What is Organisational Abuse?

Organisational abuse is where poor working practices and inadequate care in a specific setting leads to the mistreatment and/or harm of adults and children at risk. This level of abuse focuses on organisations and their explicit rules and informal norms. It occurs when the individual’s wishes and needs are sacrificed for the smooth running of a group, service or organisation.

The Care and Support Statutory Guidance (2014) describes organisational abuse as: “neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home. This 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”.

Organisational abuse can take place in a wide range of public organisations, including but not limited to:

• Care homes.
• The NHS, including hospitals, clinics, surgeries and therapeutic centres.
• Schools, nurseries, colleges.
• Children’s homes.
• Emergency children’s placements.
• Foster homes.
• Religious organisations and communities.
• Youth sport, Scouts, Guides and Cadets.
• Out of school activities such as drama clubs or youth groups.
• Service users’ own homes.
• Prisons.

The organisations may not be deliberately abusing people. It might just be the way in which the staff or management are used to doing things, their normal working practices.

Individually, the things that happen may seem small and apparently insignificant, and might not even be noticed. But when taken together, they might amount to a culture that restricts dignity, privacy, choice, independence or fulfilment. Organisational abuse is different to neglect in that it is more of a culture throughout the organisation, with often a number of people being affected.

What is institutional abuse?

Institutional abuse is identified as a form of abuse covered by multi-agency practices, policies and procedures. Multi-agencies might be health, care, education or local authorities, for example. Institutional abuse sees vulnerable people being mistreated by the system that is designed to give them care and to safeguard them from abuse.

What is the difference between organisational and institutional abuse?

In many ways both terms – organisational abuse and institutional abuse – are interchangeable; however, there are subtle differences. The main difference being that with organisational abuse it is the setting/organisation, its practices, policies, procedures and ways of working and the people within that setting/organisation that are perpetrating the abuse, whether intentionally or not. Whereas with institutional abuse it is the system that governs these settings/organisations that is letting people down and inflicting the abuse.

It is understandable that in most contexts both terms, organisational and institutional abuse, are used interchangeably as both contribute to the abuse of people from a position of power.

Abuse is said to take place when a person’s rights, human and/or civil, are violated by another person, a group of people, an organisation or an institution, in a way that results in them being maltreated. This maltreatment may be physical, sexual, financial or emotional.

Why does organisational abuse happen?

There are many different reasons why organisational abuse may happen. Often there may be a “closed culture” where input from the outside is strongly resisted and where there is very little transparency within the organisation.

Other reasons that organisational abuse happens include but are not limited to:

• It occurs when there is an imbalance of power within an organisation between the service users and service givers.
• The organisation may be systemically weak, without the proper structure or oversight with little or no accountability.
• There is bad management practice, staff are not trained or receive minimum training, they are not supervised or supported by management.
• Staff lacking interest in or commitment to good practice.
• Tasks take precedent over people, and organisational needs and wants are prioritised over people’s individual needs and wants.
• Poor interpretation and/or implementation of regulations and guidelines.
• Poor service design and working practices.
• Outdated working practices.
• Lack of service user input and consultation.
• Rigid, inflexible routines.
• Unsafe, unhygienic living environments where the organisation is responsible for maintaining this.
• Care planning is not person-centred.
• Lack of information sharing, poor communication and limited partnership working.
• Lack of understanding by staff and management of what constitutes organisational abuse.

Often organisational abuse occurs without the organisation and its staff realising that their actions are abusive; for example, when a setting schedules tasks on a generic basis without taking into account an individual’s needs, thereby failing to respect or support a person’s right to independence, dignity or choice.

Signs of organisational abuse

Some of the signs and indicators of organisational abuse may include:

• Evidence of current, basic health or care needs not being met.
• Over-medication and/or unsuitable restraint used to manage behaviour.
• Inappropriate confinement, restraint or restriction.
• Lack of personal clothing or possessions.
• Stark living areas, deprived environment or lack of stimulation.
• Lack of choice in decoration or other aspects of the environment.
• Lack of choice in food or menus or menu planning.
• Unnecessary involvement in personal finances by staff or management.
• Inappropriate use of nursing or medical procedures, e.g. using un-prescribed medication.
• Treating adults like children.
• Domineering decision-making by staff, group, service or organisation.
• Strict, regimented or inflexible routines or schedules for daily activities such as mealtimes, bed/awakening times, bathing/washing, going to the toilet.
• Lack of choice or options with food and drink, dress, possessions, daily and social activities.
• Lack of privacy, dignity, choice or respect for people as individuals.
• Unsafe or unhygienic environment.
• Lack of provision for dress, diet or religious observance in accordance with an individual’s belief or cultural background.
• Withdrawing or preventing people from individually valued community or family contact.
• Too few staff to meet people’s needs.
• People being hungry or thirsty.
• Lack of adequate procedures.
• Poor record-keeping and missing documents.
• Lack of training for staff, poor moving and handling practices.
• Absence of visitors.
• Few social, recreational and educational activities.
• Public discussion of personal matters.
• High level of minor injuries.
• Absence of individual care plans.
• Embargos and cautions being applied by the Commissioning Team.
• Rapid turnover of staff or managers.
• Multiple alerts to the CQC.
• Difficulty engaging with proprietors, managers or staff in the organisation.

Here are some examples of where organisational abuse happens:

• An organisation’s evening shift pattern starts at 5pm so evening mealtimes are set at 6pm; however, a resident suffers from indigestion if they are unable to eat their evening meal by 5pm. The organisation refuses to alter the meal timings, so the resident either forgoes their evening meal or eats it and subsequently suffers indigestion, both options of which may have consequences for their health.
• Care workers are allocated a specific amount of time with each resident for personal care. Some residents are slower than others or require more attention and help than others and the care workers could often run out of time before all tasks were completed, leaving some residents unwashed or inappropriately clothed. Even if the personal care tasks are completed there is no time for any interpersonal interaction during what is a very personal service.
• A care home resident takes a range of medication, but three times this week the resident has had their medication very late because the carer in charge hasn’t had time to bring the medication to them. This has also happened to five other residents who live on the same floor and it has caused them all a range of different side effects.

The organisation’s staff may not be deliberately or intentionally abusing people; it might just be the way in which the staff are used to doing things. However, bad organisational practices can often have the effect of causing abuse to the service users. That is why acts that may seem trivial or harmless to the organisation and its staff, but that are comparable to abuse, need to be challenged and brought to their attention.

Whether a one-off incident or a prolonged experience, abuse can harm people’s physical and mental health. The impact of abuse can vary between people, and some people may be more vulnerable to abuse than others. For some, abuse may have long-term consequences for their lives. If the organisation and the people within it think that their abusive practices are normal or even acceptable, the abuse will only continue.

In some cases, organisational abuse can span years or even decades because of a damaging culture where abuse has been ignored, overlooked or covered up to protect the reputation of the institution.

What to do if you think organisational abuse is happening

Knowing the signs of abuse helps us to look out for it and to recognise it when it is happening. Any behaviour or practices that embarrass, demean, frighten or distress people is a form of abuse and it needs to be challenged and stopped.

The Care Quality Commission (CQC) has a set of fundamental standards that they state that all care provided must never fall below.

These fundamental standards are:

• Person-centred care – You must have care or treatment that is tailored to you and meets your needs and preferences.
• Dignity and respect – You must be treated with dignity and respect at all times while you’re receiving care and treatment. This includes making sure:
  – You have privacy when you need and want it.
  – Everybody is treated as equals.
  – You are given any support you need to help you remain independent and involved in your local community.
• Consent – You, or anybody legally acting on your behalf, must give your consent before any care or treatment is given to you.
• Safety – You must not be given unsafe care or treatment or be put at risk of harm that could be avoided.
• Safeguarding from abuse – You must not suffer any form of abuse or improper treatment while receiving care. This includes:
  – Neglect.
  – Degrading treatment.
  – Unnecessary or disproportionate restraint.
  – Inappropriate limits on your freedom.
• Food and drink – You must have enough to eat and drink to keep you in good health while you receive care and treatment.
• Premises and equipment – The places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly. The equipment used in your care and treatment must also be secure and used properly. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
• Staffing – The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.
• Fit and proper staff – The provider of your care must only employ people who can provide care and treatment appropriate to their role. They must have strong recruitment procedures in place and carry out relevant checks such as on applicants’ criminal records and work history.
• Good governance – The provider of your care must have plans that ensure they can meet these standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare.
• Display of ratings – The provider of your care must display their CQC rating in a place where you can see it. They must also include this information on their website and make CQC’s latest report on their service available to you.
• Duty of candour – The provider of your care must be open and transparent with you about your care and treatment. Should something go wrong, they must tell you what has happened, provide support and apologise.
• Complaints – You must be able to complain about your care and treatment. The provider of your care must have a system in place so they can handle and respond to your complaint. They must investigate it thoroughly and take action if problems are identified.

The safety and wellbeing of service users is everyone’s business, so if you are concerned about someone or a group of people within an organisation abusing a position of trust or a position of authority, and acting in a way that amounts to organisational abuse, and providing care that falls below these fundamental standards, you should share your concerns.

In the first instance, if you are a service user or friend or family member who has concerns that organisational abuse may be taking place, you can raise the issue via the organisation’s complaints procedure or with the Safeguarding Lead. If you are a member of staff then you can raise your concerns with your line manager or through Human Resources or the Safeguarding Lead.

Organisations should take any concerns raised against an organisation, its staff, management or volunteers seriously and respond sensitively and promptly. This is regardless of who the person is, what position they hold or how long they have been involved in the organisation.

If you do not get a satisfactory response to your complaint once you have raised it or you feel that you can not raise the concern with the organisation and its management, then you can, where appropriate, contact the regulator such as Ofsted, your local authority or the Care Quality Commission to raise your concerns.

• Local authorities are the lead agency in the safeguarding process; your local authority can undertake enquires or instruct others to do so.
• Ofsted monitors, inspects and regulates services provided by the education sector including nurseries, schools and colleges.
• The Care Quality Commission monitor, inspect and regulate services that provide health and social care, including treatment, care and support provided by hospitals, GPs, dentists, ambulances and mental health services. They are also responsible for treatment, care and support services for adults in care homes and in people’s own homes (both personal and nursing care) and services for people whose rights are restricted under the Mental Health Act.

It is important that people who work in health and care organisations feel they can speak up about any issues that cause them concern. People can contact the CQC through all of their communication channels. They describe the concerns that they receive as “whistleblowing enquiries”.

When the CQC receive an enquiry, they consider the information carefully and prioritise which action to take according to the level of risk. The most serious enquiries, for example where there is a risk of harm to an individual, will trigger a safeguarding process that may include a referral, such as to the local authority. Other actions include carrying out an inspection, working jointly with other partners or taking enforcement action.

The outcome of any complaint and subsequent investigation of the complaint will be dependent upon the nature of the concerns but may include:

• Introduction or review of Human Resources processes and procedures.
• Introduction / review of workplace policy and procedures.
• Review of systems.
• Staff training.
• Suspension of provider.
• Referral to the Disclosure and Barring Service.
• Referral to Professional Registration Bodies.
• Safeguarding Reviews.

Final thoughts

The wellbeing and safety of anyone who is receiving any form of care service including health, social care or education, is paramount. Safeguarding is everyone’s responsibility, so if it is suspected that organisational abuse has occurred within an organisation it is important that the concern is raised; if not, there will not be action taken to end the abuse and to ensure that it doesn’t happen again.

The safeguarding process can be used to prevent or reduce the possibility of organisational abuse occurring, particularly if the concern is raised at the earliest opportunity.

Once reported, it may not always be necessary to commence an organisational abuse enquiry and an individual safeguarding enquiry may be more appropriate, but anything that you do report will be treated sensitively and should result in some form of action whether by the care provider or by the regulatory bodies.