Safeguarding Adults?

One of the key policies that I’ve worked a lot with over the past few years, has been the introduction of the ‘new’ Protection of Vulnerable Adults (POVA) scheme and the Safeguarding Adults procedure – when there is a suspicion of abuse of a vulnerable adult.

And it’s usually a frustrating process.

caution calamity meg calamity meg@flickr

There is little legislation in place to allow for any action even where there is – in some cases quite open – evidence that abuse is taking place.

Even after the forms have been filled, the strategy meetings have been convened, the police have confirmed that the CPS will not be able to take any further action because the victim of the abuse has dementia and therefore will not make a reliable witness – there is little that you can be left with.

The frustrating part is that you can have a very strong idea of what is going on through allegations, people saying things, but as long as the Crown Prosecution Service see people with dementia being unable to serve as witnesses, prosecutions will not be forthcoming.

Taking an elderly adult into residential care when they wish to stay in their own home is a draconian (and expensive) measure to take because the process of moving can be more permanent when someone is older. In fact, this article confirms that although there is no long term impact on elderly people who move into residential accommodation, when it is an imposed move, a higher morbidity rate can result.

Sometimes, people are left in situations that compromise their safety, dignity and financial position because the alternatives are not feasible.

I have been involved in two cases recently and without too many details, one is a standard (because unfortunately, it is probably the most common) financial abuse situation.

Someone who has dementia has a family member who feels they can use the income, savings and benefits of their parent as ‘free money’. Is this enough reason to move someone out of the property? No charges can be brought because although there is no capacity, according to the law, she is giving the money willingly (of course, this doesn’t account for the distress that is expressed through lack of being able to visit the local shops and buy a paper).

Another is a more tricky issue of possible physical and sexual abuse. Witness statements based on hearsay but fairly substantial – although not enough for criminal investigations.

That did involve a move – but it was no thanks to the Safeguarding Adults ‘strategy’ meeting which seemed to consist of policemen apologising for what they were not able to do after consulting with the Crown Prosecution Service (no criticism of the police involved, they were equally if not more frustrated by this).

And I shouldn’t even start on trying to get civil injunctions when someone lacks capacity. Civil injunctions are geared towards domestic violence and they have a part to play but when the person who wants to apply for the injunction is deemed to ‘lack capacity’ – there is a more convoluted and extensive procedure involving the Official Solicitor – none of which can be done in a reasonable time-frame.

I think civil injunctions could potentially go part of the way in some circumstances although the need for proof is still there. I’m not sure what the answer is, but I wish the procedures had more teeth.

I read in Community Care, well, on their website, that Ealing won a case to remove an adult from the care of her family who were ‘unsafe carers’. The article makes the point that

‘Vulnerable adult protective litigation is a relatively new legal area and many teams will not have the budgets in place to run a case such as this. Difficult financial choices will arise and it is to be hoped that, overall, a means can be found of taking necessary protective legal action without having to cut frontline services.

The solution may lie in the new Court of Protection established under the Mental Capacity Act 2005. Future cases of this sort are likely to be heard by that court whose specialism and relative informality may make vulnerable adult cases easier to manage.’

So perhaps the Court of Protection will provide a greater level of protection in the long run.

One can only hope.

But in the meantime Action on Elder Abuse have launched a survivors network for victims of abuse.

I’m trying my hardest not to be cynical about this because any opportunities to help the victims of abuse has to be positive.

But what I’d really like to see is an additional bump to the legislation and particularly the means of obtaining civil injunctions to cover more of the issues of adults who do not have capacity and a more streamlining (and quick) process.

Walk away

Yesterday I was called to an ’emergency’. Well, as I don’t operate strictly in a crisis setting, it was more to act as a gatekeeper to the ‘real’ emergency services.

In essence, did Mr A need to come into hospital?  It wasn’t a formal assessment – more like  a pre-assessment and an attempt  to establish levels of risk.

Mr A was homeless. Not ‘street’ homeless but as near as possible to that as could be. He had been evicted from one hostel following allegedly ‘disturbing’ behaviour. He had been moved by the Housing Department of different council to another hostel  in our area where he had been for a few days, and was due to move to a more permanent place (a bedsit) but it was again in a different local authority.

The housing officer was concerned about him. She was concerned about how he would manage in a more independent setting as he felt that the hostels had been providing more informal support. So she called us to see if Mr A needed to come into hospital.

Mr A appeared unwell. It would, of course, be wrong as well as unlawful to use the Mental Health Act to solve housing issues. Mr A was unwell enough to need support though.

He was agitated but I’d also be agitated if I had strange people trooping in to see me when I didn’t know where I was going to be spending the night. There was no way he could be said to lack capacity, at least from the history and interaction that I had access to.

So what to do?

I told the housing officer that we couldn’t refer for a compulsory admission as Mr A did not warrant it. Yes, he probably needed to see a doctor and could definitely benefit, possibly most of all, from some kind of care coordination, someone to help him and guide him to tie some of the pieces of his life together, possibly some medication – but not compulsory admission to hospital.

But I felt a bit empty on my way home. It’s likely that Mr A moved to a different area overnight. I don’t know if he would have got into the taxi to take him or not (he was fairly adamant that he wouldn’t when I left), but I think it’s one of those situations that might be on its way to deteriorate.

The housing officer will contact us later to tell us where he is, and we can contact the local team there to try and ask them to make contact. I think its unlikely that he’ll want anyone related to Mental Health to go and see him. Already when I told him (and it was the first thing I did ) that I work in a Mental Health team he became visibly more anxious (again, understandably – he has had a string of compulsory hospital stays in the past).

I have a feeling things will get worse for him before they can get better – and that is frustrating.

Sometimes, I just want to -do- something,  but have to walk away. I think those are always the hardest situations and those are the people that sometimes I think about when I’m going to sleep at night.

I know I shouldn’t. I’ve been given and have given out the advice a million times about not taking work home with you – but I suppose there must be a way to stop thinking without stopping caring.

Differences in Depression

Breaking completely unsurprising news.. Men and women express different symptoms of depression according to a study from Cardiff.

But there are some interesting points that I wasn’t aware of. The breakdown of the symptoms is quite interesting. According to the study

‘Female patients reported certain depressive symptoms more often than men, namely diminished libido (62% vs 35%) excessive sleep (19% vs 10%) self reproach (96% vs 87%), and diurnal variation (46% vs 32%).’

There don’t seem to be any symptoms listed though that men suffer more from than women.I’d be interested though to know if there are any symptoms that men express more than women.

Perhaps I’m not reading this correctly, and I’m certainly no academic, but does this mean that women just suffer from more of everything in relation to depression?

There is a higher propensity to depression in women. That is fact. There are more women who suffer from and seek help with depression during their lifetime and many arguments, discourses and studies including ones here and here.

I’m no medic either and certainly not one to fly in the face of scientific evidence, but instinctively, it seems that our society is more able to accept the model of female depression. It fits into a stereotype very easily. Would that mean that doctors are more likely to prescribe anti-depressants to women? Well, without actually conducting any research I can’t say, but a quick search on the subject (Google is a wonder resource!) seems to indicate that

More women are prescribed anti-depressants than men as noted by the WHO who say

‘Female gender is a significant predictor of being prescribed mood altering psychotropic drugs.’

and yet

male GPs are far more likely to do the prescribing

Of course, the first point would come as no great surprise if more women are actually suffering from depression (which is, I think, undeniable) – it makes sense that they are assisted pharmacologically, if that is what’s needed, of course – and more women are diagnosed with depression after all.

The second study though, if anything was more interesting in that female GPs were more likely to favour talking therapies.

Perhaps we have become more used to self-diagnosis and are asking GPs for particular medications, as The Times highlighted last year saying

‘Research on doctors’ habits also revealed that many felt they were prescribing the drugs too often, but did so because patients wanted medication. They said that funding was often not sufficient for alternative behavioural therapies and other counselling treatments, despite NICE guidance that they can be as effective as antidepressants for those with mild to moderate depression.’

So funnily enough it leads back to funding.

The likelihood of male GPs to prescribe more than female GPs remains a little baffling in the light of this discourse. Perhaps some female GPs have more sensitivity to the subject. Perhaps, became in general, women are more likely to want to talk about feelings, they can transfer some of this approach to their patients.

Or are women with depression more likely to want to talk to a female GP about their problems in the first instance so female GPs take some of the initial consultations when the depression is less severe?

I don’t know really, but I’d be interested in more information about that study. There must have been some more answers and reasons offered than just gender.

Into the ‘hoods

Yesterday was European Neighbour’s Day. I know about this because I read The Guardian’s website! It was a timely then, that yesterday I spent a morning with the neighbour of one of the people that I work with.

We’ve met a number of times and I’d say she and the community where she lives, epitomises good neighbourliness in every sense.

Anne (names changed!) lived on the same estate since she was born (she’s now well into her 80s). She never married and has no children. She is the youngest child of 7 and has out-survived all  her siblings. Her nieces and nephews are far away and out of the city.

Her neighbours though, amongst themselves, ensured she was getting good hot meals to eat regularly. They’d take her out for walks in the area, just go and keep  her company, sort out her bills and do her grocery shopping.

She was well known to everyone in the area.

When a young lad saw some smoke coming from her window, he ran for her neighbour (who had a key) to go in and put out the small electrical fire she hadn’t noticed.

When she got confused and wandered up to the local church in the evening, some of  the local teenagers took her back home and kept an eye  on her.

When she went to the local shop and forgot to take enough money, the shopkeeper would tend to turn a blind eye because he didn’t want to see her wanting for anything.

And this might sound like the idyllic rural village scenario. But this is inner city London.

When Anne moved into residential care, because she could no longer manage at home, she was missed in the community. She is visited regularly by the same neighbours who visited her at home although less regularly.


Kevin Harris, who wrote the Guardian piece, writes, in this own blog that

‘Neighbouring is now discretionary and requires a deliberate effort.’

Perhaps the ‘deliberate effort’ is based on the type of community and the longevity of it. I like to think it can sometimes be spontaneous though. I wonder if it is also, at least in cities, based somewhat on prosperity – or lack of it. The most overwhelming displays of community and neighbourliness that I have witnessed has tended to be within public housing.

Perhaps there is something more evident in the middle-class mind about neighbours being people to compete with or ‘my home being my castle’ attitudes where people built moats in their minds to keep ‘strangers’ out.

I don’t know my own neighbours except in passing, but I’ve lived in the place I am now for three years roughly. I can’t in all honesty say I’ve made any deliberate efforts apart from smiling and greeting – but the responses I have received make me think that were any effort extended, the reaction would be positive.

Yesterday, I went to Anne’s house with one of her neighbours to pack up the property. We took her clothes, her papers and.. her favourite armchair.. to the residential home where she was living.

As I was moving, people came from their houses to ask about what we were taking and mostly were concerned about Anne. They told me stories about her and how she had been in the past. I felt pangs as I took her keys back to the housing office yesterday, knowing I was giving up one part of her but to be living amongst people who have so much care and warmth is something that can only instil positive thoughts and in a world of bad news stories and negative press, it’s comforting to see the strength of community in action.

I like the idea of local solidarity. I’ve seen it and it works!

Get out of Jail Free

I haven’t had much experience of working within the criminal law system but I noticed an article via Mental Patient about Town from the Independent which was depressingly unsurprising when it states that there are a growing number of people who are mentally ill within the prison system.

I suppose this begs a question about what purpose prison is serving as I generally see the role more about rehabilitation and re-education than punishment but that’s another question entirely and while there are services that do ‘in-reach’ work within prison – how much is followed up on release though is a different matter.

jail (zavtor@flickr)

A couple of years ago, I worked with a man who had been in one of the higher security jails in the UK a few years previous to my meeting him following a ‘racially motivated aggravated assault’.

I know I am not in the position to judge people but having read the details of the assault, it didn’t exactly make me warm to him automatically. Especially as the victim of the assault had been in her 80s – I know, a victim is a victim regardless of age but this was a particularly vulnerable person.

The court (aided, no doubt, by a forensic psychiatrist) had determined he required punishment rather than hospitalisation and that’s where he went but he needed some level of treatment.

He had been released from prison on appeal due to some issues about the legality of the conviction (the CPS solicitor had basically messed up)  that I didn’t really understand.

What I did understand was that he was happy to discuss this assault, he retained his inherently racist viewpoint and had sought and received  compensation from the government for unlawful imprisonment.

My reason for bringing this up is that he had been receiving treatment in prison. When he was released on appeal, because it was through the appeal process, he walked free from prison.

There is an automatic system of referral  from prison services to Community Services when someone is released from jail but when there is an appeal and someone just walks out of prison that same day there seemed to be no provision for follow up, or it didn’t happen in this case.

So, a couple of years later, when he was brought into hospital under Section 2 of the Mental Health Act I was asked to write his Social Circumstance Report for his Mental Health Review Tribunal appeal against the detention.

The MHRT were scathing in their remarks about the lack of follow up between his release from prison and his admission to hospital. And quite rightly.

As my manager said at the time said, rather cynically, he was a newspaper headline waiting to happen..

It is easy to see how it can happen and this situation was rather particular, but it is indicative of strains in the system where situations and a possible further detention in hospital could possibly have been avoided.

Ageism – the ‘acceptable’ face of prejudice

Social workers are supposed to be a liberal group. We are trained extensively in anti-discriminatory practice. I can’t imagine there are any social work courses in the country that don’t, at least explore, the implications of discrimination, power and oppression even at the interview level.

So it is particularly upsetting and distressing to see colleagues behave, speak or act in a way that seems contrary to those values that not only were emphasised throughout training and practice but that also carry through to every facet of life.

We know that one of the fundamental foundations on which social work is based is that of combating oppressive practice and prejudices – so what to do when it is people and organisations you live and work in that are so prejudicial?

I was confronted with this towards the end of last week. I still  have some anger – but the anger has changed from writing letters and shooting ’emails of indignation’ off in my head, to a more rational, ‘what can I do about this’ process. Time, although not as good a healer as it is given credit for, can produce some more rationality!

Basically, the prejudice in question was ageism. It seems that our society is a lot more tolerant of ageism than other prejudices that are slowly, at least on an organisational level, easing out of the picture. But ageism is alive and kicking – and in some cases kicking very hard.

The particular incident that annoyed me was the result of some casual comments which I followed up and found out that there were some changes ‘in the works’ which I seemed to regard older people as a separate entity to ‘adult’ services – and the people who work with some of the other departments are very anxious to divest themselves of all responsibility to older people because they are being presented as ‘different’ – but this was just one incident among many that I have encountered. From other teams who don’t work within Older People’s Services, from hospital wards, from GPs, from Commissioners within Social Services and most disappointingly from other Social Workers.

A lot of the work of CMHTs (Community Mental Health Teams) seem to relate to risk and somehow the impression that I was getting was that risk to self is somehow less ‘cutting edge’ than risk to others. I can see how that can be much more obvious but the role is of looking at best interests and risk to self can be as damaging. The implication that older people do not have the same levels of risk to self or that the self in question has less value due to the age is something that has been making me increasingly angry and indignant.

I know that the majority of the work that I undertake is with people who have dementia but people over 65 do not and should not suddenly lose the right to an equality of service and opportunities, just because they are over 65.

The Independent writes about the growing implications for dementia for with an ageing population.

Help the Aged conducted some research which presented (what a surprise) that the NHS claiming

“The Department of Health has acknowledged that there are deep-rooted negative attitudes and behaviours towards older people and these are at the heart of failure to provide decent services for them.”

The poverty, poor care, paucity of resources and lack of public funding experienced by older people in the UK would not be tolerated by any other section of society without people generally raising arms in a sea of disgust and outrage.

Even today The Guardian has a leader about ageism within the National Health Service and working within the system, I see it very clearly and try to rage against it as far as I can  but I have my work cut out and it’s frustrating and upsetting.

So why has it been possible to maintain an oppressive attitude to older people?

Why isn’t there as much emotion and outrage when an older, vulnerable adult is abused?

Are stories about older people dying (through neglect) in institutional settings or in their own homes not even reaching the front page of their local papers – let alone instigating national outrage and soul-searching which might lead to more changes in policy and quickly?

I think when the stories are presented, people are disgusted and outraged but not to be same levels – adults can look after themselves, perhaps, people assume. Or they have families, friends, people to advocate for them where often they don’t.

For me, I am asked (as I am occasionally and was frequently when I was on Post Qualifying Training) why I work with Older Adults or whether I find it ‘depressing’

No, I don’t and partly it’s because I believe there is so much to be done in this area.

It has the opportunity to be the most dynamic area of social work because there is so much to catch up on and I don’t know if I can speak in concrete terms but at the moment, there is no other area that interests me as much.

I have strong beliefs that older people and carers don’t get the services, the respect and the focus that they deserve and that can be quite a forceful drive when some working days make you wonder why you went into this profession to begin with!


A completely self-serving and indulgent post if I can be forgiven, so I’ll keep it brief!

It’s Sunday, it’s a holiday weekend and I’m fairly busy but I did get a letter yesterday from the university confirming that the portfolio for my Approved Social Worker (ASW) training course has, quite literally, ticked all the boxes – and is being recommended for a pass.

It wasn’t easy but it possibly isn’t worthy of too much reflection as there won’t be any more ASW training. Next time round, it moves out of the exclusive domain of social workers and into the realms of Approved Mental Health Professionals….

A Healthy Mind

A lot of discussion exists around mental illness and disorder but while I was reading the Oxford Handbook of Psychiatry yesterday, I came across an interesting passage about good mental health.

Good mental health is more than simply the absence of mental disorder, it requires:

  • A sense of self sufficiency, self esteem, and self worth
  • The ability to put one’s trust in others
  • The ability to give and receive friendship, affection and love.
  • The ability to form enduring emotional attachments.
  • The ability to experience deep emotions.
  • The ability to forgive others and oneself.
  • The ability to examine oneself and consider change.
  • The ability to learn from experience.
  • The ability to tolerate uncertainty and take risks.
  • The ability to engage in reverie and fantasy’

I don’t think I had ever seen ‘criteria’ for good mental health before as a lot of the literature seems to focus on the negative so it made for an interesting read.

The list makes it much clearer how tentative the line is between the health and the illness.  I’m not sure many people could tick all those boxes with a clear conscience on a daily basis.

The Secret Life of a Manic Depressive discusses very eloquently, the relation between mental illness and self and by looking at the list it seems that a lot of factors that are very much fundamental to who we are as individuals are included. Surely some people are more forgiving than others, more thoughtful and reflective than others, but does that make them less sound of mind.

I thought it was an interesting guide, in any case!

(and the book seems to be available free in electronic form on Google Books – the above text is taken from page 7 if anyone cares to investigate!).

Prevention before cure

It is all very well for the government to call for better preventative care for older people.  It is a noble aim – and a cost effective policy too. But I can’t help but be a little bit cynical.

As long as the Fair Access to Care bands exist and restrict care provision to Critical and Substantial needs only (as is the case in the local authority where I work), a great opportunity at preventative care is being lost.

The minister’s focus is on health care for the elderly, but so much preventative work could be done if more support were given through social care services at an earlier level. Changes could be spotted, companionship afforded and sometimes just someone coming around weekly to tidy up the garden, can provide incredibly positive long term effects and potentially save hospitalisation in the longer run.

All this is very difficult to quantify but it calls to mind a woman I visited this week who had just been discharged from hospital following a very-nearly-successful suicide attempt.

Through talking to her and piecing together the parts of her life, it was clear to see that she had had absolutely noone in the world. At the age of 83 she didn’t see any point in continuing. She had no friends locally, no family within 150 miles. She had been assessed for care services about a week before she attempted to kill herself but had low level needs relating to housework that could not be met by the local authority.  I don’t think that some housework would have changed her mental state significantly but some additional human contact could have flagged her needs more humanely than a hospital admission.

Although I haven’t come across many people who have attempted to harm themselves as a result of not requiring services directly, I have assessed countless older people, living along without any social contact, support or networks who just don’t meet the ‘substantial’ criteria for provision of services.

You can look into the future and see some of these same people costing the health service increasing sums because social care needs were not linked to potential health care needs in the future.

I think additional social support would have a massive role to play in longer term preventative care if only the purse-strings could be loosened a little.

Gaining Approval

In order to become an Approved Social Worker (ASW) the requirements are as follows

undertake a course of sixty days training (a mixture of lectures, seminars and supervised practice in a placement setting )

apply for a warrant (after some more supervised practice, written work and an interview) which lasts for five years, from the local authority. There is a requirement for ongoing training throughout the time that the warrant is held.

So the usual process is that after I submit my portfolio of work – I return to my usual workplace and am asked to complete a certain number of assessments in conjunction with an experienced ASW.  I have to produce a report reflecting on these assessments and take it, along with my portfolio (marked) to a panel made up from the Trust (usually, the Trust lead for ASWs and the Director with overall responsibility for Mental Health Services) where there is an interview of sorts to determine whether I will be issued a warrant.

I have to say I was somewhat reluctant to attend the course in the first place. I understood that it would be expected of me, but didn’t feel quite ready. In the process of discussing these concerns with my manager, I was reassured when I was told that there would be no rush to warrant me after the course. I should go and study so that the training part was out of the way and then I would be given as much time as was needed before I was actually warranted.

Yesterday I was informed, indirectly that the date for my warranting panel has been set, and it will take place next month.

This is somewhat surprising as a relatively conservative guess of when it would be taking place was August at the earliest.

Of course I could refuse and ask for more time but I’m not sure it would serve any purpose at the moment.

There are more than a few political issues going on behind the scenes and I can’t help feeling like a bit of a pawn. There is a massive shortage of ASWs  in the team that I currently work in. There is a lot of annoyance in some other teams that they are ‘taking’ our work on. They have attempted to refuse to carry out assessments that have been asked for but have been railroaded by management to do them.

I expect that is why I am being rushed to warrant. I feel a bit ambivalent at the moment about it. I don’t feel as insecure as I did – the training was extremely thorough and I had excellent experience in practice through my placement that could not have been more supportive. I suspect the idea is that it will provide a better quality service to the people I work most closely with which can only be a good thing.

In some ways, I want to just finish off the process so I don’t have to think about what I need to do next.

I am also aware that my position in the team has changed ever so slightly. I mentioned to my managers something vague about not being happy and they immediately became ever so defensive and concerned about me wanting to leave. I am not desperately surprised as the cost of the course I have just completed would enter into thousands of pounds.  I don’t really have any intention to leave. I like a lot of aspects of where I am. But things seem to be changing around me and very quickly.

Interesting times, indeed.