Print this chapterPrint this chapter

RCGP Safeguarding toolkit

Part 2C: Identifying adult abuse and neglect

Organisational abuse

Organisational abuse (also known as institutional abuse) includes neglect and poor care practice within a specific care setting. This could be a hospital or care home but also the care someone receive in their own home. The abuse can either be a one-off incident or an ongoing culture of ill-treatment. The abuse can take many forms, including neglect. It can affect one person or many residents. Some aspects of organisational abuse may be hidden (closed cultures) and staff may act differently when visitors are there (disguised compliance). It can be difficult to differentiate between poor practice and ongoing organisational abuse.

Organisational abuse is distinct from other forms of abuse or neglect because it is not directly caused by individual action or inaction. Instead, it is a cumulative consequence of how services are managed, led and funded. This also therefore means that there is no on size fits all approach for managing and responding to organisational approach. This is because of the huge range of actions and inactions that may contribute to organisational abuse, at all managerial and financial levels within organisations. Organisational abuse can also be caused by a single act of neglect or omission.

Organisational abuse is particularly important for GPs and all general practice staff to be aware of because many of our adults at risk of harm will live permanently, or spend time, in institutions such as nursing/residential homes or homes for adults with learning disabilities. They may also spend time in healthcare facilities such as hospitals (NHS or private). Many will also receive care at home.

Types of organisational or institutional abuse:

  • 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.
  • Poor care of hygiene resulting in pressure areas and pressure sores.
  • 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 or institutional abuse:

  • 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.

Common safeguarding challenges in care homes:

  • Maladministration of medication.
  • Pressure sores.
  • Falls.
  • Rough treatment, being rushed, shouted at, ignored.
  • Lack of social inclusion.
  • Institutionalised care.
  • Physical abuse between residents.
  • Financial abuse.

Further information can be found at Social Care Institute for Excellence.  

Underlying causes of safeguarding challenges in care homes:

  • Recruitment.
  • Staffing levels.
  • Adherence to policy and procedure.
  • Training.
  • Choice of service.
  • Record keeping.
  • Dehumanisation.

Dehumanisation is closely related to burnout. Dehumanisation can be experienced in different ways:

  • Discriminated against or treated differently to others.
  • Isolated, dismissed or ignored.
  • Disrespected, mocked or belittled.
  • Deprived of dignity and privacy.
  • Deprived of choice and control.
  • Stripped of one’s identity.
  • Deprived of basic needs (e.g. food).
  • Abused physically, sexually or in any other way.
NICE guideline [NG189]: Safeguarding adults in care homes

NICE guideline outlines in detail the possible indicators of institutional abuse and actions to take. Within the guideline, the terms ‘consider’ and ‘suspect’ are used to define the extent to which an indicator suggests abuse or neglect, with 'suspect' indicating a stronger likelihood of abuse or neglect. None of the indicators are proof of abuse or neglect on their own.

Indicators that should lead to ‘considering’ organisational abuse and neglect:

  • Policy and governance issues.
  • Failing contractual or regulatory standards.
  • Mismanagement of safeguarding concerns and poor record keeping.
  • Staffing problems.
  • Poor quality of care.
  • Failure to refer residents for care.
  • Financial mismanagement.
  • Physical signs and lack of openness.

Actions to take if you are considering organisational abuse or neglect:

  • Raise the matter with the care home manager, in writing if possible.
  • If the care home manager is believed to be part of the problem, go to the group manager, regional manager, owner or board of trustees.
  • If the care home manager is the sole owner, follow the actions to take if you suspect abuse or neglect.
  • Explain the impact on residents, or the likely impact if the situation continues.
  • Ask for a response within a specified period of time (for example two weeks)
  • If the manager agrees to make changes, make sure these happen.
  • After taking these steps, if the situation does not improve, raise your level of concern to 'suspect'.

Indicators that should lead to ‘suspecting’ organisational abuse or neglect:

  • Incidents of abuse or neglect not reported.
  • Evidence of falsified or missing records.
  • Multiple hospital admissions leading to safeguarding enquiries.
  • Residents repeatedly cannot access medical/dental care.
  • Frequent unexplained deterioration in residents’ health and wellbeing.
  • Misuse of residents’ money.
  • Sudden increase in safeguarding concerns.
  • Residents repeatedly evicted, or they and their families feel victimised, when they complain.
  • Care home fails to improve in response to reviews, inspections or audits and deteriorates over time.

Action to take if you suspect organisational abuse or neglect:

  • Make an adult safeguarding referral following your local multi-agency safeguarding processes.
Management of concerns about organisational abuse

It is important to acknowledge that this is a complex area and there are many different professionals and organisations who may be involved such as local authority, police, safeguarding professionals across health and social care, commissioners and independent regulators. Any practitioner who has concerns about organisational abuse should seek prompt safeguarding advice if they are unsure how to proceed or unsure if their observations are indicators of abuse.

Good practice points to consider
  • Within your practice/organisation, is there a regular and formal discussion about care homes attached to your practice (for example, nursing and residential homes and homes for adults with learning disabilities; it can also include children’s homes)?
  • How are early or minor concerns about care homes being recorded within the practice/organisation including when these are not about a specific patient?
  • Is there a clear pathway within the practice/organisation to raise concerns about a care home as it may be any member of the team who may have concerns including medication/pharmacy teams?
References