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Introduction

The aim of this guide is for Hankham Lodge to promote good practice.
One important element of good practice is to guard against any kind of
exploitation, neglect or abuse of residents. An environment which is constantly
seeking to improve the life and care of residents automatically tends to guard
against bad practice.

In spite of registration, inspection, internal monitoring, quality assurance systems
and codes of practice, regrettably abuse can occur. Sometimes this may be unwitting or unintentional perhaps through ignorance or neglect. At other times, however, it may be deliberate, whether subtle or overtly cruel. There is now greater recognition of the fact that abuse does occur and a fuller understanding of how it arises.
The definition of abuse
'Elder abuse is a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.'

Action on Elder Abuse
Abuse is the harming of another individual usually by someone who is in a position of power, trust or authority over that individual. The harm may be physical, psychological or emotional or it may be directed at exploiting the vulnerability of the victim in more subtle ways (for example, through denying access to people who can come to the aid of the victim, or through misuse or misappropriation of his or her financial resources). The threat or use of punishment is also a form of abuse. Abuse may happen as a 'one-off' occurrence or it may become a regular feature of a relationship. Other people may be unaware that it is happening and for this reason it may be difficult to detect. In many cases, it is a criminal offence.
Physical abuse
Rough handling or unnecessary physical force, deliberate or unintentional, used in caring for a resident is abuse. Injuries may not always be visible although often there may be bruises, broken skin, cuts, burns or broken bones. During an episode of abuse, damage to property or clothing may also occur. Restraining residents so that they cannot move, or by shutting them in a room, is abusive. However, it may sometimes be difficult to draw the dividing line between justifiable and unjustifiable restraint.
Verbal abuse
Shouting and swearing at someone should be regarded as abusive behavior. In addition, speaking to a resident in a quiet but threatening way so as to make the resident fearful or to make the resident an object of ridicule is equally abusive.
Emotional abuse
Playing on someone's emotions to make him or her afraid, uneasy or unnecessarily dependent is another form of abuse. Exploiting a resident through using personal information gained through the caring relationship is an abuse of the trust vested in the carer.
Abuse through the misapplication of drugs
The use of drugs to control or restrain a resident is unacceptable unless medically required. The over-use and misuse of sedatives and other medication, which too often happens in homes, should be regarded as evidence of bad practice.
Financial abuse
Financial abuse includes the improper use or control of, or the withholding of, a person's money, pension book, property, bank account or other valuables.
Racial abuse
Victimising people, verbally insulting them and physically attacking them because of their racial or ethnic origin is abusive.
Sexual abuse
Forcing someone to take part in sexual activity against his or her will is abuse and a criminal offence. The force does not have to be physical. Undue emotional pressure placed on an individual may lead him or her to acquiesce in behaviour he or she finds unacceptable.
Neglect
The withholding of care and treatment when it is required is a form of abuse. Similarly, depriving residents of the essentials of everyday life, such as food, clothes, warmth and personal cleanliness should also be regarded as a form of abuse.
How and why abuse might occur
There are many reasons why abuse occurs in residential homes. They range from the individual to the institutional:
· abuse may result from the actions of individual members of staff because they lack the training, experience and management support to cope with the stresses of caring for people who require a high level of assistance;
· occasionally it may occur because individual members of staff set out deliberately to harm residents;
· more often, abuse occurs because the home, its managers and staff slip, often without realising it, into a set of attitudes which reflects low morale, defensiveness about their competence and a lack of concern and respect for residents;
· over-work, lack of appreciation, low pay and low self-esteem may all contribute to the development of an environment in which abuse becomes an accepted feature of daily life.
Hankham Lodge combats this by:
· careful staff selection procedures;
· training and management support for staff once in post;
· leadership from senior management;
· the development of a working environment which values staff, does not demand too much of them and rewards them adequately.
Hankham Lodge guards against
· inadequate staffing levels to cope with a high incidence of incontinence;
· lack of trained and experienced care staff;
· absence of staff supervision by trained and experienced managers;
· terms and conditions of employment which do not provide holidays or guarantee other basic employment rights;
· a casual approach to resident privacy where staff walk into rooms unannounced, doors are left open when residents use the toilet, staff talk about residents over their heads or divulge confidential information.

Prevention
Staffing procedures
The quality of life in the home is underpinned by the qualities of leadership and competence shown by Mr & Mrs Sims. Beyond that, much depends on the calibre of the staff team. It is essential that basic good practice in staff recruitment, training and supervision is observed.
This involves:
· Hankham Lodge takes up references, character checks and an enhanced criminal records check (CRB). We confirm written references by telephone calls;
· We provide regular supervision and appraisal sessions between manager and individual staff members to provide support in coping with stressful situations and to encourage staff;
· encouraging an atmosphere where staff feel able to discuss and therefore prevent the development of potentially abusive situations;
· assuring staff that their jobs will not be threatened if they 'brow the whistle' on abusive behaviour by other staff;
· making clear in the terms and conditions of employment and in the disciplinary procedures that abusive behaviour is a dismissible offence. Instances of serious abuse will be regarded as gross misconduct and subject to instant dismissal and be reported to the adult protection unit. Lesser forms of abuse will be subject to the formal disciplinary procedure and reported to the CQC, which if repeated would lead to dismissal;
Action to be taken if abuse occurs
If the situation is urgent, the person witnessing the abuse should:
· immediately challenge the person who is abusing the resident, even though this may be difficult to do, and try to persuade him or her to stop;
· report the incident to a senior manager straightaway.
If the immediate risk to the resident has passed a more considered approach might be helpful. The person witnessing the abuse should:
· check which of the home's policies and guidelines have been broken, or check against this guid; write down all the relevant facts;
· consider using the home's complaints procedure if appropriate;
or
· consider the most appropriate senior member of staff to approach and whether it would be helpful to have another member of staff involved;
· ask for a confidential meeting with the most senior manager appropriate at which the abuse is raised;
· the manager should then decide what action to take (for example, invoke the disciplinary procedure, take evidence, call in the police or the adult protection unit).
If the above action does not stop the abuse, or if the home's management is involved or is unwilling to take the necessary corrective action, then the person witnessing the abuse should:
· speak to another trusted member of staff if not already involved;
or
· seek advice from a professional or expert organisation, i.e. registration authority; Adult protection Unit
If at any time the situation involves something which is against the law, or the resident or witness is in danger, the person concerned should:
· contact the police and ask for immediate help.
Other abuse
In some circumstances, staff themselves may be subject to abuse from residents or residents may abuse each other. Sexual advances and verbal abuse are not uncommon. Racist behaviour from and between residents can and does occur. Staff may find this difficult to talk about and handle. They may react inappropriately. Hankham Lodge through its training and support systems attempt to managing such behaviour.


Ensuring standards: registration, inspection and quality assurance
Introduction
The procedures for ensuring standards in continuing care are both mandatory (registration and inspection) and voluntary (quality assurance). The way in which Hankham Lodge deals with them are as follows.
Registration
The CQC (Care Quality Commission) registered and is responsible for the continuing registration of Hankham Lodge. The CQC ensures that the purposes and aims of the home are clearly set out and that the standards of care we offer match these aims and objectives. They have a duty to ensure that the best quality of life for residents is achieved.
Registration process
Throughout this process, registration staff were consulted and monitored progress and preparations for the opening of the home. Advice was given to us about the initial selection of residents, selection of staff, preparation of a home brochure, and on how to ensure that the registration requirements agreed initially would be implemented.
Our suitability for registration
The Social Services (until mid 90s) The Inspection Unit (until 2000) N.C.S.C (until 2003) and now CQC ensured that we posses the relevant qualifications and have extensive experience of employment within residential care. They are also confident in our in our understanding of financial projections and budgeting. They recognise our business-like approach that will ensure that Hankham Lodge will be managed on a secure financial basis and will not put the future welfare of residents at risk.
Change of owner or manager of a home
Peter and Svetlana Sims hope to continue to provide unrivalled quality care at this site for many years to come. This is our commitment to you.
Inspection
Inspections are carried out by persons authorised to do so by the CQC. Inspections vary in content, focus and length of time depending on any outstanding issues identified on previous inspections. Inspectors focus on quality of care and quality of life issues as much as on the fabric of the building. Time is devoted to asking residents and staff about standards of care provided. Care is taken to ensure that courtesy, diplomacy and tact are used in inspecting individual residents' private rooms Hankham Lodge makes every effort to make it possible for the inspection officer to spend some time in private with individual residents We find inspection enormously constructive and recognition is given to innovative and good care practice. Time is also given to discussing and reviewing, with the us, the objectives of the home and how the care of the residents can be enhanced.
Hankham Lodge's inspection reports are available to the public and are available on the internet.
Complaints procedures
The complaints procedure is outlined on entering the home. The majority of complaints regarding the management of a home are normally satisfactorily resolved by the Mr and Mrs Sims with no need for the CQC to be involved.
When complaints cannot be resolved internally the CQC will be informed of the complaint. All complaints must be made in writing to the CQC, giving details of any action already taken and with whom the matter has been discussed. CQC will then take the necessary steps to investigate the complaint and arrange to interview the owner/manager, resident and all other people relevant to the specific complaint. Following the investigation/interview, a letter will be sent to the owner and manager, resident and the complainant stating the outcome and specifying any action.
Consumer advice
The CQC have available for consultation a list of all private and voluntary homes currently registered in its area. Many authorities have also found it helpful to publish a more detailed list of registered homes describing their individual characteristics and specific services provided, General information can also be given on how to obtain advice about financial assistance towards the cost of accommodation, and on the difference between a private and voluntary home and between a residential care home and a nursing home. We have tried to provide as much information as we ca on our web site.
Quality assurance (QA)
Quality assurance is the process whereby we can check that acceptable standards of service are being met. This is done through self-assessment and annual inspection by the CQC. In order for this process to work, agreed standards been set out in the previous pages. Performance against those standards is then be measured through the quality assurance process. The inspection report details the standards.
The benefits of QA
There are many benefits for Hankham Lodge in establishing quality assurance procedures. this process identifies what constitutes acceptable standards of care and assists in setting up processes for monitoring our progress towards achieving them. Drawing up and agreeing standards has involved all those concerned, including residents. The day-to-day experience of those who live and work in the home has provided the starting point for the process. Essential to the process of quality assurance is the idea of self-audit or self-assessment whereby we systematically examine the service we provide, assess our performance against standards which we have already agreed in conjunction with residents, and then make adjustments to improve anything shown to be deficient. Quality assurance involves all members of staff at every level. Through this, standards are raised and team-working is developed.
Accreditation
Accreditation is given in the way of an annual CQC report that doesn't outline major requirements or recommendations.


Terminal care
Introduction
As important to residents as the quality of their lives while they are living in the home will be the way in which they are cared for during the process of dying. This means that their physical and emotional needs are met, their comfort and well-being attended to and their wishes respected. Pain and distress is controlled and the privacy and dignity of a resident who is dying is at all times be maintained.
The death of people living in Hankham Lodge
The fact that most residents die in the homes they are living in rather than returning to their own homes or being moved into hospital does not mean that dying and death is routine and commonplace. The impact of death on the community of residents is significant and continuing and we ensure that opportunities are available for them to come to terms with issues of life and death in the way that each individual finds best. This is done by ensuring that opportunities are provided for meditation and reflection, for contact with local religious and spiritual leaders and that there is an openness and willingness on the part of staff and others involved at Hankham Lodge to talk about dying and death, and about those who have recently died.
Policies and procedures
The issues around dying and death are very sensitive. Hankham Lodge's operational policies which deal with quality of life before death, planning in anticipation of death and the practical and legal requirements following the death of a resident.
Considerations are:
· Physical and medical (especially with regard to comfort and pain relief);
· Spiritual and emotional aspects;
· Cultural and religious beliefs and practices;
· Legal issues and other formalities to do with death;
· Relatives' and friends' involvement;
· Support for staff.
Policies are clearly expressed and information made available to residents and their families and friends when they first come into the home.
Expressed wishes of the resident
Some people will be clear about their preferences with regard to care when they are dying and the formalities to be observed after their death. They may be very ready to discuss it with those closest to them and with staff. In other cases, people may be more reluctant to broach the subject, or have it broached with them. Staff are alert to occasions when individuals may reveal their thoughts and preferences unexpectedly so that they can make use of this when the time arises.
However it is done, the process of talking to residents about their death is a delicate one which is done sensitively and with compassion. It may be very time-consuming.
Planning ahead
Information about the resident
Where possible Hankham Lodge, perhaps in conjunction with relatives or friends, assembles information about the following, to be made use of at the time of the death of a resident:
· details of next of kin;
· people to be informed in case of serious illness or death;
· the existence and location of a will and next of kin instructions (if kept at the home);
· funeral arrangements and any preferences;
· the person to be responsible for making arrangements and taking responsibility for the resident's property;
· any religious or cultural practices;
· any other personal request.
Information of this sort, once gathered, is confirmed periodically and always observed at the appropriate time.
Financial affairs, wills and next of kin instructions
These matters are handled by relatives, a solicitor, an appointee, an attorney or the Court of Protection, Court of Session or the High Court. The resident may have completed a next of kin instruction form or left other written instructions. Wherever possible, the resident's wishes are to be respected and carried out. Hankham Lodge is never involved in any financial arrangements.
Dying
Some people may express thoughts about dying, in particular their hope for a peaceful, pain-free death or their fear of death and their concerns for those left behind. Those who are in the position of providing care and support do everything they can to calm these fears and attend to these concerns. Staff adopt an approach which is honest and open about the facts of illness and death, should the individual ask them.
At Hankham Lodge there are particular members of staff with experience and training in looking after people who are dying and can advise other members of staff. All care staff receive some training through NVQ in looking after people who are dying and are aware of their physical and emotional needs. They only act within their competence and know when to call upon others.
Care and comfort
A dying person receives all the care and comfort that is required. Particular attention is paid to keeping the person comfortable and responding to any requests. This may involve moving the person's position regularly (sitting up or lying down), keeping the person clean and cool, paying special attention to the person's mouth and giving regular drinks, and helping him or her to use the toilet. Additional staff are brought in if required and night staff are fully involved to make sure that care is given constantly throughout the night. A ripple mattress may be helpful,. Expert advice on pain control and management is sought for all residents who need it. Medical practitioners, community nurses or specialist nurses such as Macmillan or Marie Curie nurses can provide advice and assistance. Any painkilling or respiratory drugs are given only under the supervision of a doctor.
At Hankham Lodge a person close to death is not usually left alone, although any wish to be alone is respected. Relatives and friends may wish to be involved, but if there are none, staff have a special role to play. Above all, at all times, the privacy and dignity of the dying person is preserved. Attending to the physical needs of the person washing, bodily functions, feeding is done in private. Staff do not assume that the person cannot hear what is being said so they never talk about the individual when they are in his or her presence.
Place of dying
Residents are able to die in their own beds in their own rooms, surrounded by familiar people and possessions. Wherever possible, residents do not have to move away from the home to die (unless it is essential for them to go into hospital). Following death, the person's body isn't moved from his or her own room to another part of the home before being taken away by the undertaker.
Shared rooms
Complications arise if the person who is dying is in a shared room (the position is different for couples or close friends). There can be little doubt that it is easier to provide the care needed by the dying resident with dignity and in privacy in a single room and without the presence of another resident. The impact of a succession of deaths for someone living in a shared room would be intolerable. Residents in a room with a dying fellow resident or where a death has occurred are if possible offered the option of a move.
Hospices and hospitals
Hankham Lodge is aware of the care and services which local hospices have to offer. Many have outreach services and are able to offer help in the home without the resident having to be admitted to the hospice.
Where the person is in extreme pain or has other complications, it may be better for him or her to be looked after in a hospice or a hospital. Such decisions are only made after consultation with the person, any relatives and on medical advice. Any wishes of the resident, are respected if possible. The resident should also be able to return to his or her own home if possible and if he or she so wishes.
Relatives' involvement
Relatives may wish to be with their dying relative and every encouragement and opportunity is made for them to do so if this is known to be in accordance with the dying person's wishes. Space and a quiet room is available for relatives to sit, collect their thoughts and grieve. Meals, refreshments and other facilities are made available. This hospitality is extended to relatives whether they have been regular visitors or not.
Some relatives may wish to be fully involved in the care of their resident while others may just wish to be close by. Staff ask about relatives' wishes and facilitate them.
Other residents
The size and nature of Hankham Lodge to a certain extent dictates how the other residents are involved. In general they are kept informed of someone's impending death and are encouraged to visit him or her if they so wish. Cultural or religious practices may be appropriate such as prayers, vigils, playing favourite music or welcoming relatives.
Staff involvement
All staff who have had any involvement with the dying resident and this includes managerial as much as it does care staff are kept informed when someone is dying. Those who wish are given time to spend with the dying resident. This is one way we ensure that there is always someone present. Support is given to staff who have been closely involved with the resident and their emotional needs are recognised and catered for, particularly in the case of staff who are witnessing death for the first time.
Death
All the necessary procedures in terms of washing, dressing and laying out the body is undertaken sensitively and with dignity by the Undertakers.
Inform next of kin
If the next of kin or those most closely involved were not present at the time of death, then the manager or deputy will inform them as soon as possible that their relative has died.
Formal notifications and documentation
Depending on who is responsible for making the arrangements, the manager or deputy dose what is necessary or give whatever help is required to support the relatives. Whatever the position Hankham Lodge is likely to have a central role.
Things we do will include:
· obtaining the death certificate from the doctor;
· informing the coroner if the death was unexpected, if a death was unexpected then the police need to attend (this is routine)
· contacting the undertaker.
The manager will also inform the registration authority and follow any other agreed organisational procedures Re: Regulation 37.
Announcing a death
News of a resident's death will be announced in a dignified and gentle way. It may be best to announce it quietly to individuals or staff to begin with but some more public announcement may also be appropriate in due course. Some people may find this public recognition comforting. It is never assumed that people with memory loss do not understand when someone has died. Some of the following possibilities might be appropriate:
· a minute's silence at an appropriate time;
· a photograph or some other personal tribute in a suitable place;
· opportunity to visit the dead person and pay last respects;
· a memorial or thanksgiving service or some other religious or cultural ceremony;
· lighting a candle;
· playing a favourite piece of music or reading a poem;
· a plant, picture or piece of furniture in memory of the person.
Funeral
Residents and staff are able to attend the funeral or other ceremony if they wish. Transport can be arranged and staff rotas when possible will be adjusted either to provide escorts for residents or so that staff can attend in their own right. Hankham Lodge always tries to represent the home at funerals.
Bereavement
Staff are alert to the impact the death of individual residents may have on those remaining in the home. They are trained to recognize symptoms of grieving and learn how to respond. Formal bereavement counseling or contact with a specialist organization may be appropriate. In the case of people with memory loss, changes in their behavior may indicate the impact the death of a fellow resident has had on them and staff will be ready to offer comfort and support.
Within Hankham Lodge, the loss of one of a couple, or of a close friendship needs special and sympathetic support. Particular sensitivity will be needed in some practical matters such as any change of accommodation or disposal or handing over to relatives of clothes and other belongings. These are never rushed.
Moving into Hankham Lodge following bereavement
Many people come into a home after their partner has died. Staff recognizes that new residents may be going through a grieving process and they therefore are sensitive to their sense of loss and offer support. The quality of support is enhanced by specific training.
Formal and business arrangements
The agreement of residence outlines the fees payable in the case of the death of a resident. The former resident's accommodation will be available to his or her family for a reasonable period of time in order for personal possessions to be removed and affairs completed. A balance should be struck between this need and the time necessary to prepare the room for a new resident. A final account will be rendered in accordance with the terms and conditions agreed at the outset and any valuables and property held for safekeeping will be returned to the executor
Safeguards
Hankham Lodge is a small Residential Care Home for the elderly, situated in a country setting near Eastbourne, Sussex on the South coast