In a response to the Winterbourne View case, autism and mental health hospital manager Mark Goldsborough discusses some of the challenges of safeguarding vulnerable adults in hospital settings and how they can be overcome.
The Winterbourne View case has rightly created a wave of concern throughout the health and social care sector and the hospital’s closure, although providing some peace of mind, should not create complacency. Nor should it blind us to the problems with our system of safeguarding.
The history relating to safeguarding scandals serves to underline that these issues can affect all sectors and is not the exclusive domain of the independent sector. I write as the general manager of Milton Park Hospital, an independent service for people with autism, mental health and/or learning disabilities.
We asked ourselves whether what happened at Winterbourne could happen here. My view is that any answer other than yes means falling at the first hurdle.
The following is not exhaustive but provides some examples of the more tangible things that provided us with some reassurance:
• Rotating staff. We rotate membership of teams and all frontline staff rotate between night and day shifts, on the basis that teams working in isolation can develop sub-cultures of their own.
• Having ‘fresh eyes’. The hospital is used as a placement for social work and nursing students, who question what we do and encourage reflection on practice. Added to this are active advocacy arrangements on site.
• Dedicated staff member. We employed a senior social worker with a sole remit for safeguarding and complaints.
• Scrutiny from leaders. Senior managers and clinicians are frequently present at ward level, including through night visits.
We were jointly inspected by the CQC and local safeguarding team after the BBC Panorama programme on Winterbourne and our report states: “People using the service could be expected to be protected from abuse because staff had appropriate training, knowledge and guidance about safeguarding people. The provider had systems in place to enable them to recognise any emerging trends or patterns regarding safeguarding.”
I hope this provides some credibility with which to raise some difficult issues with the existing safeguarding system that may make it more challenging to keep vulnerable adults safe.
Maintaining the currency of ‘abuse’
It is my assertion that the term ‘abuse’ traditionally produces a ‘sit up and take notice’ response because it is synonymous with issues such as sexual and serious physical harm. Safeguarding rightly extends beyond these parameters and does sometimes encompass more minor issues, such as a client having a CD stolen by another client. This raises an issue regarding how we want to deploy available resources most effectively and also whether there is a danger of the terms abuse, protection and safeguarding losing their currency. Proportionality does not seem to be something that comes naturally to the health and social care sector.
Systemic delays may deter providers from making alerts
It is essential that we work transparently across agencies to ensure that safeguarding responses are robust and informed, however the system can build in disincentives for providers. For example, a long time can elapse from alert to action, when threshold criteria are reached but there are more pressing matters or under-resourcing. I have every sympathy with a stretched police service allocating its resources on the basis of need but the distressed member of staff suspended without prejudice and concerned about the potential career-ending implications of an allegation, for 12 weeks rather than two, may have less. The swifter the response, the better for the client, the staff and continuity of provision. Bearing in mind resourcing is not going to get better any time soon, how do we encourage less defensive practice and empower skilled professionals to take decisions? Safeguarding teams are rightly concerned about those providers who do not alert as opposed to those that do, but ironically their workload is dictated by the latter, a dilemma worth reflecting on.
Increasing levels of need
Clients or patients arriving at any kind of group living setting are increasingly likely to have very complex needs, challenging behaviour (often extreme) and arrive in crisis rather than placements driven by early intervention or aspiration to properly diagnose. By way of a crude measure, within the space of two years, Milton Park has seen the percentage of those detained under the Mental Health Act rise from 50% to 75%.
This is due to a move away from placing people in anything approaching an institution and pulling people back ‘in county’, which resonates powerfully with the fiscal ‘downturn’. Therefore third sector and independent providers are asked to look after those that local authorities and NHS cannot or will not work with.
The net effect of this is for such environments to become more intense and challenging. While many providers of service are specialists by definition in their area of expertise, it can be very difficult for those with a more generic skills base to gain an in-depth insight into some clients’ needs and therefore the context within which safeguarding services are provided. We have found that moving away from statements such as ‘complex’ and ‘challenging’ and instead describing the behaviours has often provided a far better insight and been illuminating for partner agencies.
Not focusing on the big picture
Our principle focus is all too often based around individual incidents; my view is that these are the ‘low hanging fruit’ and it would be good to witness a system able to scrutinise itself and more readily recognise poor, often financially-driven, decisions about how people receive care. Patients are being moved out of their current provision without due process and involvement, without due regard to their needs being met, without due regards to risk or aspiration. In short, this is a system capable of abuse. These higher-level injustices can have a very profound and lasting effect on people’s lives when they are most vulnerable. It is as a result of this kind of poor decision making that I have personally witnessed alarming outcomes: people being re-admitted in hand and ankle cuffs or brought back via a police cell having had to be restrained using considerable force, including CS spray. Of late I have witnessed an alarming increase in placements of people with complex needs being ‘reviewed’ by people working in finance departments rather than qualified and experienced clinicians. The result is often disastrous as outlined above: serious incidents, setbacks in individual pathways and more victims, whether that be the public, a police officer, a relative or the person themselves.
In summary the challenges for all of us are significant and the context is not without complexity. If anything positive has come out of the Winterbourne expose it is that the shocking footage reminds all of us during these changing times to keep safeguarding at the top of our agenda.
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