Page 8 - 20190214 - Minutes - TSAB - PUBLIC

Incidents between Residents Task & Finish Group – Lorraine Garbutt
 Briefing Paper / Prompt Sheet
Data shows that there is a high proportion of physical abuse cases that are attributed to incidents between
residents in care settings. A multi-agency Task & Finish Group was set up to look at this in more detail.
The group wanted to understand the volume of cases that LAs and Police were dealing with; since Q1
2018, LAs have been recording sub-categories in order to capture incidents of this nature. LG explained
that the data systems can capture repeat victims, but not repeat perpetrators. If reported to police the
incidents are recorded as a crime and quickly closed (if one or more individuals lack capacity the case
cannot be progressed). The Cleveland Police Referral criteria has been re-circulated and sent to care
homes to try and prevent inappropriate referrals being made.

LG advised that 2 Tees representatives attended a workshop in London that looked at conversion rates
and what constitutes as a Concern and Section 42 Enquiry in an effort to improve consistency across the
country. Following the workshop, it reiterated that these types of incidents need to be reported into
Safeguarding as by definition of the Care Act they do meet the Section 42 Enquiry criteria. It was noted
that the Enquiry may be as little as a phone call to the care provider to ensure that appropriate measures
are put in place to deal with the issues raised. The group did acknowledge that it would be useful to have
a prompt sheet for staff to use when doing an initial enquiry to ensure that the right questions are asked
to try to establish the root cause and improve consistency of how these types of incidents are dealt with
across Tees. This is included as an appendix within the briefing paper.

Emma Thompson from the ICLS Service was a member of the group and talked about how their service
works with staff in care homes to put behaviour plans in place. There is often a high turnover of staff in
care settings, regular use of agency staff and most crucially a high turnover of registered managers. This
can lead to a lack of consistency in approach, diminished level of skills, lack of knowledge of individual’s
needs and care plans. Living environments can influence the behaviour of residents and some care
homes are not fit for purpose or dementia friendly.

Gordon Bentley (GB) from South Tees CCG shared some 1:1 guidance which is currently used for
Continuing Health Care funding, however it does provide some useful guidelines. JG confirmed that
initially the guidance was developed for the South Tees area, but has since been adopted North of Tees
as well.

The group recognised that those admitted to dementia care units within residential settings are usually in
the advanced stages of their illness. This can result in residents being moved from home to home due to
changing needs, or to manage behaviour, or due to dynamics between residents, which could in effect
just move the problem elsewhere.

JG felt that people going into care later in life is a positive culture shift, however the flip side is that
individuals often have more complex needs when they do go into care. As they are entering care in the
latter stages of life, the throughput of residents is constantly changing which can also impact on the
dynamics of people living together within a care setting. The CCG has invested a substantial amount of
money to work with care providers to offer training and upskill staff which can be difficult to maintain in a
sector with such a high turnover.

LG asked if incidents between residents should be added to the Board’s Risk Register. AB felt that if it
was added, the Board would need to develop some actions to address the issue and through the Task &
Finish Group these actions have already been completed.

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