Allegations against Service Providers (including Organisational Abuse)

1. What is a Service Provider?

A service provider is any organisation that provides a paid or unpaid service to adults.

This includes both regulated and non-regulated services.

Regulated services include:

• Residential homes;
• Nursing homes;
• Domiciliary care providers (including those based in supported living and extra care schemes, and those provided in-house by the local authority or NHS Trust);
• Mental health hospitals;
• NHS Trust and independent hospitals;
• Hospices.

Non-regulated services include:

• Day centres;
• Charitable organisations providing services;
• Transport services.

2. When Concerns are Raised

As soon as the service provider is aware of the concerns, they should take corrective action and protect the adult from harm as soon as possible. As such, they should not wait until they have raised a concern before making their own initial enquiries for this purpose.

Note: Regulated providers are under a duty to take such corrective action.

The enquiries made by the service provider at this time should be carried out in line with their internal procedures.

After taking any necessary immediate action, the service provider should raise a concern to the local authority, and notify them of the initial enquiry actions undertaken to protect the adult from further harm.

Where it appears a criminal offence has taken place the service provider should notify the police as well as raise the concern.

The body commissioning the service should also be notified, for example the Local Authority, Mental Health Trust or Integrated Care Board.

If the service is a regulated service, the service provider should also notify the Care Quality Commission.

3. Allegations Against Staff Members

In all services (regulated or otherwise) the provider may decide that it is appropriate to take immediate action by way of redistributing or even suspending the staff member in question.

At this stage all action against a staff member should be done on a 'without prejudice' basis, and in line with the HR procedures of the employer.

For further guidance see: Allegations against People in a Position of Trust Procedure.

4. Poor Care or Safeguarding?

Where there is an incident of poor care it may be possible to address the cause of this within the service, with no further need for ongoing action. Wider causes for concern will likely need a more sustained approach, which could include a large scale approach and intervention from the regulatory body or Commissioners.

Poor care examples

1. A one-off medication error (with minimal consequences);
2. An incident of under-staffing, resulting in an incontinence pad being unchanged all day;
3. Poor quality, or lack of choice in food options;
4. One missed visit from a domiciliary care provider.

Examples of wider concerns

1. A series of medication errors;
2. An increase in the number of visits to A&E, especially if the same injuries happen more than once;
3. Changes in the behaviour and demeanour of adults with care and support needs;
4. Nutritionally inadequate food;
5. Signs of neglect such as clothes being dirty;
6. Repeated missed visits by a domiciliary care provider;
7. An increase in the number of complaints received about a service;
8. An increase in the use of agency or bank staff;
9. A pattern of missed GP or dental appointments;
10. An unusually high or unusually low number of safeguarding alerts.

5. Closed Cultures and Organisational Abuse

Wider concerns may indicate a closed culture within the organisation.

A closed culture is a poor culture in a health or social care service that increases the risk of harm, including abuse and human rights breaches.

For further information, see the CQC guidance: Identifying and responding to closed cultures.

Organisational abuse

The Care Act (2014) describes organisational abuse as "neglect and poor care practice within an institution or specific care setting such as a hospital or care home, or in relation to care provided in the adult's own home".

Organisational abuse can range from a one-off incident through to on-going ill treatment.

It includes neglect or poor professional practice as a result of the structure, policies, process and practices within an organisation.

Potential forms of organisational abuse include:

• Inappropriate use of power or control;
• Inappropriate confinement, restraint or restriction;
• Lack of choice – in food, in decoration, in lighting and heating, and in other environmental aspects;
• No flexibility of schedule, particularly with bed times;
• Financial abuse;
• Physical or verbal abuse.

Also see: Neglect and Acts of Omission.

There is no single cause of organisational abuse. It generally happens in institutions where staff are:

• Poorly trained;
• Poorly supervised;
• Unsupported by management, or otherwise unaccountable;
• Bad at communicating.

6. Concerns about Pressure Ulcers

All safeguarding concerns relating solely to pressure ulcers should be managed and responded to in line with Department of Health and Social Care guidance Pressure ulcers: how to safeguard adults.

To ensure that safeguarding concerns are raised appropriately, the guidance requires service providers to request a clinical assessment to be carried out by a clinician with experience in wound management, usually a nurse. Following their assessment, if the nurse has safeguarding concerns, they must complete an adult safeguarding decision guide to help determine whether a safeguarding concern should be raised to the local authority. This should be completed immediately or within 48 hours.

The tool contains 6 questions that together indicate a safeguarding decision guide score. The professional judgement of the nurse should always be used to make the final decision, but a guide score of 15 or more would normally indicate that a safeguarding concern should be raised to the local authority.

For guidance on completing the guide and to download the relevant documentation, refer to the government guidance: Pressure ulcers - how to safeguard adults.

The safeguarding concern can be raised by the nurse that completed the adult safeguarding decision guide, or, in agreement with the nurse, by the service provider.

Whoever raises the concern, the local authority must be provided with a copy of the completed clinical assessment and adult safeguarding decision guide documentation.

After reviewing the information it receives, the local authority must decide whether enquiries under Section 42 of the Care Act 2014 should be instigated and/or what investigative action is required by the service provider and others (for example, any health professionals involved in the care or treatment of the person).

7. Concerns about the use of Restraint in Mental Health Units

The use of restraint or force in mental health units is subject to the legal requirements of the Mental Health Units (Use of Force) Act 2018.

The Act provides a framework to protect patients in mental health units from the unnecessary or excessive use of force and to ensure accountability and transparency about how and when it is used.

Under the Act, force is defined as:

• The use of physical, mechanical, or chemical restraint on a patient; or
• The isolation of a patient (including seclusion and segregation).

Force should only be used as a last resort, when it is in the best interests of the patient and other less restrictive options have been considered.

For further information see: Mental Health Units (Use of Force) Act 2018: statutory guidance for NHS organisations in England, and police forces in England and Wales.

Psychological restraint

Psychological Restraint is any kind of communication strategy that puts psychological pressure on a person to do something they don’t want to do or stop them from doing something they do want to do.

Communication strategies may include verbal (written and spoken communication) and non-verbal (facial expressions, hand gestures, smiles, head nodding, eyebrow raising).

Communication pressure becomes restraint when a person feels they have no choice but to comply.

The Restraint Reduction Network (RRN) has developed a suite of resources to recognise and prevent psychological restraint in mental health units.

See: RRN Psychological Restraint Resources.

8. Making Enquiries

Where a local authority has reasonable cause to suspect that an adult may be experiencing, or at risk of abuse or neglect, then it is still under a duty to make (or cause to be made) whatever enquiries it thinks necessary to decide what, if any, action needs to be taken and by whom.

The local authority may well be reassured that the service provider's response has been sufficient to deal with the safeguarding issue and that no further action is required. However, if this is not the case, the local authority would need to undertake any enquiry of its own and any appropriate follow-up action.

Safeguarding enquiries should not be undertaken by the manager of the service (or another representative of the service) in the following circumstances:

1. There is known to be a serious conflict of interest;
2. There is a history of similar concerns;
3. Previous enquiry action by the provider has been inadequate; or
4. The police are investigating.

In any of these circumstances, provider enquiries are not appropriate and should instead be made by an independent party. The service provider remains obligated to co-operate and provide any information required.

Local authority commissioners or the regulatory body (CQC) should be given the opportunity to be involved to ensure that the action is taken and is appropriate, proportionate, effective and sustainable in line with the requirements of their registration and contract. Ongoing support may also be needed from these partner agencies to raise standards or ensure staff are well trained to reduce future risk to those adults being supported by the service.

9. After Enquiries have been made

The service provider is responsible for taking any appropriate action in regards to disciplinary, dismissal and referral of the employee to the Disclosure Barring Service.

The local authority should monitor that any relevant actions of this nature have taken place and the outcome. If a service provider fails to notify the DBS then the local authority should do so.

10. Further Information for Care Homes

See: Safeguarding Adults in Care Homes (NICE guideline).