In this article
Healthcare assistants make sure the patient experience is as comfortable and stress-free as possible. They work under the guidance of a healthcare professional such as a nurse, doctor, midwife and other healthcare professionals. All staff within health services have a responsibility for the safety and wellbeing of patients and colleagues. Safeguarding is about the safety and wellbeing of all patients but also providing additional measures for those least able to protect themselves from harm or abuse.
What is safeguarding?
A healthcare assistant could work, for example, in an NHS or private hospital, at a client’s home, at an adult care home or at a hospice. Whatever the environment, safeguarding adults and/or children is an integral part of patient care. One of the central aspects of the duty of care for providers is the obligation to identify and protect people who may not be able to look after themselves.
Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. Healthcare assistants have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients are required by professional regulators and service regulators and are supported by law.
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if an adult or young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or who are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
What risk factors make someone more likely to experience abuse?
Abuse and neglect can occur anywhere to anyone.
Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect, including but not limited to:
- Very young children
- Children with disabilities and health problems
- Socioeconomic factors such as poverty, poor housing and deprivation
- Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation
- The parent or carer does not engage with services
- There have been one or more previous episodes of child abuse or neglect
- The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting
- There is chronic parental stress
- The parent or carer experienced abuse or neglect as a child
- A family history of maltreatment
- Being in care, a looked-after child
- A history of offending, either parent or child
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health
- Be physically dependent on others
- Have a sensory impairment
- Have a learning disability
- Suffer from drug or alcohol problems
- Have low self-esteem
- Be unable to make their own decisions
- Have a previous history of abuse
- Have negative experiences of disclosing abuse
- Be of increasing age
- Be frail
- Have experienced a lack of access to health and social services or high-quality information
These lists are not exhaustive, and other people might also be considered to be adults and/or children at risk.
The types of abuse children can encounter
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected. Once a child is born, neglect may involve a parent or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment
– Protect a child/young person from physical and emotional harm or danger
– Ensure adequate supervision, including the use of inadequate caregivers
– Ensure access to appropriate medical care or treatment and also including the neglect of, or unresponsiveness to, a child/young person’s basic emotional needs
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
- Discriminatory abuse – including racist and sexist abuse or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings, and includes behaviour such as hoarding.
What safeguarding issues do healthcare assistants need to be aware of?
Abuse and neglect can take many forms, ranging from exploitation and disrespectful treatment to physical harm. It can be at a low level, and take place over a long time, or it can take place over a short time and be more extreme. It is all abuse.
Organisations and individuals should not be constrained in their view of what constitutes abuse, neglect or harm and should always consider the circumstances on a person-centred basis. Adult and children safeguarding concerns vary according to the nature of harm, the circumstances it arose in and the people concerned.
Healthcare assistants often see patients in times of distress and difficulty. It is likely that you may come into contact with someone who is at risk or suffering from abuse or neglect. The abuse or neglect can be deliberate, or the result of ignorance or a lack of proper training.
Recognising abuse or neglect is crucial, and it may:
- Be a single act or repeated acts
- Cause harm temporarily or over a period of time
- Occur when a person is persuaded to enter into a transaction to which they have not consented to, or cannot consent to
- Be an act of neglect or an omission to act
- Occur through deliberate targeting/grooming
- Occur in any relationship
- Be perpetrated by an individual or as part of a group/organisation
- Be the result of deliberate intent, be unintentional, or be through negligence or ignorance
- Involve several abusive acts which are crimes, and informing the police must be a key consideration
Who may abuse or neglect? In short, anyone.
This may include, but is not limited to:
- Other family members
- A relative or unpaid carer
- Neighbours, friends
- Paid staff including professionals such as nurses
- Another adult at risk
- People who deliberately exploit adults they perceive as vulnerable to abuse
- Strangers, that is members of the public not known to the abused
The roles and responsibilities of a healthcare assistant in regard to safeguarding
Healthcare assistants will have an individual responsibility to safeguard people, to identify and respond to allegations of abuse and neglect. Health services have a duty to safeguard all patients, but also to provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding adults and children covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A healthcare assistant’s role in safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
Healthcare assistants have a duty to make sure that:
- Safeguarding concerns are dealt with promptly, appropriately and reported in a secure and responsible way to all relevant agencies.
- Steps are taken to escalate or alert those able to protect patients and/or others at risk from harm and minimise risk of abuse.
- Appropriate and proportionate measures are in place to protect from harm all those who work with them, or come into contact with them.
Healthcare assistants may find it difficult to accept the patient’s choices such as declining services or acting against advice about how to manage their safety. They may be concerned that they are failing in their duty of care and that they could be found to be reckless or negligent. A duty of care is a requirement placed on an individual to exercise a reasonable standard of care while undertaking activities or omissions that could foreseeably harm others. However, duty of care also includes respecting the person’s wishes and protecting and respecting their rights.
The safeguarding issues healthcare assistants may come across
Understanding what abuse and neglect might look like and how to recognise warning signs is an important aspect of safeguarding.
Some examples healthcare assistants might encounter may include, but are not limited to:
- Physical signs such as hand-slap marks, bruising in unusual areas, bruised eyes, bite marks.
- The story provided by the adult/child might be inconsistent with any injuries.
- Poor physical care and inadequate hygiene, inappropriate dress.
- Nutritional state including hydration.
- Deliberate self-harm and/or drugs and alcohol misuse.
- Talking about being left home alone, with inappropriate carers or with strangers.
- Concerned for younger siblings without explaining why.
- Physical sexual health problems, including soreness in the genital and anal areas, sexually transmitted infections or underage pregnancy.
- Parents not seeking or delaying medical treatment when their children are ill or are injured.
- Bullying – this is behaviour, usually repeated over time, that intentionally hurts another individual or group, physically or emotionally. Bullying differs from banter because there is a deliberate intention to hurt or humiliate. There is usually a power imbalance that makes it hard for the victim to defend themselves. It may happen between staff and patients, or colleagues, or colleagues and managers.
- Self-harming – there are lots of different forms of self-harming including, for example, a patient not eating, over-eating, or forcing themselves to throw up.
- A girl who’s had FGM may have difficulty walking, sitting or standing and may spend longer than normal in the bathroom or toilet, and may be particularly reluctant to undergo normal medical examinations.
- Danger or risk to health and safety, such as where health and safety rules or guidelines have been broken.
- Issues to do with care in general, such as concerns over resources, products, people, staffing or the organisation as a whole.
Where should healthcare assistants go with a safeguarding concern?
Some concerns may be minor in nature but provide an opportunity for early intervention, for example advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
Immediate concerns about abuse or neglect should be dealt with under local safeguarding procedures first. The person who raises a safeguarding concern within their own organisation should follow their organisation’s policy and procedures. This concern may result from something that you have seen, been told or heard. You don’t need to have all the facts to prove your concern, but you must have a reasonable belief that wrongdoing is either happening now, took place in the past, or is likely to happen in the future. Speaking up on behalf of people in your care is an everyday part of your role. Just as raising genuine concerns represents good practice, doing nothing and failing to report concerns is unacceptable.
All NHS services are required to have a Safeguarding Adult and/or Children Lead as part of their organisational structure. Hospitals and community services are additionally required to appoint a Named Doctor, a Named Nurse or a Named Midwife (Senior Nurse/Senior Midwife) where those services are provided, to take the professional lead on all safeguarding matters. The designated safeguarding lead will normally be someone who has been given special responsibility and training in dealing with employees’ concerns.
The role includes:
- Making sure appropriate systems for raising concerns are in place and that all staff can access them
- Making sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded
- Investigating concerns promptly and including a full and objective assessment
- Taking action to deal with the concern and record and monitor this action
- Keeping the employee who raised the concern up to date with what is happening
- Having processes in place to support employees raising concerns
- Having a role in highlighting learning and may facilitate or be part of learning events
If you witness or suspect that there is a risk of immediate harm to a person in your care, you must act straight away to protect their safety. You should report your concerns to the appropriate person or authority immediately; this may be the police in some situations. Involvement of the police is indicated in incidents of suspected theft and common assault, including sexual assault, and assault causing actual bodily harm. However, police may also be involved in other patient safety incidents such as wilful neglect for a person lacking capacity.
You should also keep an accurate record of your concerns and action that you have taken, and you should always inform the designated safeguarding lead of your actions.
What legislation do healthcare assistants have to follow in regard to safeguarding?
There are a number of pieces of legislation that healthcare assistants must follow for safeguarding of both adults and children, including several Acts and statutory guidance documents which are always being amended or updated.
The Children Act 2004 – this states that safeguarding is everyone’s responsibility. Section 11 places duties on organisations and individuals to make arrangements for ensuring their functions, including services that they contract to others, are discharged with due regard to the need to safeguard and promote the welfare of children.
The Care Act (2014) – Chapter 14 of the Care Act provides guidance on adult safeguarding. It cites neglect and acts of omission as behaviour which could give rise to a safeguarding concern.
- Ignoring medical, emotional or physical care needs
- Failure to provide access to appropriate health, care and support or educational services
- The withholding of the necessities of life, such as medication, adequate nutrition and heating.
The Act also includes self-neglect in the categories of abuse or neglect. In some circumstances, where there is a serious risk to the health and wellbeing of an individual, it may be appropriate to raise self-neglect as a safeguarding concern. It is vital to establish whether the person has capacity to make decisions about their own wellbeing, and whether they are able or willing to care for themselves. An adult who can make choices may make decisions that others think of as self-neglect. Risk and capacity assessments are likely to be useful. The legislation makes clear that adult safeguarding responses should be guided by the adult themselves, to achieve the outcomes that they want to achieve.
The Mental Capacity Act (2005) – this states that “a person lacks capacity in relation to a matter if at the material time they are unable to make a decision for themselves in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.” It does not matter whether the impairment or disturbance is permanent or temporary. It cannot be assumed that someone lacks capacity based upon age, disability, beliefs, condition and behaviour or because they make a decision that is considered inappropriate. In all cases the patient must be fully informed of the decision to be made, the consequences of decisions or the lack of decision. This requires professionals to have a frank and open conversation with patients to support their understanding.
The Mental Capacity Act 2005 does not apply to children under 16. Children under 16 are not presumed to have the capacity to consent but must demonstrate their competence. The principles of assessing capacity are the same as for adults. A child can give consent if the treatment or action is in their best interests and if they have the maturity and ability to fully understand the information given and what they are consenting to.
The Children and Social Work Act 2017 replaced Local Safeguarding Children Boards with new local safeguarding arrangements, led by three safeguarding partners:
- Local authorities
- Chief police officers
- Clinical Commissioning Groups.
The Act places a duty on those partners to make arrangements for themselves and relevant agencies to work together for the purpose of safeguarding and promoting the welfare of children in their area.
Prevent Duty Guidance (2015) – the Prevent Duty Guidance forms part of the UK Government’s counter-terrorism strategy. It identifies a key challenge for the healthcare sector to ensure that: “where there are signs that someone has been or is being drawn into terrorism, the healthcare worker is trained to recognise those signs correctly and is aware of and can locate available support”. Dedicated resources for health professionals are available at: www.england.nhs.uk/ourwork/safeguarding/our-work/prevent/
GDPR – ethical and statutory codes concerned with confidentiality serve to protect individual patients but are not intended to prevent the exchange of information between different professionals and staff who have a responsibility for ensuring the protection of children, young people and adults at risk. In cases where there are safeguarding concerns, there is a duty to share all relevant information with professionals and agencies who need to know. This may include disclosing information with or without the permission of the child, young person, parents or carers or adult at risk, with other professionals for the purposes of safeguarding.
Why is safeguarding training important?
It is important that we all understand safeguarding, and know what to do should safeguarding concerns arise. It is a requirement of the Care Quality Commission (CQC) that every member of the healthcare team has an up-to-date safeguarding training certificate.
Safeguarding induction and training is essential for all staff appropriate to their role, including:
- Information on types of harm, abuse and neglect
- How to spot abuse
- How to respond to concerns
- Who to report concerns to
An example of appropriate safeguarding training includes Safeguarding Vulnerable Adults (SOVA) Level 2, designed for people who are working with vulnerable adults and teaches the skills needed to safeguard people who are at higher risk of abuse, and Safeguarding Children Level 2, designed for people who are working with children and teaches the skills needed to safeguard children who are at higher risk of abuse. The safeguarding lead should complete the Safeguarding Children Level 3 Designated Officer course and Safeguarding Vulnerable Adults Level 3.
Managers should evaluate changes in understanding and confidence before and after training, assessing this:
- Immediately after the training
- In regular long-term evaluations, for example as part of supervision sessions
- Annually, for example as part of the performance management/appraisal process
Line managers should provide feedback through supervision and appraisals, acknowledging how healthcare staff have learned from their experience of identifying, reporting and managing safeguarding concerns.
How often should healthcare assistants renew their safeguarding training?
Managers should assess healthcare assistants’ safeguarding knowledge annually, and run refresher training if needed. To help staff increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every 2 years and participate in continuing professional development (CPD).