve standards of care. Older people in
residential care or nursing homes were visited by
an adult protection co-ordinator and a contracts
officer, whose job it was to carry out all aspects
of quality assurance monitoring. Rather than
having separate additional visits to monitor adult
safeguarding, the contracts officer combined
monitoring adult safeguarding with other quality
assurance monitoring functions. The process
included a tour of the residential care or nursing
home, an opportunity to talk to residents, relatives
and staff, and an audit of documents. The initiative
led to the early identification of potential risks and
the provision of information to service providers
on how to improve service quality and take
appropriate action to reduce any potential risks to
residents.
Nisbet (2013) warned that no system of
safeguarding would be able to guarantee abuse
would never occur. He argued that to minimise
the possibility of abuse of vulnerable adults in
institutional settings, organisations need to foster
a safe environment in which all staff are trained
in safeguarding, and managers provide regular
formal checks of the organisations safeguarding
policies, procedures and practices. Nisbet (2013)
also provided advice on how information about
compliance with safeguarding can be gathered,
setting up a complaints system and how to
approach residents who may be at risk. He also
addressed the need for leadership training as well
as training in safeguarding.
Safeguarding training has also been addressed
elsewhere in the literature. Cass (2012) found care
home staff often receive only minimal training
in safeguarding and when staff are trained
individually they find it difficult to change their
practice because of the culture, environment and
peer pressure at work. Cass (2012) suggested
providing safeguarding training for teams as
a way of enabling staff to work together and
support each other to improve practice. Goodall
(2012) used this team training approach to
implement a safeguarding training programme
for residential care home staff in the north west of
England, incorporating information giving, role
play, learning from case studies and engaging in
group activities. This was found to be helpful in
improving the safety of practice.
Healthcare professionals need to work in
partnership with patients, their carers and family,
and all others involved in their care, including
agencies such as social services, to safeguard
may 21 :: vol 28 no 38 :: 2014 39

Art & science safeguarding issues


vulnerable adults (Francis 2013). The organisation
providing care must also view safeguarding
adults as a core part of its business. In other
words, all staff in the organisation will have a
responsibility to safeguard adults but, in addition,
some staff will have specific responsibilities for
managing safeguarding concerns and multi-agency
procedures (DH 2011). Safeguarding policies
and procedures also need to be integrated into
patient safety procedures and clinical governance
so that individual safeguarding concerns can be
identified and managed effectively, practitioners are
supported by the organisation, and the organisation
understands its safety activity, accountability,
learning and continued improvement (DH 2011).
In summary, the literature explores the
potential for abuse as well as the legal and
statutory documents designed to prevent abuse of
vulnerable adults. The literature also highlights
the need for robust safeguarding policies,
procedures and practices, including mechanisms
for ensuring compliance, and the need for these
to be part of the organisations core business.
The importance of comprehensive training and
education in safeguarding was also identified.
All these factors were taken into consideration by
the first author of this article, when developing
a safeguarding initiative in one hospital that
aimed to ensure staff were fully aware of their
safeguarding responsibilities.

Staff training on adult safeguarding


Forest Hospital in Nottingham opened in 2013 to
provide specialist care for people with early-onset
dementia, Huntingdons disease and alcohol-related
brain injury who require increased levels of
support. Although the hospital is run by a private
healthcare provider, it works in collaboration with
the local NHS trust to provide inpatient care for
up to 50 adults under the age of 65. Care in the
hospital is led by a multidisciplinary team that
draws on the expertise of the local NHS trust and
Forest Hospital. The hospital provides care and
treatment programmes that are tailored to each
patient and have focused outcomes. One of the
guiding principles of the hospital is that recovery
is about whole lives, not just symptoms. It
represents a movement away from pathology,
illness and symptoms to health, strength and
wellness (Nottinghamshire Healthcare NHS
Trust 2013). As well as providing inpatient
facilities, the hospital serves as a base for the
community outreach team.
The patients who receive care in Forest Hospital
are all potentially vulnerable adults. One of
the staff nurses, the lead author of this article,
40 may 21 :: vol 28 no 38 :: 2014

recognised that a large number of healthcare


professionals who were appointed to work at the
hospital when it opened in early 2013 had not
worked in the care home environment before and
several were newly qualified nurses. She believed
it was important to provide information about
safeguarding vulnerable adults so staff would be
able to recognise that all patients at Forest Hospital
are potentially vulnerable and to understand
what this means. However, to provide all possible
information about safeguarding vulnerable
adults would have made an information sheet
long and cumbersome, and might have put some
staff off engaging with the information. The first
authors intention was, therefore, to provide basic
information with guidance on how to access
any additional information about safeguarding.
Therefore, a three-page information guide on
safeguarding adults, including the safeguarding
information sheet, was developed and introduced
in 2013 for use in the hospital (Box 1). The
information sheet aimed to:
4Make

the information about safeguarding easy
to read.
4Use
 simple language to make the information
easy to understand.
4Make

the information easily accessible.
4Reflect

on national guidelines about
safeguarding adults (DH 2011), the findings
of inquiries into Winterbourne View hospital
(CQC 2011) and Mid-Staffordshire NHS
Foundation Trust (Francis 2013), The Code
(NMC 2008) and recent safeguarding literature
identified in the literature review.
The information sheet included links to various
numbered hospital policy and procedure
documents, and where nurses and other healthcare
professionals could find additional resources or
further information on adult safeguarding issues.
All staff new to the hospital receive the
information guide and undertake e-learning
induction modules on safeguarding vulnerable
adults, followed by group discussions on some
of the issues raised in the information sheet and
guide, and the modules. Through the modules
and group learning, staff are introduced to and
informed about safeguarding vulnerable adults.
Feedback was sought verbally and in writing
from staff and indicated that new staff who had
not previously worked in this type of care home
found the information sheet on safeguarding
adults informative and easy to understand. Staff
stated they appreciated the opportunity to use the
information sheet on safeguarding adults in group
discussions. They also indicated that it was helpful
having a written document to which they could
refer when they needed.

NURSING STANDARD / RCN PUBLISHING

BOX 1
Safeguarding Adults Information Sheet
Safeguarding adults is everybodys business:
4Living a life that is free from harm is a fundamental right of every person. This handout may help you to identify
what may constitute abuse and explain the responsibilities of staff working with vulnerable adults. It will help
you to recognise and report any detected or suspected abuse. Staff should aim to prevent abuse by improving
the quality of life and care that vulnerable adults receive by providing better protection, patient empowerment,
support in raising concerns, and identifying and improving bad practice.
4All staff have a responsibility for ensuring they safeguard the interests of patients at all times. The misuse of
power within the staff-patient relationship can affect any patient regardless of age, gender, ethnicity, level of
ability, sexuality, culture or religious belief.
4Although illness and disability can make people vulnerable, some groups of patients are potentially more
vulnerable to abuse than others, for example those who are physically frail, or who have mental health
problems or learning disabilities.
4Staff must always treat patients with dignity and respect. This involves identifying the patients
preferences regarding care and respecting these within current standards of practice. Staff are
personally accountable for ensuring that they promote and protect the interests of patients in their care
in a non-discriminatory manner.
Abuse is violation of an individuals human and civil rights by any other person or persons (Department
of Health 2000).
Abuse whether intended or not can be carried out by any person. It may arise out of poor or ill-informed
practice, individual cruelty, negligence or neglect. Abuse may consist of a single act or repeated acts and
can occur between a staff member and patient or between patients. It may be physical, psychological,
sexual, financial, emotional or verbal. It may be neglect or an omission to act, or it may occur when a vulnerable
person is persuaded to enter into a financial transaction or sexual relationship to which he or she has not
consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to,
or exploitation of, the person.

Conclusion
Safeguarding patients has always been a professional
ethical issue. However, recent media coverage of,
and inquiries into, poor care have illustrated that
vulnerable patients may not be adequately protected
from harm and abuse. One way that all healthcare
providers can ensure that staff are fully aware of

their responsibilities with regard to safeguarding


vulnerable adults is by providing simple and easy
to understand information and training. Forest
Hospital has developed an information sheet on
safeguarding adults to increase staff awareness
and understanding of this area to improve patient
care and safety NS

References
Care Quality Commission (2011)
Review of Compliance: Castlebeck
Care (Teesdale) Ltd. Care Quality
Commission, London.
Cass E (2012) Commissioning Care
Homes: Common Safeguarding
Challenges. Social Care Institute
for Excellence, London.
Department of Health (2000) No
Secrets: Guidance on Developing
Multi-Agency Policies and
Procedures to Protect Vulnerable
Adults from Abuse. The Stationery
Office, London.
Department of Health (2011)

Safeguarding Adults: The Role of


Health Service Practitioners. The
Stationery Office, London.
Elvidge F, MacPhail G (2009) The
Quality in Care model of quality
assurance and safeguarding for older
people in institutional care. Journal
of Adult Protection. 11, 1, 28-37.

Heslop P, Blair PS, Fleming P,


Hoghton M, Marriott A, Russ L
(2014) The Confidential Inquiry into
premature deaths of people with
intellectual disabilities in the UK:
a population-based study. The
Lancet. 383, 9920, 889-895.

Francis R (2013) Report of the Mid


Staffordshire NHS Foundation Trust
Public Inquiry: Final Report. The
Stationery Office, London.

Lawrence V, Banerjee S (2010)


Improving care in care homes:
a qualitative evaluation of the
Croydon care home support team.
Aging and Mental Health. 14, 4,
416-424.

Goodall S (2012) Safeguarding adults:


practical tips for training. Nursing
and Residential Care. 14, 11, 600-603.

Nisbet RJ (2013) A practical guide


to safeguarding. Nursing and
Residential Care. 15, 1, 45-48.

NURSING STANDARD / RCN PUBLISHING

Nottinghamshire Healthcare NHS


Trust (2013) Recovery Strategy.
Health Partnerships Local Services
Forensic Services: 2013-2016.
Nottinghamshire Healthcare NHS
Trust, Nottingham.
Nursing and Midwifery Council
(2008) The Code: Standards of
Conduct, Performance and Ethics
for Nurses and Midwives. NMC,
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Wang JJ, Lin JN, Lee FP (2006)
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domestic context. Geriatric Nursing.
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may 21 :: vol 28 no 38 :: 2014 41

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