Good record keeping is a vital component of professional practice, and should be factual and objective.
Whenever a complaint or allegation of abuse is made, all agencies should maintain clear and accurate records and each agency should identify procedures for incorporating, on receipt of a complaint or allegation, all relevant records into a file to record all action taken.
Potential patterns of concerns
When abuse or neglect is raised, managers need to look for past incidents, concerns, risks and patterns. In many situations, abuse and neglect arise from a range of incidents over a period of time.
In the case of providers registered with CQC, records of these should be available to commissioners and CQC so they can take the necessary action. Staff should be given clear direction as to what information should be recorded and in what format.
Managers need to consider:
- What information do staff need to know in order to provide a high quality response to the adult concerned?
- What information do staff need to know in order to keep adults safe under the service’s duty to protect people from harm?
- What information is not necessary?
- What is the basis for any decision to share (or not share) information with a third party?
Sharing appropriate information
Records should be stored so that the information can be easily collated for local use and national data collection.
All agencies should identify arrangements, consistent with principles and rules of fairness, confidentiality and data protection for making records available to those adults affected by (and subject to) an enquiry.
If the person thought to be the cause of risk is also in receipt of care and support services, information about their involvement in the safeguarding enquiry, including the outcome, should be included in their case record.
If it is assessed that the individual continues to pose a threat to other people, this should be included in any information passed on to service providers and other relevant agencies.
Decisions on sharing information must be justifiable and proportionate, based on the potential or actual harm to adults or children at risk, against the right of confidentiality for the individual concerned. The rationale for any decisions made should always be recorded.
When sharing information between agencies about adults, children and young people at risk it should only be shared:
- If relevant and necessary (not simply all the information held about the person).
- With the relevant people who need all or some of the information.
- When there is a specific need for the information to be shared at that time.
Requests for information made by the Safeguarding Adults Board
If someone knows that abuse or neglect is happening they must act upon that knowledge, not wait to be asked for information.
Agencies should draw up a common agreement relating to confidentiality which sets out the principles governing the sharing of information based on the welfare of the adult and other potentially affected adults, including the person thought to be the cause of risk.
Any agreement should be consistent with the principles set out in the Caldicott Review published 2013 and ensure that:
- Information will only be shared on a ‘need to know’ basis and when it is in the interests of the adult.
- Confidentiality must not be confused with secrecy.
- Informed consent to share the information should be obtained from the individual, however if this is not possible and other people are at risk of abuse or neglect, it may be necessary to override this requirement.
- It is inappropriate for agencies to give assurances of absolute confidentiality in cases where there are concerns about abuse, particularly in situations when people may be at risk.
If an adult refuses consent to share information
If an adult has refused to consent to information about them being disclosed for these purposes, then practitioners must consider whether there is an overriding public interest that would justify information sharing (for example, because there is a risk that others are at risk of serious harm) and wherever possible, the appropriate Caldicott Guardian should be involved.
Decisions about who needs to know information
Decisions about which agencies need to know what information should be taken on a case by case basis within agency policies and the constraints of the legal framework.
Principles of confidentiality, designed to safeguard and promote the interests of an adult, must not be confused with those designed to protect the management interests of an organisation. These have a legitimate role but should not be allowed to conflict with the welfare of an adult.
If it appears to an employee or person in a similar role that such confidentiality rules may be operating against the interests of the adult then a duty arises to make full disclosure in the public interest.
In certain circumstances, it will be necessary to exchange or disclose personal information. This will need to be in accordance with the law on confidentiality and the Data Protection Act 1998 where this applies.
The Home Office and the Office of the Information Commissioner have issued general guidance on the preparation and use of information sharing protocols.
Information for staff, people who use care and support, carers and the general public
Clear information should be produced in a range of different formats for adults with care and support needs and their carers. These should explain clearly what abuse is and also how to raise a concern or make a complaint.
Adults with care and support needs and carers should be informed that their concern or complaint will be taken seriously, will be dealt with independently and that they will be kept involved in the process to the degree that they wish.
They should be reassured that they will receive help and support in taking action on their own behalf. They should also be advised that they can nominate an advocate or representative to speak and act on their behalf if they wish.
If an adult has no appropriate person to support them and has substantial difficulty in being involved in the local authority processes, they must be informed of their right to an independent advocate.
Where appropriate, local authorities should provide information about how to access to appropriate services such as independent legal advice or counselling services. The involvement of adults at risk in developing such communication is sensible.
All commissioners or providers of services in the public, voluntary or private sector should disseminate information about these policy and procedures.
Internal guidelines should make staff aware of what to do when they suspect or encounter abuse of adults in vulnerable situations.
This should be incorporated into staff manuals or handbooks detailing the terms and conditions of appointment and other employment procedures so that members of staff are aware of their responsibilities in relation to safeguarding adults.
This information should emphasise that all those who express concern will be treated seriously and will receive a positive response from managers.