According to the Care Quality Commission's state of care report for 2019/20, there are over 10,800 residential care homes and 4,200 nursing homes in the UK. These provide support to around 410,000 older people (as estimated by the 2017 Competition and Markets Authority care homes market study), and to many younger adults with disabilities, mental health issues or complex support needs. In addition to long‑term residents, residential and nursing homes provide services for people who stay for shorter periods, including as day visitors. This is sometimes referred to as respite care or short break services. Many of these long- and short‑term residents have high care and support needs, and this means they are at an increased risk of abuse and neglect.
The quality of care in many care homes is good, but this is not always the case. The Care Quality Commission's report 2019/20 rated homes as follows:
inadequate: 2% of nursing homes and 1% of care homes
requiring improvement: 21% of nursing homes and 14% of care homes
good: 72% of nursing homes and 81% of care homes
outstanding: 5% of nursing homes and 4% of care homes.
Despite the legal framework and the associated statutory guidance, safeguarding procedures and practice vary at the local level. In particular, care homes often struggle to understand:
the difference between safeguarding issues and poor practice
when and how to make safeguarding referrals to the local authority.
The Safeguarding Adults 2019 Annual Report reported that care homes (including homes with and without nursing) accounted for 34% of all safeguarding enquiries conducted under section 42 of the Care Act 2014.
This guideline makes action-orientated recommendations to improve safeguarding for residents of care homes. It covers all adult residents of care homes, including people who stay at care homes for shorter periods (for example day visitors).
The guideline is based on:
the best available evidence on effectiveness (including cost effectiveness)
evidence on the views and experiences of care home residents, their families and carers, and practitioners involved in care and support for residents.
The guideline is also informed by existing adult safeguarding guidance from across these different sectors, including:
Association of Directors of Adult Social Services, Local Government Association (2019) Making decisions on the duty to carry out Safeguarding Adults enquiries.
Association of Directors of Adult Social Services, Social Care Institute for Excellence, National Health Service London, Metropolitan Police (2019) London multi-agency adult safeguarding policy and procedures.
Association of Directors of Adult Social Services North East (2011) Safeguarding threshold guidance.
Department of Health, Social Services and Public Safety (2009) Adult abuse: recognising adult abuse and what to do about it! Guidance for staff.
Royal College of Nursing (2018) Adult safeguarding: roles and competencies for healthcare staff.
Skills for Care (2017) What do I need to know about safeguarding adults?
Social Care Institute for Excellence (2018) Adult safeguarding practice questions.
Social Care Institute for Excellence (2015) At a glance 69: Safeguarding adults: Types and indicators of abuse.
Social Care Wales (2019) The social care manager: practice guidance for social care managers registered with Social Care Wales.
Volunteer Now (2010) Safeguarding vulnerable adults: a shared responsibility.
This guideline can be used together with the Making Safeguarding Personal resources published by the Local Government Association and ADASS, including understanding what constitutes a safeguarding concern and how to support effective outcomes.
The core legal duty for adult safeguarding is found in section 42 of the Care Act 2014.
The Care Act 2014 statutory guidance states that:
'Effective safeguarding is about seeking to promote an adult's rights to security, liberty and family life, as well as about protecting their physical safety and taking action to prevent the occurrence or reoccurrence of abuse or neglect. Any restriction on the individual's rights or freedom of action that is involved in the exercise of the function is kept to the minimum necessary.'
The local authority is the lead agency for adult safeguarding and should be notified whenever abuse or neglect is suspected. They will decide whether a safeguarding enquiry is necessary, and if so who will conduct it. The decision to conduct an enquiry depends on the criteria set out in the Care Act, and not on whether a person is eligible for or receiving services funded by the local authority.
Any actions taken in relation to a safeguarding concern should be based on the 6 principles set out in the Care Act statutory guidance. These principles should be known and understood by everyone working in care homes and should be part of their everyday practice:
1. Empowerment: People being supported and encouraged to make their own decisions and informed consent.
2. Prevention: It is better to take action before harm occurs.
3. Proportionality: The least intrusive response appropriate to the risk presented.
4. Protection: Support and representation for those in greatest need.
5. Partnerships: Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.
6. Accountability: Accountability and transparency in delivering safeguarding.
As well as the 6 principles, this guideline also recognises the importance of the wellbeing principle within the Care Act, and the safeguarding approaches based on the Making Safeguarding Personal framework. These both emphasise that people who have experienced or are at risk of abuse or neglect should be meaningfully involved in safeguarding whenever possible. Outcomes should be meaningful to the person, rather than simply following a process.
This approach is also endorsed by the Care Act statutory guidance, which states that:
'… safeguarding means protecting an adult's right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult's wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. This must recognise that adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances.'
The guideline complements statutory duties and good practice as set out in relevant legislation and guidance. The recommendations cross-refer to legislation and other guidance where appropriate. In particular, the guideline takes account of the Care Act 2014 and the Care Act 2014 statutory guidance, the Mental Health Acts 1983 and 2007, and the Health and Social Care Act 2008. It is also underpinned by the Human Rights Act 1998, notably Article 3 (No one shall be subjected to torture or to inhuman or degrading treatment or punishment), Article 5 (Right to liberty and security) and Article 8 (Right to respect for private and family life).
Also, because many people who use care homes may lack the capacity to make certain decisions, this guidance is also informed by the Mental Capacity Act 2005 and the Mental Capacity (Amendment) Act 2019. When a care home resident lacks capacity, this guideline should be used in line with the NICE guideline on decision making and mental capacity and relevant local guidance on this issue.
NICE guidelines provide recommendations on what works. This may include details on who should carry out interventions and where. NICE guidelines do not routinely describe how services are funded or commissioned, unless this has been formally requested by the Department of Health and Social Care.
The Care Quality Commission encourages health and social care providers to use NICE guidance to improve the quality of care they provide. Evidence of use and compliance with NICE guidance will help services achieve a Good or Outstanding rating.