Spellman Care includes:

• Ghyll Royd Nursing Home, a Limited company incorporated in England and Wales. Our company number is 04248839 and our registered address is Paget Hall, Church Street, Gargrave, BD23 3NE
• Steeton Court Nursing Home, a Limited company incorporated in England and Wales. Our company number is 02349600 and our registered address is Paget Hall, Church Street, Gargrave, BD23 3NE
• Springbank Care Home (Silsden), a Limited company incorporated in England and Wales. Our company number is 09858167 and our registered address is Paget Hall, Church Street, Gargrave, BD23 3NE
• Craven Nursing Home, a Limited company incorporated in England and Wales. Our company number is 05040794 and our registered address is Paget Hall, Church Street, Gargrave, BD23 3NE

(“Spellman Care” / “we” / “our” / “us“). We are committed to ensuring that your privacy is protected. We comply with the General Data Protection Regulation ((EU) 2016/679) (“GDPR”) unless and until the GDPR is no longer directly applicable in the UK, together with any national implementing laws, regulations and secondary legislation as amended or updated from time to time in the UK, and any successor legislation to the GDPR and the DPA (together “Data Protection Legislation”). We are the data controller of data you pass to us pursuant to this policy.

This Privacy Policy [together with our website terms and conditions and Cookie Policy] sets out how we collect personal information from you and how the personal information you provide will be processed by us. By visiting the website at N/A (the “Website”) you are accepting and consenting to the practices described in this Privacy Policy. If you do not consent, please do not submit any personal data to us.

What information does Spellman Care hold and how will we use it?

Information you give Spellman Care: You may give us information about you by completing enquiry forms on the website or by requesting via the website that we send you marketing information.  The information you give us may include your name, email address, address/location and phone number.

We will retain this information while we are corresponding with you or providing services to you or to a Service User you represent. We will retain this information for 8 years.  We will only retain your personal information for as long as necessary to fulfill the purposes for which we have collected it or to fulfill another lawful purpose (as described above). When we no longer have a lawful purpose for holding your data, we will securely destroy your personal information in accordance with our data retention policy, the relevant extract of which is:

We are obliged by care regulators to maintain accurate records of care delivery and other data about those for whom we care. When a resident or patient leaves our service, we will archive that personal data in a secure storage facility (for paper records) and in a secure server (for electronic records). We will maintain it securely for no more than 8 years, unless a complaint or claim has been notified in which case we shall retain relevant data for the purpose of addressing that matter.

From time to time, our insurers may request that data be held longer than 8 years for the purpose of an individual claim which concerns the data subject. 

Information Spellman Care collects about you: Spellman Care may collect the following information from you when you visit the website:

• Technical information, including the Internet protocol (IP) address used to connect your computer to the Internet, your login information, browser type and version, time zone setting, browser plug-in types and versions, operating system and platform; and
• Information about your visit, including the full Uniform Resource Locators (URL), clickstream to, through and from the website (including date and time), products you viewed or searched for, page response times, website errors, length of visits to certain pages, page interaction information, methods used to browse away from the page and any phone number used to call our helpline

We retain this information for 8 years.  We will retain this information while we are corresponding with you or providing services to you or to a Service User you represent. We will retain this information for 8 years.  We will only retain your personal information for as long as necessary to fulfil the purposes for which we have collected it or to fulfil another lawful purpose (as described above). When we no longer have a lawful purpose for holding your data, we will securely destroy your personal information in accordance with our data retention policy, the relevant extract of which is:

We are obliged by care regulators to maintain accurate records of care delivery and other data about those for whom we care. When a resident or patient leaves our service, we will archive that personal data in a secure storage facility (for paper records) and in a secure server (for electronic records). We will maintain it securely for no more than 8 years, unless a complaint or claim has been notified in which case we shall retain relevant data for the purpose of addressing that matter.

From time to time, our insurers may request that data be held longer than 8 years for the purpose of an individual claim which concerns the data subject. 

Information we receive from other sources: This includes information we receive about you when you use other websites operated by us or other services we provide. This information may include your name, email address, postal address and phone number. We will retain this information for 8 years We will retain this information while we are corresponding with you or providing services to you or to a Service User you represent. We will retain this information for 8 years.  We will only retain your personal information for as long as necessary to fulfill the purposes for which we have collected it or to fulfill another lawful purpose (as described above). When we no longer have a lawful purpose for holding your data, we will securely destroy your personal information in accordance with our data retention policy, the relevant extract of which is:

We are obliged by care regulators to maintain accurate records of care delivery and other data about those for whom we care. When a resident or patient leaves our service, we will archive that personal data in a secure storage facility (for paper records) and in a secure server (for electronic records). We will maintain it securely for no more than 8 years, unless a complaint or claim has been notified in which case we shall retain relevant data for the purpose of addressing that matter.

From time to time, our insurers may request that data be held longer than 8 years for the purpose of an individual claim which concerns the data subject. 

The Website uses cookies to distinguish you from other users of the website. For detailed information on the cookies we use and the purposes for which we use them, please see our Cookie Policy

Use Made of the Information

Spellman Care may use the information we receive and/or collect about you to:

• Fulfil our obligations under any contract that we have entered into with you or with a Service User that you represent, and to provide you or the relevant Service User with information or services that you or the Service User has requested
• Send you newsletters and marketing information if you have consented to us doing so
• Notify you of products and services that we feel may interest you, or permit third parties to do so if you have provided the appropriate consent
• Monitor website usage and provide statistics to third parties for the purposes of improving and developing the website and the services we provide via the website

Spellman Care processes personal information for certain legitimate business purposes, which include some or all the following:

• Where the processing enables Spellman Care to enhance, modify, personalise or otherwise improve the website, its services or communications
• To identify and prevent fraud
• To enhance the security of the network and information systems of Spellman Care
• To better understand how people interact with the websites of Spellman Care
• To administer the website and carry out data analysis, troubleshooting and testing; and
• To determine the effectiveness of promotional campaigns and advertising

If we obtain consent from you to do so, we may provide your personal details to third parties so that they can contact you directly in respect of services in which you may be interested.

Where we are processing personal data that we have obtained via the website on the basis of having obtained consent from you, you have the right to withdraw your consent to the processing of your personal data at any time. If you would like to withdraw your consent or prefer not to receive any of the above-mentioned information (or if you only want to receive certain information from us) please let us know by contacting us via the following webpage www.spellmancare.co.uk. Please bear in mind that if you object, this may affect our ability to carry out the tasks above for your benefit.

If you wish to have your information removed from our database or if you do not want us to contact you for marketing purposes, please let us know by clicking the “Unsubscribe” option in any email we send to you and providing the details requested or by contacting us via the following webpage www.spellmancare.co.uk and we will take steps to ensure that this information is deleted as soon as reasonably practicable.

We will not share, sell or distribute any of the information you provide to us (other than as set out in this policy) without your prior consent, unless required to do so by law.

We may carry out automated decision-making using the personal data you provide to us. We do so to [insert an explanation about the automated decision-making (including profiling) that you carry out. You should explain the logic involved and the significance and potential consequences for the Data Subject. For example, if you track their behaviour on your website to send targeted advertising, explain this process. If you do not carry out any automated decision making, you can delete this policy entry].

Third Party Sites

Our website may contain links to third party websites, including websites via which you are able to purchase products and services. They are provided for your convenience only and we do not check, endorse, approve or agree with such third-party websites nor the products and/or services offered and sold on them. We have no responsibility for the content, product and/or services of the linked websites. Please ensure that you review all terms and conditions of website use and the Privacy Policy of any such third-party websites before use and before you submit any personal data to those websites.

How Safe is your Information?

Where we have given you (or where you have chosen) a password which enables you to access certain parts of the website, you are responsible for keeping this password confidential. We ask you not to share a password with anyone.

Protecting your security and privacy is important to us and we make every effort to secure your information and maintain your confidentiality in accordance with the terms of the Data Protection Legislation. The website is protected by various levels of security technology, which are designed to protect your information from any unauthorised or unlawful access, processing, accidental loss, destruction and damage.

We will do our best to protect your personal data but the transmission of information via the Internet is not completely secure. Any such transmission is therefore at your own risk.

Disclosure of your Information

We may share your personal information with any member of our group, which means our subsidiaries, our ultimate holding company and its subsidiaries, as defined in section 1159 of the Companies Act 2006. We may share your information with selected third parties including:

• Business partners, suppliers and sub-contractors for the performance of any contract we enter with them or you
• Third parties who may wish to contact you in respect of services or products they offer or sell which may be of interest to you, provided we receive your consent to such disclosure; and/or advertisers and advertising networks that require the data to select and serve relevant adverts to you and analytics and search engine providers that assist us in the improvement and optimisation of the website

Please note we may need to disclose your personal information where we:

• Sell any or all our business or assets or we buy another business or assets in which case we may disclose your personal data to the prospective buyer or seller
• Are under a legal duty to comply with any legal obligation or to enforce or apply our terms and conditions; or
• Need to disclose it to protect our rights, property or the safety of our customers or others, including the exchange of information with other companies, organisations and/or governmental bodies for the purposes of fraud protection and credit risk reduction

Your Rights in Respect of your Data

If any of the information you provide to us via the website changes, please let us know as soon as possible so that we can make the necessary changes to the information we hold for you on our database. If you wish to make any changes to your information, please contact us via the following webpage www.spellmancare.co.uk..

If you wish to access or rectify the information we hold about you, or request that such information be transmitted directly to another data controller, please contact us via the following webpage www.spellmancare.co.uk. We shall process your request to access your information within one month of receipt, or we’ll let you know within that timeframe if we need more information from you. We will process your request free of charge.

To request that your information is deleted or if you wish to restrict or object to the processing of your information, please contact us via the following webpage www.spellmancare.co.uk.

If you have any complaints about our use of your personal data, please contact us. You also have the right to complain to the relevant supervisory authority in your jurisdiction. In the UK, the supervisory authority is the Information Commissioner’s Office. Contact details for the ICO can be found at https://ico.org.uk/.

If you have any further queries or comments on our Privacy Policy, please contact us via the following webpage www.spellmancare.co.uk or you can contact us by emailing admin@ghyllroydnursinghome.co.uk.  We also welcome your views about our website and our Privacy Policy 

COOKIES WEBSITE STATEMENT

Cookies are small text files which a website may put on your computer or mobile device when you first visit the website. The cookies will help the website recognise your device the next time you visit. Web beacons or other similar files can also do the same thing. We use the term “cookies” in this policy to refer to all files that collect information in this way.

We use cookies to distinguish you from other users of the website. This helps us to provide you with a good experience when you use the website and also allows us to improve the services we provide to you. On revisiting the website, we will be able to obtain information about your previous visits and about your computer including where available, your IP address, operating system and browser type, for system administration.  This is statistical data about your browsing actions and patterns and does not identify you. For the same reason, we may obtain information about your general internet usage by using a cookie file which is stored on the hard drive of your computer.

We use the following cookies:

• Strictly necessary cookies. These are cookies that are essential in order to enable you to move around the website and use its features, such as accessing secure areas of the Disabling them may mean you are not able to access parts of our website.
• Functionality cookies. These cookies are used to recognise you when you return to our website and to remember changes you have made to things such as text size, fonts and other parts of the website you can change so we can personalise our content for you.

Most browsers accept cookies automatically, but you can change your cookie preferences by adjusting your browser settings to refuse the setting of all or some cookies if you prefer. You can usually do this by visiting the “options” or “preferences” menu on your browser. Please note, however, that if you do this and choose to block all cookies (including essential cookies) we cannot guarantee that your experience will be as fulfilling as it would otherwise be, and you may not be able to access all or parts of our website.

Where we collect personal data as part of our use of cookies on the website, we will do so in accordance with our Privacy Policy.

Complaints

• Spellman Care understands complaints to be an expression of dissatisfaction requiring a response, communicated verbally, electronically, or in writing. Complaints may be made by any Service User, their family or advocate acting on their behalf, with their consent or in their best interests
• Spellman Care takes complaints seriously. We will aim to put things right that have gone wrong and learn lessons to avoid the problem happening again. This policy sets out the framework for how Spellman Care will achieve The detail of how Spellman Care will do this will be found in the associated procedures
• Spellman Care will comply with legislation, national guidelines, regulation and best practice when managing complaints and suggestions. A systematic approach will be taken with all aspects of complaints and suggestions
• Complaints made or concerns raised by staff will be addressed via the grievance process if the complaint or concern relates to them individually, or via the Whistleblowing procedure where a protected disclosure is made
• Spellman Care understands its statutory obligations in respect of the Duty of Candour and will ensure it follows the agreed policy and procedure

• Spellman Care will ensure that its complaints and compliments process is fair and transparent and does not discriminate directly or indirectly because of the following:
  • Age
  • Being or becoming a transgender person
  • Being married or in a civil partnership
  • Being pregnant or on maternity leave
  • Disability
  • Race including colour, nationality, ethnic or national origin
  • Religion, belief or lack of religion/belief
  • Sex
  • Sexual orientation

The complainant will feel free to complain without fear of reprisal and will be treated with courtesy, respect and compassion. Spellman Care will ensure that the process for how to make a complaint and the feedback given to the complainant are provided in a way that meets the Accessible Information Standard and are in a format that the Service User can understand.

Seeking Views and Engaging with Service Users

Spellman Care will seek out opportunities to obtain feedback from Service Users and stakeholders. Spellman Care will act with sensitivity, integrity and professionalism by treating individuals who do complain or make a suggestion with compassion, courtesy and respect. Spellman Care will protect the Service User’s right to confidentiality. Spellman Care will ensure that alternative methods of communication are available so that the complaints and suggestions procedures are accessible for Service Users who experience difficulties with communication or whose first language is not English.

Staff will undertake training on how to manage complaints in line with their roles and responsibilities.

• Spellman Care understands that it can be difficult to separate a complaint from a concern and, therefore, Spellman Care will follow this policy when there is any dissatisfaction with the service.
• A full record will be held of all complaints received regardless of the level of seriousness and means of communication. This approach allows an open and transparent culture around raising concerns in the earliest stage to allow resolution. A record of the complaint will also be held in the Service User’s care file and will be reported in line with contractual or regulatory

Safeguarding Concerns

Where a complaint or concern is raised that relates to a Service User being harmed or likely to be harmed, Spellman Care will follow its Safeguarding Policy and Procedures in addition to the complaints procedures, seeking advice and guidance from the Leeds Safeguarding Adults Team and escalating concerns in line with Leeds procedure. Spellman Care will also notify the CQC in line with its statutory duty.

Roles and Responsibilities All Staff

It is acknowledged that all staff working within Spellman Care may be presented with an individual wishing to raise a concern or complaint at any time. Therefore, staff need to be able to manage this in a sensitive, structured and timely manner. In order to do this, staff will:

• Be trained on induction and as a routine measure to ensure knowledge is embedded and refreshed around the complaints procedure
• Have access to the complaints procedure
• Be provided with the opportunity to reflect and learn from complaints as a means of developing and driving quality care
• Appreciate that any feedback from Service Users or their representatives that is of concern needs immediate resolution, where possible, to their satisfaction. Care Plans will be updated to reflect the planned changes to care and The Home Manager informed of the feedback. Failing to do this may result in a complaint
• Be clearly advised that, when presented with a complaint, swift escalation to management is necessary and that purposefully withholding or concealing concerns expressed by Service Users or their representatives may lead to disciplinary action

Management Team at Spellman Care

• The management team at Spellman Care is responsible for ensuring compliance with this policy, regulations, improvement planning and for having arrangements in place to provide relevant reports and information regarding complaints

• The Home Manager is the main point of contact for the receipt, investigation and management of complaints within Spellman Care. However, this may be delegated to a senior member of staff within Spellman Care who holds the experience, knowledge and competence to investigate and manage complaints
• Spellman Care will ensure the procedure for raising a complaint is accessible and displayed prominently in Spellman Care, on the website of Spellman Care and in Service User information and guides. Alternative languages and formats will be available on request

Compliments and Suggestions

Spellman Care welcomes compliments and suggestions and recognises their importance in celebrating and recognising the success of its service and opportunities for improvement. We will engage with a wide range of stakeholders in addition to Service Users to support service development and improvement. We will share feedback with our staff.

One Complaint, One Response

Spellman Care will follow the Local Government and Social Care Ombudsman best practice and, where Service Users are receiving services from more than one organisation, it will ensure they can make a complaint to anyone and be provided with a single response following a joint investigation.

Raising Complaints

A complaint can be received by Spellman Care either verbally or in writing and can be made by:

• Service Users
• Someone acting on behalf of a Service User and with their written consent, e.g. an advocate, relative, Member of Parliament
• Someone acting on behalf of a Service User who is unable to represent his or her own interests, provided this does not conflict with the Service User’s right to confidentiality or a previously expressed wish of the Service User

Spellman Care will ensure that Service Users are given information on how to make a complaint and the process once a complaint has been made, including any agreed timescales.

Time Limits for Submitting a Complaint

Complaints should be submitted within 12 months of the incident or concern arising. The time limit, however, can and should be waived, if:

• It is still practical and possible to investigate the complaint (the records still exist and the individuals concerned are still available to be questioned, etc.) and
• The complainant can demonstrate reasonable cause for delay in making the complaint It is at the discretion of the manager of the service if the time limit can be set

Complaints Procedure:

Step 1

When a complaint is raised to staff, staff will make an effort to resolve it immediately to the satisfaction of the complainant.

Step 2

Staff will apologise for the fact that there was the need to complain in the first instance and explain the complaints process as described in the procedure steps.

Step 3

Staff will report the complaint to the most senior member of staff on duty and the complaint will be logged. If the complaint relates to that individual, the staff member will report the complaint to the member of staff who is next in line in seniority.

Step 4

Formal acknowledgement of all complaints received (whether verbal or written) will be sent within 3 working days to the complainant. This could be via letter or email. Spellman Care will have a local system in place to manage out-of-hours and weekend complaints received.

The acknowledgement will include:

• An invitation to meet and discuss the complaint
• Who will be investigating the complaint
• How the investigation will be handled – the response should state what the investigation will be focused on
• A time limit for the investigation to be concluded. This should be 28 days. However, some cases may take longer and the complainant will be made aware of this
• The complaints procedure and contact details of bodies that can be accessed in the event of dissatisfaction with the outcome of the investigation

Step 5

Following a full investigation, a response letter will be sent and this will include the following:

• A summary of the issue from the complainant’s point of view
• Details of the evidence and sources consulted in order to investigate the issue fully and fairly
• A presentation of the findings for each issue clearly and concisely described
• A conclusion, stating clearly whether the issue is ‘upheld’, ‘partially upheld’ or ‘not upheld’; unless it is ineligible, in which case the reason for this will be given, e.g. out of time or out of jurisdiction
• An explanation of the outcome and whether any remedial action or learning points arise from the investigation of that issue
• An apology where the issue is upheld and shortcomings or failings have been found
• The complainant’s rights if not satisfied with the outcome to refer to The Local Government and Social Care Ombudsman
• A signature from the responsible individual or sent by email in their name

Step 6

The complaint will be closed once confirmation has been received that there is satisfaction with the outcome. In the event of dissatisfaction, Spellman Care will support the complainant to access further support. (Refer to section 5.6.)

The Complaints Log

A record will be held of all complaints raised and contain the following information:

• Each complaint received
• Subject matter and outcome
• Details of any reason for delay where investigations took longer than the agreed response period
• The date the report of outcome was sent to the complainant

Where complaints relate to a Service User, a copy of the complaint will be held in their care records so that the Service User can reflect on the recommendations.

Where complaints are raised by telephone, the log will include the date and time of the call and this will be followed up with written confirmation of the areas discussed.

Where a complaint indicates the potential abuse of Service Users, safeguarding policies will be followed as per local authority expectation and necessary notifications made to the regulatory body. Where care is commissioned by Leeds, their reporting procedure for notifying them of complaints will be followed.

Where complaints are to be shared as part of learning, the complaint will be anonymised so there is no identifiable Service User information, in line with UK GDPR and data protection law.

Investigations

All investigations will be managed by using the following approach:

• Investigating the fact
• Assessing evidence
• Review of records
• Interviewing those involved

Where necessary, advice and support will be sourced via senior managers within the organisation. The complaint must be investigated by a member of staff with the knowledge, experience and seniority to undertake the investigation robustly.

Confidentiality of information will be considered at all times and staff will adhere to the confidentiality policies and relevant codes of practice.

If an investigation of a complaint results in disciplinary action against staff within Spellman Care, the complaint will continue to its conclusion. The complainant will be informed that the investigation has led to the disciplinary process, but the details of the outcome or ongoing investigation will remain confidential.

One Complaint, One Response

Where more than one organisation is involved in the Service User’s care, they, or their representative,  will be able to complain to any of them and Spellman Care will contact the other organisations, carry out a joint investigation and provide a single joint response. Service Users must not have to contact each organisation separately.

If someone complains and Spellman Care is not responsible for the care or service complained about, rather than turning the complainant away, Spellman Care will share the concerns with the correct organisation(s). It will be necessary to obtain the individual’s permission to do this. If the person prefers that their complaint is not shared with another organisation (or organisations), Spellman Care will signpost them to the right organisation instead and provide the person with their contact details. Spellman Care will follow LGO guidance for managing this.

Who is Responsible for Complaint Resolution at Spellman Care?

All efforts will be made by The Home Manager to resolve all complaints within Spellman Care. If a Service User does not wish to raise a complaint directly to management within Spellman Care, in the first instance, staff will try and sensitively establish their reasons why and aim to resolve and address any concerns that present.

Spellman Care recognises the importance of Service Users being able to speak freely and raise

a concern or complaint regarding anyone in the organisation, including the Registered Home   Manager. Service Users are provided with information relating to who to contact in the event that this is necessary.

Please see the Complaint Procedure for Service Users in the Forms section.

• Anonymous Complaints

Anonymous complaints will be investigated in the same way as named complaints. They will be logged and any corrective action necessary will be taken and also logged.

Unresolved Complaints

In the event that a Service User feels that their complaint is unresolved, there are many bodies that can support or will need to be informed to assist with this:

1. The Care Quality Commission

The Care Quality Commission will not investigate complaints on behalf of individuals but does like to be informed of any concerns regarding a care provider, such as poor care that has been seen or experienced. Information given to the CQC will help to prevent others from going through the same experience and can be fed back via:

• Website cqc.org.uk
• Email enquiries@cqc.org.uk
• Address: Care Quality Commission (CQC) National Correspondence

Citygate, Gallowgate Newcastle upon Tyne NE1 4PA Tel: 03000 616161

Fax: 03000 616171

2. The Local Government and Social Care Ombudsman (for those Service Users that are funded by local authority-funded social services care or self-funded)

Individuals have the right to raise their complaint with the Local Government and Social Care Ombudsman. This is a free service and individuals can contact their Local Government and Social Care Ombudsman via: The Local Government and Social Care Ombudsman

PO Box 4771

Coventry CV4 0EH Tel: 0300 061 0614

Email: advice@lgo.org.uk Website: https://www.lgo.org.uk/

Complaint form: https://www.lgo.org.uk/complaint-form

Self Funded Care

The Local Government Ombudsman (LGO) may investigate complaints from people who arrange their own care. Self funders will have the right to complain to an independent and impartial Ombudsman.

Individuals must be advised that the Local Government and Social Care Ombudsman will not investigate the complaint until the provider has had the opportunity to respond and resolve the matter in the first instance.

1. Parliamentary and Health Service Ombudsman (for Service Users that are NHS funded) Individuals have the right to raise a concern about a service that is NHS funded. This is a free service and individuals can make contact via:
   • Telephone 0345 0154033
   • Email enquiries@ombudsman.org.uk
   • Website ombudsman.org.uk
   • Address: Parliamentary and Health Service Ombudsman, Millbank Tower, 30 Millbank, Westminster, London, SW1P 4QP

The Home Manager can also signpost individuals to Healthwatch and the local Independent Complaints Advocacy Service (ICAS).

4. Integrated Care Systems

Individuals can make a complaint about a health service they are receiving or have received and can discuss this with the commissioner of the service. Local contact details can be located here.

5. Local Authority Complaints Teams

Individuals have the right to raise concerns and complaints about adult social care regardless of whether or

not they pay for their own care or if the Council funds it. Individuals can make a complaint about organisations who provide services on the Council’s behalf. The contact details for the Local Authority Complaints Team are:

Local Authority Complaints Team

6. Professional Bodies

If a complaint involves the serious misconduct of a healthcare professional, their relevant professional body can be informed and this is determined on an individual case basis in discussion with the Registered Home Manager.

For any external bodies managing complaints, Spellman Care will work with the external body providing information as requested, within any agreed timescales expected.

Decisions to raise complaints outside of Spellman Care will be fully respected and the Service User will be supported to raise their complaint with the commissioner of the service or to seek the support of an independent advocate or representative. Staff can also refer to section 5.6 for a further list of organisations that can be accessed.

Service Users can also be signposted to Citizens advice guidance.

Vexatious Complaints

Occasionally, Spellman Care may receive complaints that are vexatious in that they cause considerable disruption to the work at Spellman Care, disproportionate cost and time to handle, and impact the wellbeing of staff (because of the way the complaint is made or because of its repetitive nature).

Spellman Care will ensure that it meets the requirements of the Equality Act 2010 to make ‘reasonable adjustments’ for disabled Service Users. In some circumstances, Service Users may have a disability that makes it difficult for them to either express themselves or communicate clearly and/or appropriately. Where there is an indication that this may be the case, Spellman Care will consider the needs and circumstances of the Service User or complainant in the first instance and use this information to inform any decisions that are made.

Where appropriate, Spellman Care will consider complaints to be vexatious, but would not label an individual complainant as vexatious. Even if Spellman Care decides that an individual’s complaint about the service is vexatious, that does not preclude that person from making a formal complaint. Spellman Care would still consider any such complaints in line with the usual procedures, as outlined in this policy.

To help decide whether a complaint is vexatious Spellman Care will consider the full history and context of interactions with the individual making the complaint, and will look at both the nature of the complaint and the manner in which it is made. The particular issues that will inform a decision will include whether:

• The primary purpose and/or effect of the complaint is to disturb, disrupt and or/pressurise Spellman Care, its staff or an individual member of staff
• The primary purpose and/or effect of the manner in which the complaint is made is to disturb, disrupt and or/pressurise the Spellman Care, its staff or an individual member of staff
• The complaint is otherwise clearly unreasonable

If at any point in the handling of a complaint a member of staff believes it meets the criteria to be deemed vexatious, it must be referred to the Registered Home Manager with a summary of why it is thought to be vexatious.

The Home Manager will consider the complaint, seek external advice if appropriate, and will either declare the complaint as being vexatious or not. Where a complaint is not deemed to be vexatious it will be returned to the appropriate point in the complaints handling process.

If a complaint is deemed to be vexatious, the Registered Home Manager will respond directly to the complainant explaining why it is thought to be so and will explain that the complaint will be closed with no further action. The Registered Home Manager will also consider if the making of a vexatious complaint also requires the application of a restriction on communication following unreasonable behaviour.

The decision to declare a complaint as vexatious will be recorded in the complaints register for future reference.

Any declaration that refers to the specific complaint being vexatious and any further complaints from the same individual will still be considered.

If any individual wishes to challenge a decision made in relation to this policy, and all attempts to resolve the complaint locally have been unsuccessful, details of the Complaints Team of Leeds and Parliamentary

and Health Service Ombudsman (PHSO) will be shared with the complainant.

Compliments

Receiving compliments is an opportunity to celebrate and recognise success. Spellman Care will ensure that:

• All compliments are shared with staff and displayed in a public area to highlight good practice
• Compliments are anonymised or permission is sought before displaying them
• The number of compliments received is logged as part of a quality assurance programme
• Verbal, positive feedback from Service Users and relatives is also deemed a compliment and will be recorded and shared with colleagues
• Compliments form a core agenda item at staff, Service User and relative meetings

Suggestions

Suggestions can be made verbally or in writing and generally are in response to seeking a means of changing practice for the better.

• Suggestions are not complaints, but in some circumstances, if they are not considered or actioned, they could lead to a complaint
• When suggestions are raised in meetings or as part of a conversation, these will be documented and then outcomes of such suggestions recorded to show consideration
• Staff will be encouraged to share their suggestions, or suggestions received by relatives and Service Users, with The Home Manager
• The Home Manager will consider implementing a suggestions system to encourage comments from Service Users, staff and visitors

Audit and Evaluation

Spellman Care will monitor, review and analyse all information received about the service as a means of continuously reviewing performance, quality and safety.

Spellman Care will also:

• Share themes and trends with Care Workers working for Spellman Care
• Ensure that staff are trained to deal with complaints and understand the procedure for managing complaints

Compliment

• A compliment is an expression of satisfaction about a service the Service User has received
• Compliments are positive feedback that can be received verbally or in writing and can include expressions of praise, admiration, congratulation and encouragement

Complaint

• A complaint is an expression of dissatisfaction, disappointment or discontent. This could be in response to an act of omission, decision or act
• Complaints can be made in various ways and include:
  • Verbally
  • Electronically
  • Local feedback channels
  • Writing

Self-Funded Care

• Self-funded care is defined as care that is paid for entirely by the person receiving it

Vexatious Complaint

• A vexatious complaint is one that is pursued, regardless of its merits, solely to harass, annoy or subdue somebody; something that is unreasonable, without foundation, frivolous, repetitive, burdensome or unwarranted

Infections are common. They are caused by micro-organisms such as bacteria, viruses, fungi, and parasites, which are more commonly known as germs. Germs can be found everywhere; most do not cause infection and the risks surrounding infection remain low. In some cases, however, an infection can be caused.

Infections in Service Users at Spellman Care can be serious, and in some cases, life threatening. They can also make existing medical conditions worse.

Spellman Care Responsibilities and Representatives

In line with the Policy Management Policy and Procedure at Spellman Care. The Registered Home Manager, The Home Manager, and Nominated Individual, Mr S Spellman, of Spellman Care, have overall management responsibility for this policy and procedure to ensure:

• Safe working practices required for infection prevention and control
• It clearly communicates the safe working practices required for infection prevention and control to all staff
• It is committed to minimising the risk of infection to staff and Service Users by ensuring good standards of basic hygiene and applying universal infection control procedures
  • Spellman Care achieves this through a robust risk assessment process, implementation of effective controls and the provision of appropriate training and equipment to all

It will ensure that all staff understand the importance of good hand hygiene and how to use personal protective equipment (PPE).

Infection Prevention Lead (IPL)

The Infection Prevention Control Lead within Spellman Care is The Home Manager.

The IPL, in line with the Health and Social Care Code of Practice on the prevention and control of infections and related guidance (2022) and the Infection prevention and control resource for adult social care (2022), will:

• Have the knowledge and skills for IPL
• Be responsible for the infection prevention (including cleanliness) management at Spellman Care
• Assess the Infection Prevention and Control (IPC) measures needed
• Oversee local prevention of infection policies and their implementation
• Support staff to understand their responsibilities to reduce the risks of infection, and the frequency and content of training and education needed
• Monitor the standards of IPC to ensure the highest standards
• Review episodes of infection, and disseminate learning
• Monitor the arrangements for cleaning
• Monitor how information regarding infection will be shared with other providers, when Service Users move between services
• Support Service Users and those significant to them to understand IPC measures
• Promote IPC practices at Spellman Care
• Support staff and Service Users with vaccination, in line with national guidance and local risk assessment
• Provide suitable accurate information on infections to ensure Service User’s safety and reduce risk of spread
• Report directly to Mr Steven Spellman
• Have the authority to challenge inappropriate practices
• Have the authority to set and challenge standards of cleanliness
• Assess the impact of all existing and new policies on infection risk, and make recommendations for change
• Be an integral member of the governance and safety teams and structures at Ghyll Royd Nursing

Home

• Ensure that there is evidence of appropriate action taken to prevent and manage infection
• Undertake an audit programme to ensure that appropriate policies have been developed and implemented
• Provide evidence that the Annual Statement from the Infection Prevention Lead has been reviewed and, where indicated, acted upon

Chain of Infection

For staff to be effective in infection prevention and control (IPC) they need to understand how infections spread. The Chain of Infection contains 6 links to show how infection spreads:

• Pathogen is the microorganism or germ that causes disease – Norovirus, MRSA, Influenza
• Reservoir is where pathogens live and replicate – A person, the environment, equipment, food/drink
• Portal of exit (way out the body) is how pathogens leave the reservoir – Faeces, urine, blood, vomit, sneeze
• A means of transmission is how pathogens are spread from one person or place to another – Contact: hands, equipment, droplets, airborne
• Portal of entry is how pathogens enter the body – Inhalation, mucus membranes (eyes, nose, mouth), or via a wound
• Susceptible host is the person who is at risk – Age, lack of immunity, underlying health conditions Breaking the chain prevents the infection spreading, this can be done at each point:
• Pathogen – Completing antibiotics stops pathogens becoming resistant
• Reservoir – Cleaning and decontamination reduces the number of pathogens. Isolation or distancing when someone is infectious stops the pathogen finding a new host
• Portal of exit – Covering nose and mouth when sneezing reduces spread
• Means of transmission – Hand hygiene removes pathogens
• Portal of entry – Ensure wounds are covered, wearing face masks
• Susceptible host – Vaccination

Standard Infections Control Procedures (SIPCs)

These should be used by all staff at Spellman Care at all times, whether there is a known infection or not. Implementing these measures will reduce the risk of infections spreading.

There are 10 IPC measure according to the National Infection Control Manual (NIPCM) 2023, they are:

• Service User placement/assessment for infection risk
• Hand hygiene
• Respiratory and cough hygiene
• Personal Protective Equipment (PPE)
• Safe management of care equipment
• Safe management of the care environment
• Safe management of laundry
• Safe management of blood and body fluid spills
• Safe disposal of waste (including sharps)
• Management of exposure

Service User Assessment

• All new Service Users will be assessed at pre-admission for infection risk, this will be re-assessed on admission and throughout their stay at Spellman Care to ensure appropriate infection prevention and control measures are in place, including isolation when required
• When Service Users are transferred from another health or social care provider, the transfer documentation must be checked for confirmed or suspected infection risks

• A suitably qualified, knowledgeable and experienced member of staff will ensure that risk assessments are carried out for all Spellman Care services and activities in order to protect Service Users from the harm of acquiring an infection
• This involves a simple review of what could cause harm to Service Users in Spellman Care, including the risk of infection, so that judgements can be made for adequate protection to be in place to reduce the risk. Consideration should also be given to how susceptible Service Users are and any risks that the environment and other people may pose to them
• Staff can refer to the Risk Assessment Policy and Procedure at Spellman Care for standards required of risk assessment and the appropriate documentation. All relevant staff are responsible for having an awareness of the risk assessment and the actions necessary to reduce the risk of infection
• Service Users will be risk assessed on transfer to and discharge from hospital, and attendance at another health or adult social care setting
• On discharge of a Service User to another service, staff will ensure any confirmed or suspected infection is communicated and documented to the provider and transport service

The assessment should include all factors which place the Service User at a higher risk of catching or spreading infection and may include:

• Symptoms: history of current diarrhoea or vomiting
• Unexplained rash
• Fever or temperature
• Respiratory symptoms, such as coughing or sneezing
• Contact: previous infection with a multi-drug resistant pathogen (where known)
• Recent travel outside the UK where there are known risks of infection
• Contact with people with a known infection
• Person risk factors: vaccination status which will assist assessment of their susceptibility to infection and allow protective actions to be taken when necessary
• Wounds or breaks in the skin
• Invasive devices such as urinary catheters
• Conditions or medicines that weaken the immune system
• Environmental risk factors, such as poor ventilation
• Not vaccinated against respiratory illness
• Not able to follow IPC precautions

Hand Hygiene

Most healthcare-associated infections are preventable through good hand hygiene – cleaning hands at the right times and in the right way. The aim of routine hand washing is to remove dirt and most transient

micro-organisms (germs that can be easily removed by hand washing) found on the hands. All staff must wash their hands:

• Before starting work and going home
• Before eating, preparing or handling food
• Before and after giving any direct care to each Service User
• Before administering medications
• After any activity that contaminates the hands or when hands are visibly soiled
• After using the toilet
• After sneezing/blowing the nose
• After cleaning activities or handling waste
• Before providing clinical care, e.g. catheter care, dressing wounds
• Any other occasions when hands are thought to have been contaminated
• Before donning and doffing PPE
• Before and after having a break

• After handling used laundry, e.g. stripping beds, dirty clothing
• After emptying commodes, urine bottles, catheter bags

Notices and hand hygiene posters are clearly displayed for staff, Service Users and visitors.

Service Users are supported to understand and follow hand hygiene:

• After using the toilet
• Before eating and drinking
• If hands are visibly soiled

Choice of Hand Hygiene Product

Staff should choose the product suitable to the situation.

Alcohol gel/rub will not remove dirt or organic material and is not effective against Clostridium Difficile and Norovirus, staff must use liquid soap and water.

Liquid Soap

Hand washing with liquid soap and water removes dirt and organic material and must be used:

• Prior to and following direct contact with Service Users
• Following direct hand contact with body fluids when gloves must be worn
• When hands are visibly dirty or visibly soiled with body fluids and other organic matter
• When caring for Service Users with diarrhoea and/or vomiting, Service Users with COVID- 19, Clostridium Difficile or Norovirus and during outbreaks of these organisms
• After several consecutive applications of alcohol gel/rub

Alcohol Hand Rub

Alcohol hand rub is recommended for routine hand decontamination because:

• It is more effective (WHO 2009)
• It is quicker and easier to use
• It is better tolerated by the hands
• It can be provided at the point of care
• It can be used when liquid soap is not available Alcohol gel/rub is flammable and must be correctly stored. Muslims and Alcohol-Based Hand Gel

In accordance with the ‘Muslim Spiritual Care Provision’ in the NHS (MSCP) advice, alcohol-based hand gel

contains synthetic alcohol and does not fall within the Muslim prohibition against natural alcohol. Therefore, Muslims can use such gels.

Bar Soap

Bar soap must not be used by staff at Spellman Care as they can harbour pathogens.

Service Users

• Skin wipes can be used for Service Users unable to access handwashing facilities
• Soap and warm running water or non-alcohol skin wipes should be used if the Service User’s hands are visibly soiled or dirty, or they have confirmed or suspected viral gastroenteritis or C. difficile

Hand Hygiene Facilities Handwashing Facilities

Hand hygiene facilities at Spellman Care must be available and not compromise standards by being dirty or in a poor condition:

• Facilities should be adequate and conveniently located
• Hand wash facilities should be available in each Service User’s room
• Hand wash basins in clinical areas should have a single lever or sensor mixer tap which does not run directly into the drain aperture, with no plug or overflow. If a lever or sensor mixer tap is not provided, use a paper towel to turn off the tap to avoid contaminating the hands
• Clinical hand wash basins should not be used for any other purpose, e.g. decontamination of care equipment, due to the risk of cross-contamination
• In areas where a sink is used for other cleaning purposes, e.g. emptying buckets of water in the cleaner’s room, there should also be a separate dedicated hand wash basin
• Liquid soap dispensers should be wall mounted with disposable soap cartridges. Do not use refillable soap dispensers as there is a risk of contamination of the liquid soap and the dispenser
• Communal fabric hand towels must not be used
• Paper towels should be in a wall mounted dispenser next to the hand wash basin, but not so close as to risk contamination of the dispenser or towels
• Dispensers must be clean and replenished
• A foot operated lidded bin, lined with a disposable plastic bag, should be positioned near the hand wash basin
• Nail brushes should not be used routinely as they can cause skin damage and harbour bacteria. If nail brushes are used, they should be single use and disposed of after use
• Hand hygiene technique posters should be displayed

Availability of Alcohol Handrubs

Alcohol handrubs should be available in wall mounted dispensers which use disposable cartridges (not refillable):

• At the entrance to Spellman Care
• At the point of care

The Home Manager must conduct a risk assessment before setting up alcohol dispensers. If wall mounted dispensers or free standing pump dispensers are not appropriate, staff should be issued with personal dispensers which can be clipped to the uniform.

Bare Below the Elbows Guidance

Bare below the elbows is an infection prevention strategy intended to reduce transmission of pathogens that may occur due to contact of the Service User with the contaminated clothing of staff at Spellman Care.

‘Bare below the elbows’ is:

• Exposing forearms by wearing short sleeved clothing or rolling sleeves up to the elbows. If disposable over-sleeves are worn for religious reasons, these must be removed and disposed of before performing hand hygiene, then replaced with a new pair
• Removing wrist and hand jewellery. Rings with jewels, stones, ridges or grooves should not be worn as these may harbour bacteria and also prevent good hand hygiene. A plain band ring may be worn but ensure the area under the ring is included when hands are washed or alcohol handrub applied. A religious bangle can be worn, but should be moved up the forearm during hand hygiene and secured during resident care activities
• Not having dermal piercings on the arms or wrists
• Keeping nails clean and short (fingertip length), as long fingernails will allow a build-up of dirt and bacteria under the nails and impede effective handwashing
• Keeping nails free from nail polish/gel as flakes of polish/gel may contaminate a wound and broken edges can harbour microorganisms
• Keeping nails free from acrylic/artificial nails, nail art/accessories, as these can harbour microorganisms, become chipped or detached

Hands can only be decontaminated effectively by ensuring that the correct technique is used which encompasses the wrists. It is therefore imperative that staff comply with ‘Bare Below the Elbow’ in order to facilitate this.

Uniforms:

• Uniforms may include provision for sleeves that can be full length when staff are not engaged in direct patient care activity
• Uniforms can have three-quarter length sleeves
• Any full or three-quarter length sleeves must not be loose or dangling. They must be able to be rolled or pulled back and kept securely in place during hand-washing and direct patient care activity
• Staff should refer to the Appearance Policy and Procedure at Spellman Care.

Hand-Washing Technique Using Liquid Soap

• Expose the wrists and forearms. All parts of the hands and, where exposed, forearms must be included in the process
• Where forearms require cleaning, they must be cleaned first and then the hands
• Wet the hands under warm, running water before applying soap
• Apply liquid soap in the recommended product volume
• Using the six-step technique:
  • Rub all parts of the hands vigorously, without applying more water
  • Use one hand to rub the back of the other hand and clean in between the fingers. Do the same with the other hand
  • Rub your hands together and clean in between your fingers
  • Rub the backs of your fingers against your palms
  • Rub your thumb using your other hand and do the same with the other thumb
  • Rub the tips of your fingers on the palm of your other hand and do the same with the other hand
• Rinse under running water
• The hand washing process must take 40-60 seconds, and a useful tip to check that you are washing your hands for the right amount of time is to sing ‘Happy Birthday’ twice
• Dry thoroughly with a disposable paper hand towel
• Dispose of paper towel into bins with foot-operated pedals
• Do not touch the bin with hands

Using Alcohol Gel/Rub

• Hands must be free from dirt and organic matter; if not, wash them first
• Avoid using excessive amounts of alcohol gel/rub to minimise skin damage. Apply one shot (approx. 5 ml) of alcohol hand rub
• The hand rub must come into contact with all surfaces of the hands, so hands must be rubbed together vigorously and systemically to include wrists, tips of fingers, backs of hands, palms, thumbs and webs of fingers, for ten to fifteen seconds until the solution has evaporated

(Refer to ‘How to Handwash’ in the Forms section (Source: World Health Organisation))

Skin Damage

Skin damage is associated with poor hand-washing technique or frequent use of hand hygiene agents. Excoriated hands are associated with increased growth of germs and increase the risk of infection. Irritant and hand drying effects of hand preparations are one of the reasons why staff fail to follow hand hygiene guidelines.

The best practice below will help to prevent skin damage:

• Staff should be aware of the potentially damaging effects of hand hygiene products
• Avoid putting on gloves while hands are still wet (from washing or applying alcohol rub)
• Avoid rubbing hands with paper towels; the skin should be patted dry
• Avoid over-use of gloves
• Use emollient hand cream regularly, e.g. after washing hands, before breaks, when going off duty and when off duty
• If irritation occurs, review compliance with the hand decontamination technique and then inform your line manager
• Avoid communal ‘pots’ of moisturiser as they can become a potential source of infection
• Individual tubes of hand creams may be used, provided that care is taken not to contaminate the nozzle Where members of staff continue to experience soreness or sensitivity, this will be discussed with The Home Manager.

Respiratory Hygiene and Cough Etiquette

Respiratory hygiene and cough etiquette will be applied as a standard infection control precaution at all times. The measures include:

• Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and blowing noses
• Ensure there is an adequate supply of tissues available and in reach of Service Users and staff
• Dispose of used tissues into a waste bin
• Wash hands with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions
• Cough or sneeze into the crux of their elbow on any occasion when there is not a tissue available. Do not cough or sneeze into hands and not into the air. Although this won’t stop all the respiratory secretions spreading, it can reduce the distance they travel
• Keep contaminated hands away from the mucous membranes of the eyes and nose
• Don’t contaminate surfaces and pockets with used tissues
• Staff should support Service Users who need assistance with respiratory hygiene

Personal Protective Equipment (PPE)

Staff should also refer to the Personal Protective Equipment Policy and Procedure at Spellman Care.

Safe Management of Care Equipment

Care equipment must be properly decontaminated after each use, otherwise pathogens can be transferred between Service Users.

The Home Manager must ensure that staff understand whose responsibility it is to decontaminate equipment after each use, following the manufacturer’s instructions.

Decontamination processes:

• Cleaning – Physically removes contamination but may not destroy pathogens
• Disinfection – Reduces the number of visible pathogens but may not inactivate all
• Sterilisation – Will remove all pathogens

Single Use Items:

• Must only be used on a single Service User for a single procedure
• Must not be used again, even on the same Service User

Single Person Use Item:

• Must only be use for one Service User
• Not to be used on different Service Users
• Limited number of uses according to manufacturer’s instructions
• Follow instructions for decontamination

Staff can refer to Appendix 7 of the National Infection Prevention and Control manual for England – appendices, which can be found in the further reading section of this policy.

Staff should also refer to the Management of Medical Devices Policy and Procedure at Spellman Care.

Safe Management of the Care Environment

Staff should refer to the Housekeeping Policy and Procedure at Spellman Care. Ventilation:

• Increasing ventilation by opening windows when practicable and safe can help to reduce the risk of the spread of some respiratory infections

Mr Steven Spellman and The Home Manager should consider:

• Appropriate storage of equipment to reduce contamination
• Furniture that can be easily cleaned and is resilient
• Flooring that can be easily cleaned
• Provision of adequate hand hygiene stations
• Storage space for
  • Waste
  • Linen
  • Cleaning equipment
• Enough toilets, bathrooms, en suites, sluices, clean utility rooms

Safe Management of Laundry

Staff should refer to the Laundry Policy and Procedure at Spellman Care.

Management of Blood and Bodily Fluid Spills

Staff should refer to the Safe Management of Blood and Body Fluid Spillages Policy and Procedure at Spellman Care.

Safe Disposal of Waste (including sharps)

Staff should refer to the Healthcare Waste Policy and Procedure and the Sharps and Needlestick Policy and Procedure at Spellman Care.

Management of Exposure Blood-Borne Viruses (BBVs):

BBVs are viruses carried in the blood. They are spread by direct contact with the blood, blood-stained body fluids or certain body fluids, of an infected person.

The main BBVs of concern are:

• Human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS)
• Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)

Spellman Care will assess the risk of BBV transmission in its services and in the conduct of its procedures, taking precautions and implementing controls in accordance with the risk assessment.

A significant occupational exposure is:

• An injury through the skin from a needle, instruments, bone fragments, or bites which break the skin
• Exposure of broken skin (abrasions, cuts, eczema, )
• Exposure of mucous membranes including the eye from splashing of blood or other high risk body fluids

To prevent exposure to blood and body fluids:

• Follow standard infection control precautions (SICPs)
• Use safety sharps where assessment indicates they will provide safe systems of working for staff To reduce the risk of transmission:
• All staff at risk of exposure to BBVs must be vaccinated against Hepatitis B
• Cuts and abrasions must be covered with a waterproof dressing before providing care
• Staff with skin conditions must seek advice from their GP to minimise their risk of infection through open skin lesions
• Protect eyes, mouth and nose from blood splashes where there is a risk of splashing
• Avoid direct skin contact with blood and blood-stained body fluids (if blood/blood-stained body fluids are splashed on to the skin, wash off with liquid soap, warm running water and dry with paper towels)
• Wear disposable latex or nitrile gloves when contact with blood or blood-stained body fluid is likely (vinyl gloves are not recommended for contact with blood)
• Always clean hands before putting on and after removing gloves
• Always clean hands before and after giving first aid
• Contain and promptly clean and disinfect surfaces contaminated by spillages of blood and blood- stained body fluids
• Never share razors or toothbrushes as they can be contaminated

Staff can also refer to the Safe Management of Blood and Body Fluid Spillages Policy and Procedure at Spellman Care.

Exposure to Blood and Bodily Fluids:

Where the eyes or mouth have been exposed:

• They should be rinsed/irrigated copiously with water
• Use eye/mouth washout kits if
• If contact lenses are worn, rinse/irrigate with water, remove lenses, then irrigate again
• Report and document the incident
• An urgent risk assessment should be undertaken to establish if there is the potential to transmit a blood borne virus (BBV)

Where skin/tissue is affected:

• Encourage the area to bleed
• Do not suck the damaged skin or tissue
• Wash/irrigate with warm running water and no-antimicrobial soap
• If running water is unavailable, use pre-packed solution (sterile water/saline)
• Report and document the incident
• An urgent risk assessment should be undertaken to establish if there is the potential to transmit a blood borne virus (BBV)

Sharps Injuries:

Staff should refer to the Sharps and Needlestick Policy and Procedure at Spellman Care.

Human Bites:

Human mouths contain a wide variety of organisms which have the potential to be transmitted, some of which can be transmitted by bites. Human bites are rare and generally occur in certain Service User groups. However, human bites are more likely to become infected, so it is important that they are treated promptly.

Where it is identified that a Service User is at risk of biting others, a risk assessment must be completed as well as a clear set of guidelines to manage the risk.

If a bite does not break the skin:

• Clean with soap and water
• Complete an accident/incident form
• Review the risk assessment and identify if any changes are required to minimise the risk of incidents arising again

If a bite breaks the skin:

• Clean the skin around the wound with soap and warm water or antiseptic, but try not to get it in the wound
• Try to remove any objects like dirt from the wound using running water
• Gently squeeze the wound so it bleeds slightly (unless it’s already bleeding) – this can help reduce the risk of infection
• Press a dry dressing or clean cloth firmly onto the wound to stop the bleeding if it’s bleeding heavily
• After cleaning the wound, gently pat it dry and cover it with a clean dressing
• Contact NHS 111
• If the wound is deep, large, and/or will not stop bleeding, attend A&E

Staff can refer to the National Infection Prevention and Control manual for England – appendices: Appendix 10: Best practice – management of occupational exposure incidents, which can be found in the further reading section of this policy.

Vaccination

Staff should refer to the Staff and Service User Vaccination and Immunisation Policies and Procedures at Spellman Care.

Signs and Symptoms of Infections

It is important that staff can identify Service Users who have an infection and what has caused it. This enables them to access the most appropriate support for the Service User, and also minimise the spread of the infection to other Service Users and staff.

Staff should look for signs of infection, some may depend on the infection location:

• Raised temperature
• Skin flushing
• Change in usual behaviour
• Increased or new confusion Gastrointestinal:
• Stomach pain
• Nausea and vomiting
• Loss of appetite
• Frequent bowel movements
• Diarrhoea Respiratory Tract:
• Sore throat
• Cough
• Headache
• Production of green or yellow sputum
• Shortness of breath Urinary Tract Infections:
• Pain in lower abdomen
• Pain or burning sensation when passing urine
• Cloudy or offensive smelling urine
• Need to pass urine more often
• Nausea and vomiting Skin/Soft Tissue:
• Redness
• Feels warm or hot
• Itching
• Pain and tenderness
• Pus
• Blisters
• Swelling

Managing Infection

Standard precautions alone may not be sufficient to prevent the spread of infection.

Staff should assess any additional measures needed when a Service User or staff member is suspected or known to have an infection.

Additional precautions are based on:

• Which pathogen is causing the suspected, or known infection or colonisation
• How the pathogen is spread
• The severity of the illness
• Where the person is supported or cared for
• The procedure or task being undertaken

Identifying Service Users and staff who have an infection, and the pathogen causing it, is essential to ensure appropriate support is provided to minimise the risk of spreading it to others at Spellman Care.

Staff should:

• Be alert to people experiencing symptoms of infection, or exhibiting any changes in their usual behaviour
• Be curious if more than one person is experiencing similar symptoms – this may indicate spread, even where the people have no obvious links
• Consider who may need to know this information, for example the health protection team, primary care network, social care providers and local infection control team

Staff who have a confirmed or suspected infection which can be spread to others should not work until they are no longer at risk of passing on infection to others. This will require an individual assessment of the pathogen causing the infection and the individual circumstances.

Service Users should continue to be supported while infectious, but the arrangements for their care will be different. Service Users may be encouraged to minimise contact with others or be isolated and staff may wear different PPE equipment.

Acute Respiratory Infections (ARI) COVID-19

Staff should refer to the Acute Respiratory Infections (ARI) (COVID-19) Policy and Procedure at Spellman Care.

Transmission Based Precautions (TBPs)

Transmission based precautions (TBPs) are additional precautions to standard infection control precautions, used to prevent transmission of specific infectious agents.

These precautions are based on the route of transmission of the infectious agent.

The Home Manager must ensure that staff use their clinical judgement or seek advice from the local infection prevention and control team (IPCT), as to what additional precautions are required, this should be based on:

• Suspected/known infectious agent
• Severity of the illness caused
• Transmission route of the infectious agent
• Spellman Care setting

Contact Precautions:

• These are used to prevent and control infections that spread by direct contact
• Contact could be with the person (direct) or via contact with a contaminated surface (indirect)
• This is the most common route of cross-infection from one person to another
• Infections include – Gastroenteritis, Norovirus, Blood Borne Viruses

Droplet Precautions:

• These are used to prevent and control infections spread over short distances (at least 1 metre) via droplets from the respiratory tract
• Droplets transfer from one individual directly onto a mucosal surface or conjunctivae of another

individual

• Generated through talking, coughing, sneezing
• Droplets penetrate the respiratory system to above the alveolar level
• Infections include – Cold, flu, COVID-19

Airborne Precautions:

• These are used to prevent, and control infection spread without necessarily having close patient contact via aerosols from the respiratory tract
• Aerosols transfer from one individual directly onto a mucosal surface or conjunctivae of another individual
• Generated from breathing, coughing, sneezing, talking, laughing and aerosol generating procedures (AGPs)
• Aerosols can penetrate the respiratory system to the alveolar level
• Infections include – Chickenpox, Measles, COVID-19

Staff should refer to the National Infection Prevention and Control manual for England – appendices: Appendix 5b: Personal protective equipment (PPE) when applying transmission based precautions (TBPs), which can be found in the further reading section of this policy, and the PPE Policy and Procedure at Spellman Care.

For details of the type of precautions, isolation requirements and respiratory precautions required for different infections, staff should refer to the National Infection Prevention and Control manual for England – appendices: Appendix 11a.

If more than one Service User is showing symptoms of the same infection, staff should refer to the Outbreak Management and Isolation Policy and Procedure at Spellman Care.

Deceased Service Users

It is assumed that when the Service User was alive, before providing an episode of care, all staff will have risk assessed the task and applied the appropriate standard infection control precautions, e.g. hand hygiene, personal protective equipment (PPE), safe management of waste.

The same principle should apply after the Service User’s death.

Staff should refer to the Care After Death Policy and Procedure at Spellman Care.

Use of Portable Fans

Portable fans used in clinical areas have been linked to cross infection in health and social care environments. Therefore, before use and reuse, a clinical risk assessment must be completed. The risk assessment must include the following:

• Portable fans are not recommended for use during outbreaks of infection or when a Service User is known or suspected to have an infectious agent
• Availability of the manufacturers’ information and advice on how to maintain and decontaminate the fan, which must be consistent with the contents of this policy and any associated national policies
• Consideration must be given to whether the fan can be adequately decontaminated for safe reuse, or whether it should be disposed of after use
• Any assurance and evidence provided by the manufacturer that internal contamination will not be dispersed into the clinical/care area

Staff Sickness

• Staff should not work if there is a risk of passing on an infection
• Staff with diarrhoea and vomiting must not attend work, but must phone work to report sick
• Staff must not attend work until they are clear for 48 hours in order to prevent the spread of infection

If a staff member has symptoms of acute respiratory infection

• Symptomatic staff should stay away from work
• Staff who have symptoms of respiratory infection and who have a high temperature or do not feel well enough to go to work are advised to stay away from work and try to avoid contact with other people. They should not return to work until they no longer have a high temperature (if they had one) or until they no longer feel unwell
• Managers should undertake a risk assessment before staff return to work in line with normal return to

work processes

• The staff member should also follow the guidance for people with symptoms of a respiratory infection including COVID-19

Staff should refer to the Sickness Absence Policy and Procedure at Spellman Care.

Visitors

The Home Manager will ensure that all visitors to Spellman Care are prevented from catching and spreading infection.

All visitors will be asked to refrain from entering Spellman Care if they are unwell. This will be clearly explained to visitors.

Clear signs and instructions will be in reception to explain what visitors should do to ensure compliance with infection prevention control.

Handwashing facilities or hand gel must be in place on entering and leaving Spellman Care, with guidance on correct hand hygiene.

Visitors will be supported to wash hands before and after PPE use as recommended by any guidance.

Annual Statement

The Home Manager must ensure completion of an annual statement of infection to include:

• Outbreaks of infection and actions taken
• Audits and subsequent actions
• Training and education received
• Reviews and updates of policies, procedures and guidance
• Risk assessments undertaken for prevention and control on infections

Infection Prevention and Control (IPC) Champions

The Home Manager will be responsible for arranging infection control champions at Spellman Care.

They should be members of staff who are:

• Passionate and enthusiastic about infection prevention and control and in sharing best practice with other staff
• Able to motivate and encourage other staff
• Confident to challenge poor practice
• A role model initiating best practice in infection prevention and control issues within Spellman Care

The role:

• Provide advice, support and training in infection prevention and control to staff
• Identify training gaps
• Promotes relevant aspects of infection prevention and control to staff, Service Users and relatives
• Conducts audits (hand hygiene, PPE)
• Shares new guidance with staff
• Attends IPC champion meetings in local area

The Home Manager should ensure that they are allocated protected time to focus on the role within their hours of work.

They should receive additional training for the role.

The Home Manager can find resources at The Queen’s Nursing Institute, which has an Infection Prevention and control (IPC) Champions scheme, a link can be found in the further reading section.

Reporting

• UK Health Security Agency
  • The Home Manager should be aware that medical professionals are duty bound to report certain diseases and can refer to the UK Health Security Agency

l  The Care Quality Commission (CQC)

• Spellman Care will ensure that the CQC is notified of incidents relating to infection control and disease outbreaks in line with regulatory requirements

Records of any reporting must be kept, specifying dates and times.

Training

Infection Control training is a mandatory requirement for all staff and must be updated annually. Spellman Care will ensure that Infection Control Champions in the service will undertake additional training relevant for this role.

Staff will receive training and direction regarding infection prevention and control practice in addition to information on induction and during periodic review.

Training must be appropriate to the staff member’s role at Spellman Care. All training will be recorded on the training matrix.

Ongoing, observation in practice will take place by The Home Manager (or designated other) and used to monitor for compliance with this policy as well as assessing knowledge in practice.

As well as formal training, further development will occur through other forums such as team meetings, supervision, audit and practical observation.

Staff must be trained to use tools such as RESTORE2 and relevant equipment such as pulse oximeters, staff can refer to the Medical Emergency Policy and Procedure at Spellman Care.

Audit and Review

The Home Manager will complete all Spellman Care audits as agreed by Mr Steven Spellman, as per schedule and in accordance with the Auditing Policy and Procedure of Spellman Care.

Complaints, concerns and suggestions will be reviewed with themes and trends identified to determine the level of satisfaction within Spellman Care.

Findings will be investigated and actions set with changes embedded in practice in a timely manner.

Daily observation of infection control practices at Spellman Care by The Home Manager or

a designated other must take place to demonstrate a responsive means of quality assurance. Although subjective, it can act as a means of addressing any areas immediately.

Staff will be informed in a supportive way of any areas noticed that need remedy and involved in how practice can be improved.

Records of all audits and quality assurance systems will be maintained and filed accordingly as evidence.

Definitions

Needlestick or Sharp Injury

• A needlestick (or sharp) includes items such as needles, sharp-edged instruments, broken glassware, or any other item that may be contaminated with blood or body fluids and may cause laceration or puncture wounds – such as razors, sharp tissues, spicules of bone and teeth

Outbreak

• An outbreak can be defined as two or more cases of infection occurring around the same time, in a Service User and/or their carers, within a 14-day period, or an increase in the number of cases normally observed. The most common outbreaks are due to viral respiratory infections and gastroenteritis.

RESTORE2

• RESTORE2 is a physical deterioration and escalation tool for care/nursing homes

Norovirus

• Also referred to as the winter vomiting disease, the most common cause of gastroenteritis

Viral Gastroenteritis

• An intestinal infection marked by watery diarrohea, abdominal cramps, nausea or vomiting

Clostridium Difficile (C.diff)

• Infection of the large intestine cause by the bacteria Clostridium difficile

PEG

• Percutaneous Endoscopic Gastrostomy is a tube passed into a Service User’s stomach for feeding

What is Safeguarding?

Spellman Care recognises the definition of ‘safeguarding’ as the actions taken to keep Service Users safe from harm and neglect.

The Care Act 2014 sets out that adult safeguarding duties apply to any adult who:

• Has care and support needs, and
• Is experiencing, or is at risk of, abuse and neglect, and
• As a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of, abuse or neglect

Safeguarding adults includes:

• Protecting their rights to live in safety, free from abuse and neglect
• People and organisations working together to prevent the risk of abuse or neglect, and to stop them from happening
• Making sure people’s wellbeing is promoted, taking their views, wishes, feelings and beliefs into account
• This must recognise that adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances

Spellman Care should always promote the Service User’s wellbeing in its safeguarding arrangements. Service Users have complex lives and being safe is only one of the things they want for themselves. Staff should work with the Service User to establish what being safe means to them and how that can be best achieved. Staff should not be advocating ‘safety’ measures that do not take account of individual wellbeing.

What Constitutes Abuse?

Employees at Spellman Care understand that the Service Users it supports can be extremely vulnerable to abuse and neglect, especially if they have care and support needs.

Abuse is a violation of an individual’s human or civil right by any other person. It is where someone does something to another person, or to themselves, which puts them at risk of harm and impacts on their health and wellbeing.

Abuse can have a damaging effect on the health and wellbeing of Service Users. These effects may be experienced in the short and long term and can sometimes be lifelong.

The signs of abuse are not always obvious, and a victim of abuse may not tell anyone what is happening to them. Sometimes they may not even be aware they are being abused.

The robust governance processes at Spellman Care will make sure that staff working for, and on behalf of, Spellman Care, recognise and respond to the main forms of abuse which are set out  in the Care Act 2014 Statutory Guidance Chapter 14.

The local authority is the lead agency for adult safeguarding and should be notified whenever abuse or neglect is suspected. It will decide whether a safeguarding enquiry is necessary, and if so, who will conduct it. The decision to conduct an enquiry depends on the criteria set out in the Care Act 2014, and not on whether a Service User is eligible for, or receiving, services funded by the local authority

Everybody has the right to live a life that is free from harm and abuse. Spellman Care recognises that safeguarding adults at risk of abuse or neglect is everybody’s business. Spellman Care aims to ensure that all adults at risk of abuse or neglect are enabled to live and work, be cared for and supported in an environment free from abuse, harassment, violence or aggression.

The safeguarding policies and procedures of Spellman Care will dovetail with the Leeds multi- agency policy and procedures, which we understand take precedence over those of Spellman Care. Spellman Care will ensure that the Leeds policies and procedures are reflected within its own policy and procedure, that this is shared with all staff and is accessible and available for staff to follow.

Spellman Care aims to provide services that will be appropriate to the adult at risk and not discriminate because of disability, age, gender, sexual orientation, race, religion, culture, or lifestyle. It will make every effort to enable Service Users to express their wishes and make their own decisions to the best of their ability, recognising that such self-determination may well involve risk.

Spellman Care will work with Service Users and others involved in their care to ensure they receive the support and protection they may require, that they are listened to and treated with respect

(including their property, possessions and personal information) and that they are treated with compassion and dignity.

A chaperone is always present when a Service User needs treatment, and missed healthcare appointments must be monitored to consider signs of abuse or neglect. These must be followed up with the healthcare provider and information shared in the best interests and safety of the Service User.

Spellman Care will follow the six principles as set out in guidance to the Care Act 2014 and this will inform practice with all Service Users:

• Empowerment – People being supported and encouraged to make their own decisions and informed consent
• Prevention – It is better to take action before harm occurs
• Proportionality – The least intrusive response appropriate to the risk presented
• Protection – Support and representation for those in greatest need
• Partnership – Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse
• Accountability – Accountability and transparency in delivering safeguarding

Spellman Care is committed to the principles of ‘Making Safeguarding Personal’ and aims to ensure that safeguarding is person-led and focused on the outcomes that Service Users want to achieve. It will engage Service Users in a conversation about how best to respond to their safeguarding situation in a timely way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety.

Spellman Care understands the importance of working collaboratively to ensure that:

• The needs and interests of adults at risk are always respected and upheld
• The human rights of adults at risk are respected and upheld
• A proportionate, timely, professional and ethical response is made to any adult at risk who may be experiencing abuse
• All decisions and actions are taken in line with the Mental Capacity Act 2005
• Each adult at risk maintains:
  • Choice and control
  • Safety
  • Health
  • Quality of life
  • Dignity and respect

Whistleblowing

Spellman Care has a clear Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure in place which staff are frequently reminded about and with which they must be familiar.

They must also understand how to escalate and report concerns.

Whistleblowing is an important aspect of the support and protection of adults at risk of harm where staff are encouraged to share genuine concerns about safety or wrongdoing within Spellman Care.

The Care Worker’s Responsibilities

• To be able to recognise and respond to suspected abuse and substandard practice
• To report concerns of harm or poor practice that may lead to harm
• To remain up to date with training
• To read and follow the policy and procedure
• To know how and when to use the whistleblowing procedures
• To understand the Mental Capacity Act and how to apply it in practice

The Registered Home Manager’s Responsibilities

• To establish the facts about the circumstances giving rise for concern
• To identify sources and level of risk
• To ensure that information is recorded and that the Leeds Adult Safeguarding Team is contacted to inform them of the concern or harm
• If a Service User is at immediate risk of harm, the Registered Home Manager will contact the The CQC will also be informed
• In all cases of alleged harm, there will be early consultation between The Home Manager, Leeds and the police to determine whether or not a joint investigation is required. Spellman Care understands that it may also be necessary to advise the relevant Power of Attorney if there is one appointed. In dealing with incidents of potential harm, people have rights which must be respected and which may need to be balanced against each other
• The wishes of the person harmed will be taken into account whenever possible. This may result in no legal action
• Documentation of any incidents of harm in the Service User’s file and using body maps to record any injuries
• Follow Leeds policy guidelines where applicable
• Report any incidents of abuse to the relevant parties
• Work with multi-agencies
• Advise and support staff
• Ensure staff are trained during induction, assess knowledge annually and run refresher training if needed
• Actively promote the whistleblowing policies
• Ensure that agency staff working at Spellman Care have completed the necessary safeguarding training for their role
• Participate in local Safeguarding Adults Board arrangements for sharing experiences about managing safeguarding concerns in care homes
• Share relevant information from Safeguarding Adults Board meeting minutes and reports with staff

General Principles

• We will have robust recruiting and safer staffing policies in place to make sure that our staff are fit to work with adults at risk and are compliant with national, safe recruitment and employment practices, including the requirements of the Disclosure and Barring Service
• Safeguarding responsibilities should be included in the job description of all staff
• A named safeguarding lead will be in place who is responsible for embedding safeguarding practices and improving practice in line with national and local developments. At Spellman Care, this person is Registered Home Manager
• Any staff member who knows or believes that harm is occurring will report it to their line manager as quickly as possible, or if they feel they cannot follow the regular reporting procedure, they must use the whistleblowing process
• Spellman Care will work collaboratively with other agencies, including liaison in relation to the investigation of allegations and will ensure its procedures dovetail with the Leeds multi-agency procedures
• Spellman Care will use incident reporting, root cause analysis, lessons learned and auditing to determine themes to improve care practice
• Spellman Care will have a learning and development strategy which specifically addresses adult safeguarding. Spellman Care will provide training on the identification and reporting of harm, as well as training on the required standards in relation to procedures and processes should something need to be reported
• Spellman Care recognises its responsibilities in relation to confidentiality and will share information appropriately
• Spellman Care will have zero tolerance to harm
• Spellman Care will work in partnership with other agencies to ensure that concerns or allegations of abuse are appropriately referred for investigation to the most appropriate agency
• Spellman Care will ensure that any action that is taken is assessed, proportionate and

reflective of the risk presented to the people who use the services

• Spellman Care will report any incidents in line with its regulatory requirements
• Spellman Care will adhere to the Code of Conduct for Care Workers
• There is a clear, well publicised Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure in place that staff know how to use

Leadership, Staff and Culture

The Home Manager is responsible for providing leadership.

Good governance in safeguarding will follow where it is seen as an integral part of Service User care and all staff take responsibility. Risks of neglect, harm and abuse will be reduced where there is strong leadership and a shared value base where:

• The Service User is the primary concern
• Service Users and staff are partners in their care
• Quality is prioritised and measured
• Staff understand the risks of neglect, harm and abuse
• There is a culture of learning and improvement
• There is openness and transparency, and all staff are listened to

Prevention – Providing information to support Service Users

• Spellman Care will support Service Users by providing accessible, easy to understand information on what abuse is and what signs to look out for
• A Safeguarding Leaflet can be found in the Forms section of this policy, and links to support can be found in the Further Reading section
• Spellman Care will comply with the Accessible Information Standard
• All Service Users will receive a copy of the Service User Guide, have access to the

Complaints, Suggestions and Compliments Policy and Procedure and be given information on how to escalate any concerns to the Commissioner, CQC, advocacy or Local Government and Social Care Ombudsman should they not be satisfied with the approach taken by Spellman Care or at any time they wish

Prevention – Raising awareness

• Staff will need to be trained and understand the different patterns and behaviours of abuse as detailed in the Care Act 2014, Chapter 14 and Spellman Care will ensure that it is able to respond appropriately
• Spellman Care will ensure that all staff are trained on the Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure
• During induction training, all employees will complete the ‘Understanding Abuse’ workbook, as part of the Care Certificate

There are different types of abuse and signs and indicators for each. While indicators are not proof of abuse or neglect, they should alert staff to follow the Safeguarding Policy.

It is important that staff at Spellman Care are aware of the signs of abuse and what to look out for.

Physical abuse includes:

• Being hit, slapped, pushed or restrained
• Being denied food or water
• Not being helped to go to the bathroom when you need to
• Misuse of medication
• Restraint
• Inappropriate physical sanctions

Signs and indicators of physical abuse include:

• No explanation for injuries or inconsistency with the account of what happened
• Injuries are inconsistent with the person’s lifestyle
• Bruising, cuts, welts, burns and/or marks on the body or loss of hair in clumps
• Frequent injuries
• Unexplained falls
• Subdued or changed behaviour in the presence of a particular person
• Signs of malnutrition
• Failure to seek medical treatment or frequent changes of GP Domestic violence or abuse:

This is typically an incident or pattern of incidents of controlling, coercive or threatening behaviour,

violence or abuse by someone who is, or has been, an intimate partner or family member, and can be:

• Psychological
• Physical
• Sexual
• Financial
• Emotional
• So called ‘honour’ based violence, female genital mutilation and forced marriage Signs and indicators of domestic violence or abuse include:
• Low self-esteem
• Feeling that the abuse is their fault when it is not
• Physical evidence of violence such as bruising, cuts, broken bones
• Verbal abuse and humiliation in front of others
• Fear of outside intervention
• Damage to home or property
• Isolation – not seeing friends and family
• Limited access to money Sexual abuse includes:
• Indecent exposure
• Sexual harassment
• Inappropriate looking or touching
• Sexual teasing or innuendo
• Sexual photography
• Being forced to watch pornography or sexual acts
• Being forced or pressured to take part in sexual acts
• Rape
• Sexual assault

Signs and indicators of sexual abuse include:

• Bruising, particularly to the thighs, buttocks and upper arms and marks on the neck
• Torn, stained or bloody underclothing
• Bleeding, pain or itching in the genital area
• Unusual difficulty in walking or sitting
• Foreign bodies in genital or rectal openings
• Infections, unexplained genital discharge, or sexually transmitted diseases
• Pregnancy in a woman who is unable to consent to sexual intercourse
• The uncharacteristic use of explicit sexual language or significant changes in sexual behaviour or attitude
• Incontinence not related to any medical diagnosis
• Self-harming
• Poor concentration, withdrawal, sleep disturbance
• Excessive fear/apprehension of, or withdrawal from, relationships
• Fear of receiving help with personal care
• Reluctance to be alone with a particular person Psychological or emotional abuse include:
• Threats to hurt or abandon
• Deprivation of contact
• Humiliating
• Blaming
• Controlling
• Intimidation
• Harassment
• Verbal abuse
• Cyberbullying
• Isolation
• Unreasonable and unjustified withdrawal of services or support networks Signs and indicators of psychological or emotional abuse include:
• An air of silence when a particular person is present
• Withdrawal or change in the psychological state of the person
• Insomnia
• Low self-esteem
• Uncooperative and aggressive behaviour
• A change of appetite, weight loss/gain
• Signs of distress: tearfulness, anger
• Apparent false claims, by someone involved with the person, to attract unnecessary treatment Financial or material abuse include:
• Theft
• Fraud
• Internet scamming
• Coercion in relation to a Service User’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions
• Misuse or misappropriation of property, possessions or benefits Signs and indicators of financial abuse include:
• Missing personal possessions
• Unexplained lack of money or inability to maintain lifestyle
• Unexplained withdrawal of funds from accounts
• Power of attorney or lasting power of attorney (LPA) being obtained after the person has ceased to have mental capacity
• Failure to register an LPA after the person has ceased to have mental capacity to manage their finances, so that it appears that they are continuing to do so
• The person allocated to manage financial affairs is evasive or uncooperative
• The family or others show an unusual interest in the assets of the person
• Signs of financial hardship in cases where the person’s financial affairs are being managed by a court appointed deputy, attorney or LPA
• Recent changes in deeds or title to property
• Rent arrears and eviction notices
• A lack of clear financial accounts held by a care home or service
• Failure to provide receipts for shopping or other financial transactions carried out on behalf of the

person

• Disparity between the person’s living conditions and their financial resources, e.g. insufficient food in the house

Modern slavery includes:

• Slavery
• Human trafficking
• Forced labour and domestic servitude
• Traffickers and slave masters using whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment

Signs and indicators of modern slavery include:

• Signs of physical or emotional abuse
• Appearing to be malnourished, unkempt or withdrawn
• Isolation from the community, seeming under the control or influence of others
• Living in dirty, cramped or overcrowded accommodation and or living and working at the same address
• Lack of personal effects or identification documents
• Always wearing the same clothes
• Avoidance of eye contact, appearing frightened or hesitant to talk to strangers
• Fear of law enforcers Discriminatory abuse includes:

Some forms of harassment, slurs or unfair treatment because of:

• Race
• Sex
• Gender and gender identity
• Age
• Disability
• Sexual orientation
• Religion

Signs and indicators of discriminatory abuse include:

• The person appears withdrawn and isolated
• Expressions of anger, frustration, fear or anxiety
• The support on offer does not take account of the person’s individual needs in terms of a protected characteristic

Organisational or institutional abuse:

Including neglect and poor care practice within an institution or specific care setting, or in relation to care provided in a Service User’s own home, this may range from one-off incidents to ongoing ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within Spellman Care:

• Discouraging visits or the involvement of relatives or friends
• Run-down or overcrowded establishment
• Authoritarian management or rigid regimes
• Lack of leadership and supervision
• Insufficient staff or high turnover resulting in poor quality care
• Abusive and disrespectful attitudes towards people using the service
• Inappropriate use of restraints
• Lack of respect for dignity and privacy
• Failure to manage residents with abusive behaviour
• Not providing adequate food and drink, or assistance with eating
• Not offering choice or promoting independence
• Misuse of medication
• Failure to provide care with dentures, spectacles or hearing aids
• Not taking account of individuals’ cultural, religious or ethnic needs
• Failure to respond to abuse appropriately
• Interference with personal correspondence or communication
• Failure to respond to complaints

Signs and indicators of organisational abuse include:

• Lack of flexibility and choice for people using the service
• Inadequate staffing levels
• People being hungry or dehydrated
• Poor standards of care
• Lack of personal clothing and possessions and communal use of personal items
• Lack of adequate procedures
• Poor record-keeping and missing documents
• Absence of visitors
• Few social, recreational and educational activities
• Public discussion of personal matters
• Unnecessary exposure during bathing or using the toilet
• Absence of individual care plans
• Lack of management overview and support Neglect or acts of omission include:
• Ignoring medical emotional or physical care needs
• Failure to provide access to appropriate health, care and support or educational services
• Withholding of the necessities of life, such as medication, adequate nutrition and heating
• Failure to administer medication as prescribed
• Not taking account of individuals’ cultural, religious or ethnic needs Signs and Indicators of neglect or acts of omission include:
• Poor environment – dirty or unhygienic
• Poor physical condition and/or personal hygiene
• Pressure ulcers
• Malnutrition or unexplained weight loss
• Untreated injuries and medical problems
• Inconsistent or reluctant contact with medical and social care organisations
• Accumulation of untaken medication
• Uncharacteristic failure to engage in social interaction
• Inappropriate or inadequate clothing

Self-neglect includes:

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 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 Service User’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.

• Lack of self-care to an extent that it threatens personal health and safety
• Neglecting to care for one’s personal hygiene, health or surroundings
• 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 Signs and indicators of self-neglect include:
• 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

High Risk Groups

Certain groups of people may be at higher risk of abuse or neglect, including:

• Those with care and support needs, such as older people or people with disabilities. They may be seen as an easy target and may be less likely to identify abuse themselves or to report it
• Those with communication difficulties because they may not be able to alert others
• Those with a cognitive impairment, as they may not even be aware that they are being abused

Who Abuses and Neglects?

Anyone in contact with the Service User can perpetrate abuse or neglect, including:

• Volunteers
• Family members
• Friends
• People who deliberately exploit adults they perceive as vulnerable to abuse
• Staff
• Professionals
• Other Service Users

Incidents of Abuse

Patterns of abuse vary and include:

• Serial abuse – in which the perpetrator seeks out and ‘grooms’ individuals. Sexual abuse sometimes falls into this pattern as do some forms of financial abuse
• Long-term abuse – in the context of an ongoing family relationship such as domestic violence between spouses or generations, or persistent psychological abuse
• Opportunistic abuse – such as theft occurring because money or jewellery has been left lying around Abuse may be one-off or multiple and affect one Service User or

Staff should look beyond single incidents or Service Users. Spellman Care should have systems

in place to track and monitor incidents, accidents, disciplinary action, complaints and safeguarding concerns, to identify patterns of potential harm..

Repeated instances of poor care may be an indication of more serious problems (organisational abuse). In order to see these patterns, it is important that information is recorded and appropriately shared.

Concerns

A concern might arise from:

• Something you observe (for example: bruises, a marked change in behaviour)
• An allegation that is made (for example, you are told that someone has behaved inappropriately or put a Service User or colleague at risk)
• A disclosure where a Service User tells you something about themselves or their circumstances that lead you to believe that they are being abused or are at risk of abuse

Staff must be able to:

• Recognise: Identify that the Service User at risk may be describing abuse, even when they may not be explicit
• Respond: Stay calm, listen and show empathy
• Record: Write up notes of the conversation clearly and factually as soon as possible
• Report in a timely manner to the appropriate people and organisations

Staff who Consider or Suspect Abuse or Neglect

If staff observe something that causes concern, they should ask the Service User what happened, unless this would be inappropriate or cause further distress.

If the Service User does not communicate with speech, they should help them explain what has happened as far as possible.

The staff member should document what they have seen or been told and report to the Registered Home Manager and the Safeguarding Lead, Registered Home Manager.

If staff are unsure if there is an indicator of abuse or neglect with a Service User, they should discuss this with the Registered Home Manager and the Safeguarding Lead, Registered Home Manager at Spellman Care.

The Registered Home Manager and the Safeguarding Lead, Registered Home Manager, will decide whether to make a safeguarding referral or to seek further advice form Leeds.

Staff who suspect abuse or neglect must act on it; staff must not assume that someone else will do this.

If someone makes an allegation to a member of staff about them or another member of staff

or volunteer, that staff member must listen carefully and explain that they will need to pass these concerns to the Registered Home Manager and the Safeguarding Lead, Registered Home Manager, reassuring them that their concerns will be taken seriously. If the allegation is made by a family member or a worker from another agency, the staff member should take their name and contact details and assure them that the Registered Home Manager and the Safeguarding Lead, Registered Home Manager, will contact them as soon as possible. The staff member must pass the information to the Registered Home Manager and the Safeguarding Lead, Registered Home Manager, immediately.

Responding to a Disclosure or Suspicion of Abuse or Neglect

If a Service User discloses potential or actual abuse, staff will:

Straight away:

• Remain calm and non judgemental
• Try not to show shock or disbelief
• Not interrupt the Service User who is freely recalling significant events, allow them to tell you whatever they want to share
  • Some Service Users may simply be telling a story and not realise that they are subject to abuse. It is important to keep this in mind and be thoughtful in response
• Take whatever action is required to ensure the immediate safety or medical welfare of the Service User

• at risk
  • Where appropriate, call 999 for the emergency services if there is a medical emergency, other danger to life or risk of imminent injury, or if a crime is in progress. Where a crime is suspected of being committed, leave things as they are wherever possible
  • Call for medical assistance from the GP or NHS 111 if there is a concern about the Service User’s need for medical assistance or advice, when the situation is not life-threatening or is out of hours
    • Reassure the Service User that they are right to share this information with you; show empathy with them
    • Do not press for more detail
    • Do not make promises that cannot be kept
    • Remain sympathetic and attentive Then:
    • Listen carefully and reflect back what you are being told to ensure you have correctly grasped what is being said
    • Use simple and open questions, do not ask leading questions, (e.g. ‘So was it Peter who did that?’) or attempt to ‘investigate’ in any way
    • Explain carefully that what they have said is worrying and that you have to share that with your line manager
      • Explain the safeguarding process to the Service User and discuss the next steps
      • Explain that your manager may contact the Leeds Safeguarding Adults Team and/or the Police
    • Seek the Service User’s consent to share this information
    • As soon as you can, write down an account of your conversation, try to use the words/phrases that the Service User used. Sign and date your record
    • Preserve evidence (physical evidence – for example, ask the Service User to not wash or bathe)
    • Inform the Registered Home Manager or the Safeguarding Lead, Registered Home Manager, as soon as possible to inform them of the incident or concern
      • The Registered Home Manager, The Home Manager, will be contacted on The Home Manager – 01943 870 720
      • The Safeguarding Lead, Registered Home Manager, will be contacted on 01943 870 720
    • Do not share this information with anyone else
    • Do not contact the alleged abuser about the incident yourself, unless this is essential (for example, if The Home Manager needs to immediately suspend a member of staff)
    • The Service User may feel frightened, so ask whether they want someone they feel comfortable with to stay with them

Staff must inform the Registered Home Manager or Safeguarding Lead, Registered Home Manager, unless they are the alleged abuser; if this is the case, then support should be sought directly from another manager, Mr Steven Spellman or Leeds.

Staff must also take action without the immediate authority of the Registered Home Manager or Safeguarding Lead, Registered Home Manager:

• If a discussion with them would involve a delay in an apparently high-risk situation
• If they have raised concerns with the Registered Home Manager or Safeguarding Lead, Registered Home Manager, and they have not taken appropriate action (whistleblowing)

There should be effective and well publicised ways of escalating concerns where the Registered Home Manager or Safeguarding Lead, Registered Home Manager, does not take action in response to a concern being raised.

The Registered Home Manager or Safeguarding Lead, Registered Home Manager, will:

• Listen to any staff member if they speak up about abuse or neglect, take them seriously and act accordingly
• Consider if there are other adults or children with care and support needs who are at risk of harm and take appropriate steps to protect them
• Support and encourage the Service User to contact the police if a crime has been, or may have been, committed

When responding to indicators of abuse and neglect, staff must:

• Follow the principles of the Making Safeguarding Personal Framework:
  • Ensure that any actions are guided by the wishes and feelings of the Service User
  • Be aware that Service Users experiencing abuse or neglect may be influenced, coerced or controlled by someone else
  • Be aware that duties of care and public interest can override personal preference, for example, there is a risk that a perpetrator could abuse again – this needs to be addressed and prevented
• Staff must also follow the principles of the Mental Capacity Act 2005 if the Service User lacks capacity

Documenting a Disclosure

Spellman Care must ensure that staff:

• Record what the Service User actually said, using their own words and phrases
• Describe the circumstance in which the disclosure came about
• Note the setting and anyone else who was there at the time

• When there are cuts, bruises or other marks on the skin, use a body map to indicate their location, noting the colour of any bruising
• Record information that is factual
• Use a pen with black ink so that the report can be photocopied
• Keep writing clear
• Sign and date the report, noting the time and location
• Are aware that the report may be needed later as part of a legal action or disciplinary procedure The Home Manager must ensure they preserve any evidence relating to a safeguarding concern, including care records, as these may be required in future for local authority enquiries or police

Response by the Registered Home Manager or Safeguarding Lead to Reports of Abuse or

Neglect

The Registered Home Manager and the Safeguarding Lead, Registered Home Manager, at Spellman Care should treat any report of abuse or neglect as a safeguarding concern and:

• Ask the Service User at risk what they would like to happen next
• Ensure that they have access to communication support
• Explain that they have a responsibility to report concerns to Leeds, and tell the Service User who they will report to, why, and when

Decision-Making Pre-referral to the Leeds Safeguarding Adults Team:

The Registered Home Manager or Safeguarding Lead, Registered Home Manager, will lead on decision- making.

When considering if a safeguarding concern needs to be completed, the Registered Home Manager

or Safeguarding Lead, Registered Home Manager, must consider the three duties in Section 42 (1) of the Care Act 2014:

• Does the person have needs for care and support (whether or not the authority is meeting any of those needs)?
• Are they experiencing, or at risk of, abuse or neglect? and
• As a result of those needs, are they unable to protect themself against the abuse or neglect or the risk of it?

When using professional judgement to determine whether an incident is reported to the local authority safeguarding adults team/police, the Registered Home Manager or Safeguarding Lead, Registered Home Manager, should consider the following:

• The consequences to the alleged victim and the equality of the relationship between the alleged perpetrator and the alleged victim
• The ability of the alleged victim to consent
• The mental capacity of the alleged perpetrator to understand the consequences of their decision to act in the way that is alleged
• The intent of the alleged perpetrator
• The frequency of this and similar allegations regarding the alleged perpetrator
• The alleged victim considers the actions against them to be abusive
• The alleged victim or carer is distressed, fearful or feels intimidated by the incident
• You believe that there is a deliberate attempt to cause harm or distress
• Incidents are repetitive and targeted to either the Service User or others
• The action resulted in a physical injury
• A crime has been committed
• The incident involves a member of staff
• If any other people (including children) are at risk as well as the Service User you are concerned about In the decision-making process, they must evidence the following:
• Why does this adult(s) need safeguarding – what are the risks?
• What actions need to be taken to reduce that risk?

• Do they consent to this action?
• Are others potentially at risk?

The Registered Home Manager or Safeguarding Lead, Registered Home Manager, will document their decision-making process.

If the Registered Home Manager or Safeguarding Lead, Registered Home Manager, is not sure whether to make a safeguarding referral to Leeds (because they are not sure whether they suspect abuse or neglect), they should discuss this with Leeds.

If a Service User does not want any safeguarding actions to be taken, but abuse or neglect is suspected, a safeguarding referral must still be made.

Spellman Care will ensure that staff are aware of the Leeds reporting procedures and timescales for raising adult safeguarding concerns.

If a referral is made but the Service User at risk is reluctant to continue with an investigation, this must be recorded and brought to the attention of the Leeds safeguarding adults team. This will enable a discussion on how best to support and protect the Service User at risk.

Consent

When reporting information that directly concerns the safety of an adult at risk of harm, consent from the Service User is not required. However, informing the Service User of your concerns and your referral is good practice unless it would put you or your colleagues at risk or it would put the adult at further risk.

When reporting allegations or concerns about an adult at risk of harm to the Local Authority, the Local Authority must be informed whether or not the Service User is aware of the report.

In reporting all suspected or confirmed cases of harm, an employee has a responsibility to act in the best interest of the Service User but still operate within the relevant legislation and the parameters of the codes and standards of their practice.

Referral to the Leeds Safeguarding Adults Team

Spellman Care must ensure that the Leeds safeguarding adult referral process is followed and must collect the following information to assist with the referral. The referral process must be clearly visible with contact numbers, including out-of-hours, where staff can access the information.

Where the Integrated Care Board is the commissioner they must also be informed.

The referral information will also be required for some of the CQC notification of abuse documentation. Spellman Care must use any up-to-date Care Plan information where possible and have the following information available where possible:

• Contact details for the adult at risk, the person who raised the concern and for any other relevant individual, and next of kin
• Basic facts, focusing on whether or not the Service User has care and support needs including communication and ongoing health needs
• Factual details of what the concern is about; what, when, who, where?
• Immediate risks and action taken to address risk
• Preferred method of communication
• If reported as a crime, details of which police station/officer; crime reference number
• Whether the adult at risk has any cognitive impairment which may impede their ability to protect themselves
• Any information on the person alleged to have caused harm
• Wishes and views of the adult at risk, in particular consent
• Advocacy involvement (includes family/friends)
• Information from other relevant organisations, for example, the CQC
• Any recent history (if known) about previous concerns of a similar nature or concerns raised about the same person, or someone within the same household
• Names of any staff involved

Local Authority Safeguarding Enquiry

Leeds may well be reassured by the response of Spellman Care so that no further action is required. However, Leeds would have to satisfy itself that the response of Spellman Care has been sufficient to deal with the safeguarding issue and, if not, to undertake any enquiry of its own. This will identify if action needs to be taken and who needs to take that action.

The enquiry:

• Could be an informal conversation with the Service User at risk
• Could be a more formal multi-agency discussion
• Does not have to follow a formal safeguarding process The objectives of an enquiry are to:
• Establish facts
• Ascertain the Service User’s views and wishes
• Assess the needs of the Service User for protection, support and redress and how they might be met
• Protect from the abuse and neglect, in accordance with the wishes of the Service User
• Make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect
• Enable the Service User to achieve resolution and recovery

If Leeds decides that Spellman Care should make the enquiry, then Leeds should be clear about timescales, the need to know the outcomes of the enquiry and what action will follow if this is not done.

What happens as a result of an enquiry should reflect the Service User’s wishes wherever possible, as stated by them or by their representative or advocate. If they lack capacity, it should be in their best interests if they are not able to make the decision, and be proportionate to the level of concern. The Service User should always be involved from the beginning of the enquiry.

Strategy Meeting/Case Conference:

• Following the investigation or at any time during the process, a case conference with all relevant agencies may be called to make decisions about future action to address the needs of the Service User
• Any agency involved in the case may ask for a case conference to be held but the final decision to hold a conference is with the Leeds Safeguarding Adults Team Manager
• Spellman Care must ensure that it attends this meeting when invited and that all relevant information about the incident is available. A timeline of events is a useful document to prepare in complex cases

Safeguarding Adults Reviews:

• Safeguarding adults reviews (SARs) are a statutory requirement for Safeguarding Adults Boards with the purpose of promoting learning and improving safeguarding practice
• A safeguarding adults review must be arranged by a Safeguarding Adults Board if:
  • There is reasonable cause for concern that partner agencies could have worked more effectively to protect an adult and
  • Serious abuse or neglect is known or suspected and
  • Certain conditions are met, in line with section 44 of the Care Act 2014 and related statutory guidance

Involve the Service User Concerned Throughout the Enquiry:

• The process must be explained to the Service User in a way they will understand and their consent to proceed with the enquiry obtained, if possible
• Arrangements will be made to have a relative, friend or independent advocate present if the Service User so desires. The relative, friend or independent advocate must not be a person suspected of being in any way involved or implicated in the abuse
• A review of the Service User’s Care Plan and risk assessments must be undertaken to ensure individualised support following the incident
• The Service User will be supported by Spellman Care to take part in the safeguarding process to the extent to which they wish, or are able to, having regard for their decisions and opinions. They must be kept informed of progress

Desired Outcomes Identified by the Service User:

The desired outcome by the Service User at risk must be clarified and confirmed:

• To ensure that the outcome is achievable
• To manage any expectations that the Service User may have
• To give focus to the enquiry
• The Home Manager will support Service Users at risk to think in terms of realistic outcomes but must not restrict or unduly influence the outcome that the Service User would like. Outcomes must make a difference to risk and, at the same time, satisfy the Service User’s desire for justice and enhance their wellbeing
• The Service User’s views, wishes and desired outcomes may change throughout the course of the enquiry process
• There must be an ongoing dialogue and conversation with the Service User to ensure that their views and wishes are gained as the process continues and enquiries re-planned if the Service User changes their views
• The Service User will be informed of the outcome of any investigation, but guidance will be sought from the Leeds Safeguarding Adults Team before any outcome is shared

After An Enquiry

Once an initial enquiry has been undertaken, discussions should be had with the Service User as to whether a further enquiry is needed and what further action could be taken.

That action could include disciplinary, complaints or criminal investigations or work by contracts managers and CQC to improve care standards.

Leeds must determine what further action is necessary. One outcome may be the formulation of agreed action or a safeguarding plan for the Service User which should be recorded in their Care Plan. This will be the responsibility of the relevant agencies to implement. This will entail joint discussion, decision taking and planning with the Service User for their future safety and wellbeing.

In relation to the Service User, this could set out:

• What steps are to be taken to assure their safety in future
• The provision of any support, treatment or therapy including ongoing advocacy
• The need for fuller assessments by health and social care agencies
• Any modifications needed in the way services are provided (for example, same gender care or placement; appointment of an OPG deputy)
• How best to support the Service User through any action they take to seek justice or redress
• Any ongoing risk management strategy as appropriate
• Any action to be taken in relation to the person or organisation that has caused the concern

If a Safeguarding Concern is not agreed

If Leeds decides not to investigate, staff must ensure the continual safety of Service Users. Staff should:

• Evaluate existing risk assessments and Care Plans. Ensure that there is clear, documented evidence that this has occurred
• If the existing risk assessments and Care Plans do not cover the current risk(s), staff must implement new ones to ensure measures have been put in place to reduce future risk
• Staff can consider other referral options (this list is not exhaustive):
  • Human resources (capability/disciplinary routes)
  • Health and safety
  • Complaints
  • Leeds care management, request review of current Care Plan, request for a case conference
  • NHS continuing care team, request a review
  • Request for a best interest meeting

Informing the Relevant Inspectorate

• By law, Spellman Care must notify the Care Quality Commission without delay of incidents of abuse and allegations of abuse, as well as any incident which is reported to, or investigated by, the police
• Spellman Care must notify CQC about abuse or alleged abuse involving a person(s) using the service, whether the person(s) is/are the victim(s), the abuser(s), or both
• Spellman Care must also alert the relevant local safeguarding authority when notification is made to CQC about abuse or alleged abuse
• The forms are available on CQC’s website
• If a concern is received via the whistleblowing procedure, Spellman Care must inform the Leeds Safeguarding Team and CQC

Support and Supervision

Spellman Care will recognise that dealing with situations involving abuse and neglect can be stressful and distressing for staff and workplace support should be available.

During safeguarding enquiries, The Home Manager should:

• Be aware of how safeguarding allegations can affect the way other staff and Service Users view a Service User subject to a safeguarding enquiry
• If staff are concerned about working with a Service User who has made allegations, The Home Manager should provide support, additional training and supervision to address these concerns and ensure that the Service User is not victimised by staff
• Acknowledge that enquiries are stressful and that morale may be low
• Think of ways to support staff (such as one-to-one supervision and team meetings)
• Provide extra support to cover absences as part of the enquiry, and to help staff continue providing consistent and high-quality care
• Direct staff to sources of external support or advice if needed

Regular face-to-face supervision and reflective practice from skilled line managers is essential to support staff, and to enable staff to work confidently and competently with difficult and sensitive situations.

The Home Manager has a central role in ensuring high standards of practice at Spellman Care and that staff are properly equipped and supported.

Confidentiality and Information Sharing

In seeking to share information for the purposes of protecting adults at risk, Spellman Care is committed to the following principles:

• Personal information will be shared in a manner that is compliant with the statutory responsibilities of Spellman Care
• Adults at risk will be fully informed about information that is recorded about them and, as a general rule, be asked for their permission before information about them is shared with colleagues or another agency. However, there may be justifications to override this principle if the adult or others are at risk
• Staff will receive appropriate training on Service User confidentiality and secure data sharing
• The principles of confidentiality designed to protect the management interests of Spellman Care must never be allowed to conflict with those designed to promote the interests of the adult at risk
• Staff will follow policies at Spellman Care on UK GDPR, data protection, confidentiality and comply with the Caldicott principles

Staff Alleged to be Responsible for Abuse or Neglect

Spellman Care does not only have a duty to the Service User, but also a responsibility to take action in relation to the employee when allegations of abuse are made against them. Spellman Care should ensure that their disciplinary procedures are compatible with the responsibility to protect adults at risk of abuse or neglect.

When a member of staff is subject to a safeguarding enquiry, The Home Manager should:

• Tell them about any available Employee Assistance Programme
• Tell them about professional counselling and occupational health services (if available)
• Make them aware of their rights under employment legislation and any internal disciplinary procedures
• Nominate someone to keep in touch with them throughout the enquiry (if they are suspended from work)
  • They should be able to request that the nominated person be replaced, if they think there is a conflict of interest
  • The nominated person should not be directly involved with the enquiry
• If the police are involved, tell them who the nominated person is

For members of staff who return to work after being suspended, The Home Manager should:

• Arrange a return-to-work meeting when the enquiry is finished, to give them a chance to discuss and resolve any problems
• Agree a programme of guidance and support with them

Where appropriate, The Home Manager should report staff to the statutory and other bodies responsible for professional regulation such as the Nursing and Midwifery Council.

If The Home Manager is subject to a safeguarding enquiry, Mr Steven Spellman should put an acting manager in their place if required.

Disclosure and Barring Service (DBS) Referral

There is a statutory requirement for providers of care to refer workers to the DBS for inclusion on the DBS Vetting and Barring scheme list if they consider that the person is guilty of misconduct such that an adult at risk was harmed or placed at risk of harm. The legal duty to refer to the Disclosure and Barring Service  also applies where a staff member leaves their role to avoid a disciplinary hearing following a safeguarding incident and Spellman Care feels they would have dismissed the person based on the information they hold.

Please see the DBS/Disclosure Policy and Procedure for further procedures regarding initial employment and referral.

Abuse by Another Adult at Risk

Spellman Care recognises that they may also have responsibilities towards the person causing the harm, and certainly will have if they are both in a care setting or have contact because they attend the same place (for example, a day centre). The person causing the harm may themselves be eligible to receive an assessment. In this situation, it is important that the needs of the Service User at risk who is the alleged victim are addressed separately from the needs of the person causing the harm. It will be necessary to reassess the adult allegedly causing the harm.

Under the Mental Capacity Act 2005, people who lack capacity and are alleged to be responsible for  abuse, are entitled to the help of an Independent Mental Capacity Advocate to support and represent them in the enquiries that are taking place. This is separate from the decision whether or not to provide the  victim of abuse with an independent advocate under the Care Act.

Management of Allegations Against People in Positions of Trust (PiPoT)

A relationship of trust is one in which one person is in a position of power or influence over the other person because of their work or the nature of their activity. Any allegation against a person who works with adults with care and support needs must be reported immediately to The Home Manager.

When an allegation is made against a PiPoT, Spellman Care will refer this to Leeds as part of the safeguarding process.

Where the person alleged to have caused the harm or neglect is a volunteer or a member of a community group, Spellman Care must work with adult social services to support any action under this policy.

Where the person alleged to have caused the harm is a neighbour, a member of the public, a stranger or a person who deliberately targets vulnerable people, the Service User at risk should receive the services and support that they may need. In all cases, issues of consent, confidentiality and information sharing must be considered.

Safeguarding Concerns about the Manager and or Safeguarding Adults Lead

If staff at Spellman Care have safeguarding concerns about the Registered Home Manager, they can report their concerns to the Safeguarding Adults Lead – Registered Home Manager in confidence. In some services where this may be a dual held role by the same person, you can report your concerns in the following routes:

l  Follow the Raising Concerns, Freedom to Speak Up, Whistleblowing Policy and Procedure at Spellman Care

Alternatively you may wish to contact:

l  Local Authority Safeguarding Team: Leeds

• Contact: Leeds Safeguarding Adults, Leeds, 0113 222 4401
• Telephone: 0113 222 4401

l  The Care Quality Commission (CQC):

• Address: Citygate, Gallowgate, Newcastle upon Tyne NE1 4PA
• Email: enquiries@cqc.org.uk
• Telephone: 03000 616161
• Report online: https://www.cqc.org.uk/give-feedback-on-care

l  The Police

• If your safeguarding concerns involve criminal activity, such as physical or sexual abuse or if someone is in immediate danger, you should report the matter to the police. They can investigate and take immediate action if needed

Allegations Against People who are Relatives or Friends

There is a clear difference between unintentional harm caused inadvertently by a relative or friend and a deliberate act of either harm or omission, in which case the same principles and responsibilities for reporting to the police apply. In cases where unintentional harm has occurred, this may be due to lack of knowledge or due to the fact that the relative’s own physical or mental needs make them unable to care adequately for the adult at risk. The relative may also be an adult at risk. In this situation, the aim is to protect the adult from harm, work to support the relative to provide support and to help make changes in their behaviour in order to decrease the risk of further harm to the person they are caring for. A carer’s assessment will take into account a number of factors and a referral to Leeds will be made as part of the safeguarding process.

Pressure Ulcers

Spellman Care must follow local safeguarding reporting requirements and the Department of Health and Social Care (DHSC) guidance ‘Pressure Ulcers: How to Safeguard Adults’ (a link can be found in the Underpinning Knowledge section of this policy) with regards to pressure ulcers.

The aim of the DHSC guidance is to provide a national framework, identifying pressure ulcers as primarily an issue for clinical investigation rather than a safeguarding enquiry led by the local authority. Indicators to help decide when a pressure ulcer case may additionally need a safeguarding enquiry are included.

‘It is the responsibility of the designated safeguarding lead in each setting to appropriately triage any safeguarding concerns and ensure that referrals to the local authority for consideration of a section 42 (2) enquiry are appropriate.’ (GOV.UK 2024)

The DHSC guidance contains the following appendices that are used in the decision making:

• Appendix 1: Adult safeguarding decision guide
• Appendix 2: Body map
• Appendix 3: Adult safeguarding concern proforma regarding pressure ulceration

Safeguarding Concern Assessment Guidance:

• A history of the development of the skin damage should first be obtained by a clinician, usually a nurse
• Where there is concern from the clinician assessing the pressure ulcer that there has been abuse or neglect that can be directly associated with the pressure ulcer, there is a need to raise it as a safeguarding concern within Spellman Care
• In some cases it may warrant raising a safeguarding concern with Leeds
• If the Service User’s care has recently been transferred, this may require contact being made with former care providers for information to seek clarification about the cause and timing of the skin damage. This is the responsibility of Spellman Care and a concern should not be raised with Leeds until this has been done
• If a concern is raised that a Service User has severe damage, The Home Manager should:
  • Complete the adult safeguarding decision guide
  • Raise an incident immediately as per the policy of Spellman Care
  • (Severe damage in the case of pressure ulcers may be indicated in some cases by multiple category 2 or single category 3 or 4 ulcers, but could also be indicated by the impact the pressure damage has on the Service User affected (for example, pain)

Adult Safeguarding Decision Guide:

• The decision guide should be completed by a qualified member of staff who is a practising registered nurse (RN) with experience in wound management and not directly involved in the provision of care to the Service User at the time the pressure ulcer developed
• The adult safeguarding decision guide should be completed immediately or within 48 hours of identifying the pressure ulcer of concern. In exceptional circumstances this timescale may be extended but the reasons for extension should be recorded
• The outcome of the assessment should be documented on the adult safeguarding decision guide. If further advice or support is needed with regards to making the decision to raise a concern to Leeds, the Registered Home Manager or the Safeguarding Lead, Registered Home Manager, should be involved
• Where the Service User has been transferred into the care of Spellman Care it may not be possible to complete the decision guide. Contact should be made with the transferring organisation to ascertain if the decision guide has been completed or any other action taken
• Following this, a decision should be made whether to raise a safeguarding adults concern with Leeds, in line with agreed local arrangements
• The decision as to whether there should be a Section 42 enquiry will be taken by the local authority, informed by a clinical view. A summary of the decision should be recorded and shared with all agencies involved
• Where an internal investigation is required, this should be completed by the organisation that is, or was, taking care of the Service User when the pressure ulcer developed, in line with the local policies
• The local authority needs to decide or agree after completion of the internal investigation if a full multi- agency meeting (virtual or face to face) needs to be convened to agree findings, decide on safeguarding outcomes and any actions
• The safeguarding decision guide assessment considers 6 important questions that together indicate a safeguarding decision guide score. This score should be used to help inform decision making regarding escalation of safeguarding concerns related to the pressure ulceration. It is not a tool to risk assess for the development of pressure damage
• The threshold for raising a concern is 15 or above in most instances. However, this should not replace professional judgement
• Photographic evidence to support the report should be provided wherever possible. Consent for this should be sought as per local policy but great sensitivity and care must be taken to protect the identity of the individual
• A body map should be used to record skin damage and can be used as evidence, if necessary, at a later date. If 2 workers observed the skin damage, they should both sign the body map where possible
• Documentation of the pressure ulcer should include as a minimum:
  • Site
  • Size (including its maximum length, width and depth in centimetres)
  • Tissue type
  • Category
• Where the decision guide score is 15 or higher, or where professional judgement determines safeguarding concerns, copies of the completed decision guide and safeguarding concern proforma should then be sent to the adult safeguarding team within Leeds. Copies of both should also be retained in the Service User’s Care Plan
• Where there is no indication that a safeguarding concern needs to be raised, the completed decision guide should be retained in the Service User’s Care Plan

Medication Errors

Spellman Care must follow local safeguarding reporting procedures for medication errors and ensure that notifications are made to the CQC in line with statutory requirements. Spellman Care will have an open and transparent approach to medication incidents, ensure that staff follow the Medication Errors and Near Misses Policy and Procedure at Spellman Care and understand their duty of candour responsibilities.

Exploitation by Radicalisers who Promote Violence

Individuals may be susceptible to exploitation into violent extremism by radicalisers. Staff will be expected to follow the Protecting Adults at Risk from Radicalisation Policy and Procedure in place at Ghyll Royd Nursing

Home.

Self-neglect and Refusal of Care

Spellman Care must ensure that staff understand the importance of delivering care as detailed in the Care Plan. Where a Service User refuses care, this must always be documented. Where refusal occurs repeatedly, it must be escalated by Spellman Care as a safeguarding concern and a request for a review of the Service User’s care will be instigated.

Abuse and Sexual Safety

We recognise that culture, environment and processes support a Service User’s sexuality and keep them and staff safe from sexual harm. As such, Spellman Care will ensure that sexuality is discussed as part of the Care Plan process and is addressed positively to support people to raise concerns where necessary.

The CQC publication on sexuality and sexual safety can be referred to for further guidance in this area.

Criminal offences

Everyone is entitled to the protection of the law and access to justice. Behaviour which amounts to abuse and neglect, for example physical or sexual assault or rape, psychological abuse or hate crime, wilful neglect, unlawful imprisonment, theft and fraud and certain forms of discrimination also often constitute specific criminal offences under various pieces of legislation.

Leeds has the lead role in making enquiries. However, where criminal activity is suspected, the early involvement of the police should take place.

Risk Assessment and Management

Achieving a balance between the right of the Service User to control their care package and ensuring that adequate protections are in place to safeguard wellbeing is a very challenging task. The assessment of the risk of abuse, neglect and exploitation of Service Users will be integral in all assessment and planning processes. Assessment of risk is dynamic and ongoing, especially during the adult safeguarding

process, and must be reviewed throughout so that adjustments can be made in response to changes in the levels and nature of risk.

Training and Competencies

Staff, including volunteers at Spellman Care, are trained in recognising the symptoms of abuse or neglect, how to respond and where to go for advice and assistance.

Training should take place at all levels in Spellman Care and be updated regularly to reflect current best practice. To ensure that practice is consistent, no staff group should be excluded.

Spellman Care will ensure that staff receive training in recognising and responding to incidents, allegations or concerns of abuse or harm as part of their induction programme. Spellman Care will benchmark its training and competencies within the service with the framework outlined in ‘Adult Safeguarding: Roles and Competencies for Health Care Staff”, which it recognises applies to social care staff also and does not replace any local or contractual requirements but acts as a minimum benchmark. Spellman Care will also refer to the ‘NHS Prevent Training and Competencies Framework’ for more specific training requirements in relation to the Prevent strategy.

Specialist training will be provided for those who will be undertaking enquiries, the Registered Home Manager and the Safeguarding Lead, Registered Home Manager at Spellman Care.

Registered Home Manager will cascade safeguarding information about adults at risk to appropriate staff members. Registered Home Manager will undertake and provide internal training and attend local safeguarding partnership updates, education and development sessions including regular group-based supervision.

Training needs to make a difference to the understanding, confidence and competence of staff. Assess what changes it has prompted through regular supervision sessions as well as annually during appraisals. Arrange refresher training if the annual check indicates this is needed.

Audit and Compliance

It is essential that the implementation of this policy and associated procedures is audited to ensure that Spellman Care is doing all it can to safeguard those receiving its services. The audit of this policy will be completed through a systematic audit of:

• Recruitment procedures and disclosure and barring checks
• Incident reporting, frequency and severity
• Training processes, including reviews of uptake of training and evaluations

Safeguarding concerns and incidents will be reviewed by the senior management team as part of a root cause analysis with the following terms of reference:

• Review incident themes
• Reports from the lead responsible for safeguarding within Spellman Care
• Look in detail at specific cases to determine learning or organisational learning
• Ensure implementation of the Safeguarding Adults Policy and Procedure

Spellman Care should maintain and regularly audit care records (in addition to external checks, such as audits or Care Quality Commission inspections) and ensure that they are complete and

available in case they are needed if a safeguarding concern is raised.

Sharing of Information

Spellman Care acknowledges that the sharing of information may be required when dealing with Safeguarding concerns.

Information will be made accessible to health professionals, advocates, families, legal representatives acting on behalf of Service Users, and those close to them. The process for sharing information will follow the steps set out within the Data Protection and UK GDPR Policies and Procedures at Spellman Care.

The Registered Home Manager, and Nominated Individual, Mr S Spellman, of Spellman Care, have overall management responsibility for this policy and procedure. This is in line with the Policy Management Policy and Procedure at Spellman Care.

Mental Capacity Act: 5 Principles

Spellman Care will ensure that all staff know and work within the Mental Capacity Act and its 5 underpinning principles:

• The presumption of capacity – every adult has the right to make his or her own decisions and must be assumed to have the capacity to do so unless it is proved otherwise
• Individuals must be supported to make their own decisions – people must be given all appropriate help before anyone concludes that they cannot make their own decisions
• Individuals must be able to make what might be seen as eccentric or unwise decisions, without this being used as the sole reason to say they lack capacity
• Best interests – anything done for, or on behalf of people who lack capacity must be in their best interests
• Least restrictive option – before any act is done or a decision is made, staff must consider if they have found the option that, while meeting the need, is the least restrictive possible of the person’s basic rights and freedoms

Supporting Service Users to Make their Own Decisions – Consent

Staff at Spellman Care ensure that they support Service Users to make their own decisions at every opportunity by using all available means to enhance their capacity for each specific decision.

Spellman Care understands the importance of supporting people to make their own informed decisions through informed choice and will ensure:

• Staff know how to present the right information in the right way, providing accessible information and resources, including using easy read or pictures where suitable, and being clear about all the available options
• Staff actively look for the best ways to communicate with an individual, by checking that their vision and hearing are as good as they can be, or querying if an interpreter might be needed
• Staff put the Service User at ease, whether by choosing the right time of day to explain about a decision to the person, or asking whether they would like a relative or friend present
• Staff allow time for the Service User to ponder on the decision, or go away and discuss it with trusted relatives or friends

Spellman Care will never pressure or coerce Service Users, or withhold information which is relevant to their decision-making process.

Assessing Capacity

Spellman Care understands that all Service Users will be presumed to have capacity unless there is reason to believe otherwise.

Spellman Care understands a capacity assessment is not required if there is no doubt about an individual’s capacity.

When a Service User lacks the mental capacity to make a particular decision, all actions taken are in the best interests of that person and align, as far as possible, with the Service User’s wishes and feelings.

Where appropriate (for more major decisions), staff will ensure that they use the MCA best interests checklist to inform best interest decision making.

Any assessment of a Service User’s mental capacity is decision specific and time specific to decide whether they can make a particular decision at the time it needs to be made.

The Home Manager or a designated and trained individual will undertake capacity assessments when they are required.

All assessments will be completed using the form found in the ‘Forms’ section of this policy.

Best Interest Decisions

When a person lacks the mental capacity to make a particular decision, everything that is done for, or on behalf of that person is in the person’s best interests and restricts their rights as little as possible. In working out what is in someone’s best interests, the Registered Home Manager or appointed trained

staff apply the mandatory checklist of factors laid out in the Mental Capacity Act.

Restrictive Practices

Staff refer to the associated policies and procedures at Spellman Care, such as restraint/physical interventions and restriction of freedom of movement, when considering capacity and best interest decision making and ensure that their actions are in accordance with the MCA.

Staff know how the Mental Capacity Act 2005 defines restraint, and that restraint can be:

• Physical or mechanical
• Environmental
• Chemical

Any physical intervention must be agreed as part of a multidisciplinary decision involving external health professionals and senior managers in Spellman Care. Staff must follow strategies as detailed by an approved, accredited training provider (please refer to the Restrictive Practices Including Restraint and Physical Interventions Policy and Procedure).

Deprivation of Liberty

Staff know that the Mental Capacity Act 2005 does not allow a person to be deprived of their liberty in settings such as care homes, domiciliary care and supported living unless this follows deprivation of liberty policies and procedures at Spellman Care.

Deprivation of Liberty Safeguards (DoLS) are checks under the Mental Capacity Act 2005, ensuring the rights of individuals receiving care with restricted freedom.

The DoLS assessment evaluates the alignment of care with the person’s best interests, covering age, mental health, capacity, best interests, eligibility, and refusals. Post-authorisation, safeguards continue, such as appointing a representative and setting review dates.

Staff must be aware of, and understand, any conditions attached to a Deprivation of Liberty Authorisation. Further information can be found in the deprivation of liberty policies and procedures at Spellman Care.

Third Parties with Legal Responsibilities

Spellman Care understands that families and friends do not have the legal right to make decisions on behalf of Service Users without their consent, or if they do not have capacity.

Spellman Care will ensure that they have a record of those lawfully able to act on a Service User’s behalf and under what circumstances.

This includes:

• Lasting power of Attorney (Health and Welfare)
• Lasting Power of Attorney (Property and Finance)
• Enduring powers of attorney (signed and dated before 2007 and applicable to the decision and circumstance)
• Court Appointed Deputies
• Advance Decisions

Spellman Care will ensure that all legal requirements are met, including registration, before accepting the above.

Advance Statements of Wishes

These are not legally binding, but it is good practice to encourage people to think about the ways they would like to be cared for if they should lose mental capacity.

Spellman Care will make sure that Advance Statements are considered thoroughly when making best interest decisions for Service Users.

Advocacy / IMCA

In cases where a Service User lacks capacity and has no relatives or friends to be consulted about their wishes and feelings apart from paid staff, and there is a need for serious medical treatment or a change in accommodation (e.g. moving into a care home), staff know that an independent mental capacity advocate (IMCA) must be appointed by the relevant NHS body or local authority.

Staff of Spellman Care will cooperate with any IMCA who is instructed.

Staff can refer to the Advocacy Policy and Procedure at Spellman Care for further details.

Training

All staff at Spellman Care are given training on the Mental Capacity Act 2005. References to training resources can be found in the Underpinning Knowledge/References section of this policy. Staff at Spellman Care know and work within the Mental Capacity Act principles and codes

of practice, including knowing what deprivation of liberty is, the legal framework to support Service Users lacking mental capacity, and the procedures that must be followed in such circumstances.

The Government has also introduced a requirement for CQC registered service providers to ensure their employees receive learning disability and autism training appropriate to their role. This is to ensure the health and social care workforce have the right skills and knowledge to provide safe, compassionate and informed care to autistic people and people with a learning disability. This requirement is set out in the Health and Care Act 2022. A link to this requirement can be found in the Further Reading section of this policy.

Roles and Responsibilities

The Home Manager is responsible for this policy and the dissemination of its contents.

• The Home Manager maintains and raises awareness among all staff of the Mental Capacity Act 2005 principles and practice, including:
  • Recognising the central importance of the MCA to protect the human rights of vulnerable people
  • Understanding among all staff that the MCA springs out of human rights law combined with existing best practice in health and social care, so it is intuitive to work within, and aligns with good, person- centred practice
  • The requirement to do everything possible to enable Service Users to make their own decisions, even small ones, wherever they can do so
  • The definition of restrictive interventions/restraint within the MCA, and how to recognise when deprivation of liberty is unavoidable in the Service User’s best interests
  • The requirement to interfere with the Service User’s basic rights and freedoms as little as possible, while keeping them as safe as possible
• The Home Manager is responsible for assessing capacity and arranging best interest meetings, as well as more complex best interest decisions for Service Users if this is required, or delegating responsibility to a trained deputy
• The Home Manager is responsible for reporting all breaches and raising safeguarding concerns to the regulator and local authority
• The Home Manager is responsible for checking the registration of those with third party legal responsibilities

All staff have a responsibility to read this policy and procedure and direct questions to their line manager or The Home Manager if there is any element they do not understand.

Staff have a responsibility to follow this policy and procedure and report any intentional or accidental breach of the process.

Training will be set by The Home Manager, and staff have a duty to attend or make alternative arrangements to attend. It is every member of staff’s responsibility to maintain this knowledge and raise any concerns or gaps in knowledge with The Home Manager.

Staff should access the Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure if they have witnessed any wrongdoing and wish to use this process to report a concern.

Consent

Any decision about a Service User’s care or treatment must involve the informed and lawful consent of the Service User. A list of considerations can be found in the Policy section to ensure that the Service User is offering their informed consent.

If a Care Worker has concerns that a Service User is unable to give informed and lawful consent (whether that be a refusal or agreement on the issue), the Care Worker must inform the Registered Home Manager and record this information in the Care Plan notes to see if a capacity assessment needs to be completed.

Supporting Service Users to Make Decisions and the MCA Process

Where it is helpful for the Service User, a Care Worker or a family member, advocate or representative may sit with them during the assessment process to reassure them and help them relax and feel comfortable.

Staff adopt the following best practice in relation to supporting Service Users to make decisions:

• Knowing how to present the right information in the right way, including being clear about all the

available options

• Actively looking for the best ways to communicate with a Service User, including checking whether they can see and hear as well as possible, or need an interpreter, or need to have pictures to understand their options
• Putting the Service User at ease, choosing the right time of day to explain about a decision to them, or asking whether they would like a relative or friend present
• Taking care to enable the Service User, wherever possible, to take away the information (in an accessible format such as easy read where suitable) and think it over, or discuss it with trusted friends or family
• Actively trying to create options that will fit with the Service User’s wishes, feelings, history and personality
• Documenting any support given to help the Service User make decisions in the Service User’s Care Plan

If it is determined that the Service User does not have the mental capacity to make a particular decision at the time it needs to be made, any action taken or any decision made must be in their best interest and recorded by the Care Worker.

Day-to-Day Decisions

Care Workers must work from the Care Plan for day-to-day decisions. For more important decisions, best interests decisions should be recorded. This can be done by completing the forms that accompany this policy with the Service User.

Advance Care Planning

Staff should ensure that Service Users who are at risk of losing capacity to make decisions and Service Users with fluctuating capacity have the opportunity to discuss advance care and support planning prior to commencing a package of care with Spellman Care and when Care Plans are reviewed.

This will ensure that the Service User’s wishes are known and documented for the future.

Who Should Assess Capacity?

A Service User’s capacity should be assessed by the staff member caring for the Service User when the decision needs to be made.

Staff completing capacity assessments must be trained, confident and competent to carry out assessments, and have the communication skills and ability necessary.

If a healthcare professional is proposing treatment, it is their responsibility to assess capacity.

For complex decisions, a formal assessment may be required from a social worker, occupational therapist, psychologist or psychiatrist, who will advise those making the decision.

Assessment of Capacity

Any assessment of a Service User’s mental capacity is decision specific and time specific to decide whether they can make a particular decision at the time it needs to be made. It is not about a range of decisions.

Staff should involve the Service User’s family or significant others or an Independent Mental Capacity Advocate if one has been appointed.

Staff assessing a Service User’s capacity to make a decision for themselves should use the two-stage test of capacity.

Stage 1: Does the Service User have an impairment of the mind or brain, or is there some sort of disturbance affecting the way their mind or brain works? (It does not matter whether the impairment or disturbance is temporary or permanent.)

• If a Service User does not have such an impairment or disturbance of the mind or brain, they will not lack capacity under the Act

These could include:

• Conditions associated with some forms of mental illness
• Dementia
• Significant learning disabilities
• Long-term effects of brain damage
• Delirium
• Physical or medical conditions that cause drowsiness or loss of consciousness

If ‘yes’, does that impairment or disturbance mean that the Service User is unable to make the decision in

question at the time it needs to be made?

Stage 2: Does the impairment or disturbance mean that the Service User is unable to make a specific decision when they need to, after being given all the practical and appropriate support to help them make the decision for themselves? Staff must have supported the Service User to make the decision for Stage 2 to apply.

A Service User is unable to make a decision if they are unable to do the following:

• Understand information relevant to the decision that is to be made
• Retain that information in their mind
• Use or weigh the information to reach a decision, and
• Communicate their decision, by any means at all that can be understood

There must never be a generalised statement that someone lacks mental capacity. It is never enough to say that the Service User lacks mental capacity solely because of a diagnosis (such as dementia), or because someone thinks their decision is unwise, or because of their age, or their appearance.

When assessing a Service User’s capacity, the Service User does not have to prove that they have capacity to make a certain decision. It is up to the person(s) who will make decisions on behalf of the Service User to prove that, on the balance of probabilities, the Service User lacks the mental capacity to make this decision.

If it is decided that, on the balance of probabilities, and after all possible help has been given to enable them to do so, the Service User does not have the mental capacity to make a particular decision at the time it needs to be made, any action taken or any decision made must be in the Service User’s best interests and recorded by the Care Worker.

Fluctuating Capacity or Temporary Capacity

Some Service Users may have fluctuating capacity, meaning at times they can make decisions, but at other times their condition may affect their ability to make decisions. This could include:

• A psychotic episode during a delusion phase
• Manic depression during a manic phase
• Acute illness, severe pain, effect of medication

Staff must assess the Service User’s capacity to make the particular decision at the time it needs to be made. They should also consider if the decision can wait until the Service User has the capacity to make it.

Complete Record of Assessment

Any member of staff responsible for assessing capacity must ensure that all the required documentation is completed to evidence that the Mental Capacity Act 2005 has been followed. Staff must refer to the documentation that can be located in the Forms section of this policy.

The capacity assessment must clearly document:

• The decision to be made
• The domains of capacity that the Service User is lacking (understanding, retaining, weighing and/or communicating)
• Details of how staff have attempted to maximise the Service User’s capacity

Care Workers must work to a Care Plan which is clearly based on the assessment of capacity and best interests and is subject to review in accordance with local agreement and the Service User care and support planning policies and procedures at Spellman Care.

All Care Workers know that they can raise issues that might show that the Care Plan should be reviewed more urgently with senior staff. Examples of this include when the staff member thinks the Service User has regained capacity, or that there is a decision they used to be able to make but now might have lost that capacity.

The records of all assessments must be completed fully, signed by the assessor and dated. Assessments will be kept with the Care Plan so they are readily available and can be revisited when reviewing aspects of the Service User’s care.

All information will be stored in line with data protection law and the UK General Data Protection Regulation.

Where a Service User lacks capacity over a long period of time for many kinds of decisions, capacity must be reviewed whenever a Service User’s Care Plan is being developed or reviewed, or there appears to be some change in their capacity to make decisions, or when they lack capacity for a major decision that needs to be made, for example, about where to live, or whether to have serious medical treatment.

Disputes

If there is a dispute about best interests, firstly staff must ensure they have followed the mandatory best interests checklist, and tried, in particular, to make a decision that is in alignment with what the Service User wants. The following must be considered:

• Families and friends with legal responsibilities will not always agree about what is in the best interests of an individual. However, they usually have greater knowledge than Care Workers of what this Service User would have wanted, and sometimes of what the Service User now wants
• The decision-maker will need to clearly demonstrate in the record kept that the decision is based on all available evidence and has taken into account all conflicting views. Particular care will be taken to look for the option that is the least restrictive of the Service User’s rights

If there is a dispute, The Home Manager will consider the following things to assist in determining what is in the Service User’s best interests:

• Where it might help, involve an advocate who can represent the Service User and highlight their relevant wishes and feelings
• Hold a best interests meeting to identify all the possible options and explore the pros and cons of each, or, if for example, relatives or some professionals cannot attend in person, enable all relevant views to be properly recorded and shared
• Consider mediation
• As a last resort, apply to the Court of Protection for a ruling (normally undertaken by the relevant Local Authority or NHS Trust when a complex and serious decision is to be made)

The Home Manager must ensure that all documents completed are both signed and dated.

Best Interest Meetings/Mental Capacity Act Check List

In making a decision in a Service User’s best interests because they lack capacity to make this decision for themselves, the Mental Capacity Act 2005 makes it compulsory to use a checklist covering matters to be considered, except in an emergency.

Decisions can be complex or life changing and a formal best interest decision meeting may be required. A number of different people may be involved if the decision would benefit from their input for the Service User such as:

• Staff
• Third parties such as those with power of attorney
• Family/close friends

A record of the conversations and conclusions must be recorded when making a decision in a Service User’s best interests, and the following must be taken into account (except in an emergency, when there is no time).

This checklist is a mandatory requirement under the Mental Capacity Act 2005 of matters to be considered by a decision-maker:

• Is the Service User likely to regain the mental capacity to make this decision and, if so, can this decision wait until then?
• Do everything possible to encourage the Service User to take part in the making of the decision, even though they lack the capacity to make the decision
• Give great weight to the Service User’s past and present wishes and feelings (in particular if they have been written down)
• Identify any beliefs and values (e.g. religious, cultural or moral) that would be likely to influence the decision in question
• Include any other factors that would be relevant and important to this Service User if they were able to make their own decision
• Be sure that you are not making assumptions about the Service User’s best interests simply based upon the Service User’s age, appearance, condition or behaviour
• As far as possible, the decision-maker must consult other people who might have views on the Service User’s best interests and what they would have wanted when they had mental capacity, especially the following people:
  • Anyone previously named by the Service User lacking capacity as someone to be consulted

• Staff at Spellman Care, close relatives, friends or anyone else interested in the Service User’s welfare
• Any attorney appointed under a Lasting Power of Attorney
• Any deputy appointed by the Court of Protection to make decisions for the Service User

Making a decision in a Service User’s best interests requires evidence of the following:

• That the Act’s statutory principles and best interests checklist are properly considered
• That the Service User remains central to the decision or decisions needing to be made and they are involved in the decision-making process where possible
• That relevant professionals and informal networks are properly consulted and if the statutory criteria are met, an Independent Mental Capacity Advocate is instructed
• A clear structure to the meeting, promoting partnership and collaborative working, the sharing of relevant information, the positive expression of different views, and an analysis of the risks and benefits attached to different options

Advocacy

An advocate is someone who can help the Service User express their wishes and views, and support them if:

• They have no family or friends and do not qualify for an Independent Mental Capacity Advocate (IMCA)
• Their family members disagree about their best interest
• There is conflict of interest with those who have been consulted over the best interest decision
• The Service User has previously used an advocate

Independent Mental Capacity Advocate (IMCA)

The IMCA service helps Service Users who lack the capacity to make important decisions about serious medical treatment and other changes such as accommodation or a care provider, and who have no family or friends that it would be appropriate to consult about those decisions.

IMCAs are independent and will work with, and support, the Service User who lacks capacity, to express their views to those who are working out their best interests.

An IMCA must be instructed when a Service User with no one else to support them lacks capacity and:

• An NHS body is proposing to provide serious medical treatment, or
• An NHS body or local authority is proposing to arrange accommodation (or a change of accommodation) in hospital or a care home, and
• The Service User will stay in hospital longer than 28 days, or
• They will stay in a care home for more than eight weeks Spellman Care should also consider an IMCA for:
• Support/care reviews, where no one else is available to be consulted
• Adult protection cases, whether or not family, friends or others are involved

Education and Training

• All staff at Spellman Care are given training (including regular refresher training) in the Mental Capacity Act and the attendance of staff is recorded on a matrix at Spellman Care
• All staff understand the importance of seeking consent whenever staff intervene in a Service User’s privacy or lifestyle, unless it can be shown the person lacks capacity to make this specific decision
• All staff understand that capacity is ‘decision and time specific’, so they must do all they can to enable this person to make this particular decision at the time it needs to be made, for example, by clearly explaining their options and the likely outcomes of different decisions they might make
• Staff recognise that Service Users have the important right to consent to, or refuse, any staff interventions in their lives, provided they have capacity to do so
• All staff understand how to assess capacity when required, if appropriate, in cooperation with more senior staff
• All staff evaluate how effective the training is and feedback their views to The Home Manager
• New staff are expected to complete standard 9 of the Skills for Care Certificate
• Forums such as supervision, team meetings and observation of practice are used to continue

improving staff practice in applying the MCA

Mr Steven Spellman makes accessible documents and resources about the Act, including training resources available to staff.

References to resources can be found in the Further Reading and Underpinning Knowledge sections of this policy.