An 'undercurrent of unease'

I recently had the opportunity of some reflection time with colleagues involved in the safeguarding work at the private hospital that was the focus of the Safeguarding Adult Review (SAR) for Joanna, Jon and Ben. This was such a helpful opportunity to pause and look back at the various perspectives to tease out an overall picture from across the system.

There were lots of concerns, some specific and rightly addressed as formal safeguarding responses, others more generic and perhaps summed up as wider, lower level concerns. The phrase shared with me (which has stayed with me) was that there was a general ‘undercurrent of unease’ about the service across different professional groups. This was difficult to articulate and evidence at the time but used as a kind of shorthand.

These reflections were to help me prepare my part of a presentation for a Partners in Care and Health webinar on Learning from SARs: a focus on organisational abuse (28 February 2023). Our board independent chair (Heather Roach) and I were there to share learning from the SAR for Joanna, Jon and Ben.

On the day I was a little nervous (seeing hundreds of people joined the webinar) but excited to share our reflections on this topic alongside national leading colleagues in safeguarding adults. Do have a look at the other really interesting presentations by Professor Michael Preston-Shoot, Fiona Bateman, Frances Pearson and Dr Sheila Fish (in link above).

Our presentation followed Sheila. Adi Cooper was chairing, gives a few words of introduction and then hands over to me …

‘Good afternoon colleagues, my name is Walter Lloyd-Smith and I am ….’ then TOTAL disaster as my internet connection crashes and does not restart!!!

I felt sick. Everything I frantically tried to do, would not work. The air was filled with some choice words, but I still get couldn’t get the connection back. Oh, the joy of homeworking!!

I finally got back on the call just as Heather was finishing speaking to the last few slides - she had stepped in and saved the day – a total professional.

Organisational (previously called institutional) abuse is not new. Shamefully a line can be drawn from Cawston Park Hospital through Edenfield, Whorlton Hall, Atlas Care Homes, Mendip House, Winterbourne View right the way back to the Ely Hospital scandal in 1967! We know what the problems and risks are so why have we (as a collective system) not implemented change to better protect adults who are so vulnerable?...  a question asked by the webinar.

A standout statement from the Winterbourne View review was that all Safeguarding Adults Boards, the Care Quality Commission (CQC) & others should regard hospitals for adults with learning disabilities and adults with autism as high-risk services. In May 2022 CQC published work on how they identify and respond to closed cultures.

A key phrase to consider is that harm (reflecting any of the different types of abuse set out in the Care Act guidance) has occurred ‘as a result of the structure, policies, processes and practices within an organisation’ (Spreadbury and Hubbard, The Adult Safeguarding Practice Handbook 2020).

Section 14.17 of the Care Act statutory guidance describe that organisational abuse may range from ‘one off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation.’

Using research and safeguarding practitioner experience has enabled us to identify a number of elements that could be early indicators of concern - these can include:

• staff do not see people as equals / people are unable to speak up for themselves
• weak relationships between families and staff; often families portrayed as hostile or overprotective
• families’ concerns are not taken seriously, and their expertise is not valued
• weak management and supervision
• concerns about staff skills, knowledge and practice
• the service resisting the involvement of external people and isolating individuals
• the way services are planned and delivered / concerns about the quality of basic care and the environment
• people who are visited less often / patients are a long way from their communities

Indeed, the SAR for Joanna, Jon and Ben found a number of these features.

See NSAB’s website page on organisational abuse for a fuller list of indicators. There is also this very good resource from Surrey SAB – making good referrals of adult safeguarding concerns in Surrey – appendix C is a methodology to facilitate early identification of organisational abuse across partner organisations.

Because it may develop in routine (sometimes nuanced ways) this makes its complexity harder or difficult to spot. This can mean making judgement calls about what is an acceptable level of care - where does poor practice cross a line into organisational abuse?

Marsland, Oakes and White (2012) have helpfully set out suggested indicators of organisational abuse across 6 domains; one of these is concerns about management and leadership. Spreadbury & Hubbard suggest ‘they are a significant early indicator; other indicators will follow if this indicator is present’.

We must use what we know to better effect; to drive action to better protect some of our most vulnerable citizens. Next time you have visited a service, or a colleague shares a reflection of a service they are working with which gives you an ‘undercurrent of unease’, use this a signal to look further. Use your professional curiosity - talk with other colleagues from different services to get their view - do they feel the same? Do you need to raise this a concern to the local authority?

Thank you.

PS I would like to dedicate this blog to anyone who has had the internet fail them just before giving a presentation or an important meeting. I feel your pain.

Walter Lloyd-Smith

NSAB Board Manager

Email: [email protected]

April 2023