Jef Smith reports on the abuse of older people by domiciliary care workers.

Ask most members of the public what they know about elder abuse and they’ll likely recall an account of cruelty by workers in a residential home or hospital. Those are the cases that have most often hit the headlines over recent years, and the damage done to the image of residential care, most of whose practitioners provide a perfectly satisfactory, sometimes excellent, service, is inestimable.

We know, however, that most incidents of domestic violence occur within families, that the abuse of children by parents is much more common than similar crimes committed by other adults, and that the majority of murders are carried out by spouses and partners.

It almost certainly follows that the most numerous abusers of older people are likely to be their own relatives, often a child, husband or wife who lives in the same house as a vulnerable elderly person.

Abuse by care workers

There is another category of abuser of people in their own homes of which even less is heard: domiciliary care workers. Examples of this dreadful betrayal of trust feature in the news from time to time, but we would be ill-advised to believe that its rarity means home care staff are routinely more virtuous than their residential care colleagues.

This is an area in which it is near-impossible to produce comprehensive statistics or even reliable projections, nor should we exaggerate a problem that can only undermine the peace of mind of dependents and their caring families. Nevertheless, among professionals, we should certainly face up to this issue.

The incidence of abuse by domiciliary care workers is likely higher than evidence suggests, because of the simple fact of opportunity. Most clients are in some ways disabled. Many lack mobility, most have some degree of sensory impairments, increasing numbers are at least somewhat confused or forgetful, and some are fully in the grip of dementia.

Home care service users, in short, have in abundance the characteristics that make up vulnerability. They are deeply reliant on the care they receive, a reliance that leaves them open to a betrayal of that trust.

Both care workers and family carers are close to the people they are helping for substantial periods, in locations in which they are unobserved, and in relationships where their role implicitly involves a substantial imbalance of power. Regrettably, where the opportunity to abuse exists, there will be people who see their chance and take it.

As Action on Elder Abuse (AEA), the major charity working in this field, puts it, “The reality of domiciliary care is that the people who provide it do so in a one-to-one situation and rarely have contact with other carers.”

A further dimension comes into the picture when a home care worker does have contact with an informal carer — a family member, neighbour or a friend — and becomes aware of the fact that abuse is occurring. This will rarely be a situation of simple observation, since most abusers are sufficiently aware that what they are doing is wrong and so conceal it from witnesses.

However, experienced care practitioners will sometimes pick up on the subtly negative aspects of personal interactions, sense that something is wrong, that their client is uncomfortable, or find themselves becoming the confidante of an abused person simply by being the most trusted person around.

Four sorts of responsibility

AEA argues that society in general, and social care professionals in particular, have four sorts of responsibility relating to abuse, which it summarises under the headings of awareness, prevention, intervention and empowerment.

Awareness

The meaning of awareness is pretty obvious, though it is still a struggle to get the topic of elder abuse accorded the status that cruelty to children has attained. Denial, guilt and a tendency to blame the old people themselves — and seriously old people can indeed be very demanding, unreasonably so at times, to a point of understandable irritation in those around them — all play a part.

Campaigning to make the general public more aware of elder abuse involves a delicate balance between fearlessly exposing shocking practice and carefully explaining the policy issues. AEA is to be congratulated on the job it does in this extremely tricky field.

Prevention

Prevention follows on the successful promotion of awareness. It is obviously better to prevent abuse than to tackle the damage done after it has occurred, and creating a culture in which abuse is simply unacceptable can involve action in a variety of areas.

These include:

  • better support for hard-pressed carers, whose levels of stress can easily tip over into resentment and hostility

  • closer and more sympathetic training and supervision of home care workers, whose isolation at the coalface of social care generates both pressures and opportunities from which abuse can flow

  • a stronger sense of responsibility among the general public, who need to understand that vigilance in relation to vulnerable members of their communities is commendable and not simply nosy meddling.

Intervention

When everything to promote awareness and to prevent abuse has been done, however, some instances will still occur, so AEA’s next listed task, intervention, remains all too relevant.

When abuse happens, whoever is the perpetrator, what are the responsibilities of the workers and managers of home care agencies? AEA has long sought to answer that question, its first training aide for domiciliary care having been produced more than 20 years ago. This has been successively refined into Consequences, a pack consisting of a DVD and a selection of materials that can be used either by a trainer working with a group or by an individual aiming to refine his or her knowledge and skills.

To the four types of abuse — psychological, financial, sexual and physical — can be added a fifth: neglect. These sorts of acts of omission, that are often seen as quite different and even less reprehensible, can be equally devastating to victims. For each abuse type, participants are invited to identify what they already know, to take in new information from the written text and a DVD scenario, to list what they and their organisation need to do to achieve better practice, and to make a personal commitment to action.

Spotting the signs

There is an emphasis throughout on honing observational skills and spotting the signs that abuse is taking place.

The unexplained disappearance of money or valuable possessions might be an obvious indicator that something is going wrong financially, but the addition of signatories to a bank account or an unexplained transfer of assets may be less easy to spot though in fact equally sinister.

Bruises around the genitals should certainly arouse suspicions of rape, but would all of us be alerted by a client’s difficulty in walking or standing? An older person’s account of being slapped or kicked will clearly indicate physical abuse, but it is equally important to pick up the evidence of mysteriously broken spectacles or bruises acquired without convincing explanations.

If there is to be a criticism made of Consequences it is that the five-fold categorisation of abuse with which it deals is no longer regarded as comprehensive by many experts.

Financial abuse really needs to be supplemented by the closely related misappropriation of other possessions and even property. Psychological abuse needs also to include the range of emotional pressures arising from intimidation, disrespectful talking, ignoring someone who is trying to gain attention, ridiculing, and the like.

Perhaps more seriously, inappropriate restraint, which is often not regarded as physical abuse though its effects can be just as devastating, is not given the status it merits. In addition, discrimination, in the form of unfavourable remarks, hurtful jokes or the failure to provide facilities appropriate to a person’s faith or culture, must now be regarded as sufficiently prevalent to be treated in its own right.

Empowerment

The most significant clue to elder abuse and how we should react to it lies in the fourth Consequence — the concept of empowerment.

The sad and undeniable fact is that power in our society, perhaps any society, is unevenly distributed. This inequality is often correlated with the maldistribution of resources. Again, the contrast between attitudes to elderly people and to children is instructive.

Childhood is widely recognised as conferring a certain subservience, a relationship which, despite what most teenagers protest, is not always inappropriate given adults’ greater experience, if not always greater wisdom.

For older people, this disparity is more subtle. They can often lay claim to greater maturity simply by dint of years, but failing mental and physical powers combine with static or wasting material worth to contribute to a general, seemingly inevitable, decline in status.

For some — particularly those whose situation includes risk factors tending to private or professional exploitation in their own homes — the accumulation of these factors places them in situations of severe disadvantage.

Empowering the elderly is one of the great causes of our age. Larger numbers help, and not only with politicians needing votes. Championing ageing, not least by people who are already old, is beginning to shift attitudes. Official policies play their part, though the Department of Health’s drive towards personalisation has adopted too narrow a financial focus, as if the only route to exercising influence over the support you receive is to control the budget that finances it.

The struggle will be long-term, and the stakes are still heavily weighted against older people, but at least the battle has been engaged. It falls to all of us who have dealings with the older generation to be both scrupulous in our own behaviour, and vigilant in observing and reporting that of other possible offenders.

Though elder abuse will probably never be totally eliminated, domiciliary care workers and their employers are at the forefront of minimising its impact.

Last reviewed 29 August 2014