All About You Care Services Limited Staff Handbook
All About You Care Services Limited has published this handbook for the benefit of its
employees to enable them to have a clear understanding policy, procedure, philosophy and
administration of the company. It is also intended to provide the first point of reference for
employees seeking information. Adherence to its content will promote high quality, person
centred and sustainable care that supports people to live independently in their own homes.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted by any means electronically, mechanical or chemical without the
specific written permission of the publisher.
V2.18 Reviewed 30 April 2021
© Copyright All About You Care Services Limited 2019
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All About You Care Services Limited
Staff Handbook
Table of Contents
............................................................................................................................................. 2
MISSION STATEMENT.......................................................................................................11
AIMS AND OBJECTIVES ...................................................................................................11
Aims of Reablement Service............................................................................................11
DIGNITY IN CARE CHARTER............................................................................................12
Dignity ..............................................................................................................................12
Respect............................................................................................................................12
Privacy .............................................................................................................................12
Independence ..................................................................................................................12
Choice..............................................................................................................................13
Rights...............................................................................................................................13
Fulfilment .........................................................................................................................13
Nutrition............................................................................................................................13
Staffing.............................................................................................................................13
Policies and Procedures ..................................................................................................13
Commissioning ................................................................................................................13
THE DIGNITY CHALLENGE...............................................................................................14
............................................................................................................................................14
SERVICE USER’S CHARTER ............................................................................................15
Your Rights ......................................................................................................................15
Involvement with Your Affairs...........................................................................................15
Independence ..................................................................................................................15
Equality ............................................................................................................................15
Confidentially ...................................................................................................................15
Non discriminatory Practice .............................................................................................16
Extent of Services ............................................................................................................16
Quality of services............................................................................................................16
PRINCIPLES OF SERVICE ................................................................................................16
Competence.....................................................................................................................16
Reliability..........................................................................................................................17
Responsiveness...............................................................................................................17
Co-ordination ...................................................................................................................17
Planning of care ...............................................................................................................17
COMPLAINTS, GRIEVANCES AND SUGGESTIONS .......................................................18
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COMPLAINTS PROCEDURE .............................................................................................19
POLICIES............................................................................................................................20
PERSONALISATION ..........................................................................................................22
SAFEGUARDING ADULTS POLICY AND PROCEDURE .................................................23
Definition of Abuse ...........................................................................................................24
Base Values.....................................................................................................................25
Types of Abuse ................................................................................................................25
Physical Abuse ................................................................................................................25
Indicators of Physical Abuse: ...........................................................................................25
Financial or Material Abuse..............................................................................................25
Indicators of Financial Abuse: ..........................................................................................26
Sexual Abuse...................................................................................................................26
Indicators of Sexual Abuse: .............................................................................................26
Psychological Abuse ........................................................................................................26
Neglect or Acts of Omission.............................................................................................26
Indicators of Neglect or Acts of Omission ........................................................................26
Discriminatory Abuse .......................................................................................................27
Indicators of Discriminatory Abuse...................................................................................27
Institutional Abuse............................................................................................................27
Indicators of Institutional abuse........................................................................................27
Mental Capacity Act 2005 ................................................................................................27
Recruitment......................................................................................................................29
Abuse Reporting Procedure.............................................................................................29
Body Map Instructions (for recording evidence of abuse) ................................................30
Reporting an Allegation of Abuse Flow Chart .................................................................31
.........................................................................................................................................31
Safeguarding Incident Report Sheet ................................................................................34
DUTY OF CANDOUR POLICY & PROCEDURE ................................................................36
INDEPENDENT MENTAL CAPACITY ADVOCATES POLICY ..........................................38
1. Policy statement...........................................................................................................38
The whole Act is underpinned by a set of five key principles: ..........................................38
What does the Act do?.....................................................................................................38
2. Purpose........................................................................................................................39
3. Scope...........................................................................................................................39
4. Legal context................................................................................................................39
5. Mandatory Procedures.................................................................................................39
6. Eligibility .......................................................................................................................40
7. Attorneys, family and friends, existing advocates ........................................................42
8. Referral to the Advocacy Service (N-COMPASS)........................................................43
9. Role and responsibilities of the referring staff member ................................................44
10. Role and responsibilities of the Advocacy Service (N-Compass)...............................44
11. Role and responsibilities of the IMCA ........................................................................44
11. Reports ......................................................................................................................45
12. Disagreements ...........................................................................................................46
13. Complaints .................................................................................................................46
14. Practice guidance.......................................................................................................46
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15. Code of Practice.........................................................................................................46
16. Advance directives and DNAR ...................................................................................46
17. Security and confidentiality ........................................................................................47
18.The Deprivation of Liberty Safeguards (DOLS)...........................................................47
VALUING PEOPLE PLAN ..................................................................................................48
FOUR KEY PRINCIPLES OF VALUING PEOPLE .............................................................49
VALUING PEOPLE OBJECTIVES .....................................................................................51
Objective 1: Maximising Opportunities for Disabled Children...........................................51
Objective 2: Transition into Adult Life...............................................................................51
Objective 3: Enabling People to Have More Control Over Their Own Lives.....................51
Objective 4: Supporting Carers ........................................................................................51
Objective 5: Good Health .................................................................................................51
Objective 6: Housing ........................................................................................................51
Objective 7: Fulfilling Lives...............................................................................................51
Objective 8: Moving into Employment ..............................................................................52
Objective 9: Quality ..........................................................................................................52
Objective 10. Workforce Training and Planning ...............................................................52
Objective 11: Partnership Working...................................................................................52
MEDICINES POLICY ..........................................................................................................52
1. Governance for Managing medicines safely & effectively.........................................53
2. Assessing and reviewing a person's medicines support needs ................................53
3. Joint working between health and social care...........................................................54
4. Sharing information about a person's medicines ......................................................55
5. Ensuring that records are accurate and up to date ...................................................56
6. Managing concerns about medicines........................................................................58
7. Consent ....................................................................................................................59
8. Supporting people to take their medicines ................................................................59
9. Giving medicines to people without their knowledge (covert administration) ............62
10. Medication Administration Record (MAR charts)...................................................63
11. Body Maps (for medication administration) ...........................................................66
12. Guidance Notes on Medical Issues .......................................................................67
13. Ordering and supplying medicines ........................................................................69
14. Emergency Supplies .............................................................................................71
15. Transporting, storing and disposing of medicines .................................................72
16. Storage of Medicines at Room Temperature.........................................................73
17. Training and competency ......................................................................................75
18. Terms used in this guideline..................................................................................76
LONE WORKER POLICY ...................................................................................................79
Who is a Lone Worker?....................................................................................................79
Zero Tolerance.................................................................................................................79
The Law ...........................................................................................................................79
Individual Responsibilities ................................................................................................79
PRIORITISING OF TASKS .................................................................................................83
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STRESS POLICY................................................................................................................84
Guidance for Employees..................................................................................................86
EQUAL OPPORTUNITIES POLICY....................................................................................91
GENERAL DATA PROTECTION REGULATIONS (GDPR) ...............................................92
Data Protection Policy......................................................................................................94
Data Quality Policy...........................................................................................................99
Network Security Policy .................................................................................................103
Policy for the Use of Mobile Devices..............................................................................107
Subject Access Request Policy......................................................................................109
GDPR: Freedom of Information Requests ....................................................................112
Data Breach Policy.........................................................................................................114
Data Privacy Notice for Job Applicants ..........................................................................118
Privacy Notice for Employees ........................................................................................125
Privacy Notice for Service Users....................................................................................132
THE PERSONAL INFORMATION WE COLLECT AND USE IN RELATION TO PEOPLE
WHO ENQUIRE ABOUT AND USE OUR SERVICES......................................................133
YOUR RIGHTS..................................................................................................................135
KEEPING YOUR PERSONAL INFORMATION SECURE ................................................136
HOW TO COMPLAIN........................................................................................................136
CHANGES TO THIS PRIVACY NOTICE ..........................................................................137
DO YOU NEED EXTRA HELP?........................................................................................137
Data Retention Policy & Retention Schedule .................................................................138
Website Privacy Policy...................................................................................................141
GDPR: Privilege Access Agreement; System Administrators ........................................144
SOCIAL MEDIA POLICY ..................................................................................................146
Use of social media at work ...........................................................................................146
Company’s social media activities .................................................................................146
Social media rules..........................................................................................................147
Social media references.................................................................................................148
Social media monitoring.................................................................................................148
Contravention of Social Media policy .............................................................................149
WHATSAPP RULES FOR USE ........................................................................................150
Rule 1 Use the Official company WhatsApp for work.....................................................150
Rule 3 Anonymise Service Users Names ......................................................................150
Rule 4 Anonymise all photographs ................................................................................150
Rule 5 Use the group professionally ..............................................................................151
ELECTRONIC TELEPHONE CALL MONITORING..........................................................152
Download App to phone.................................................................................................152
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Open the App.................................................................................................................152
Logging in to your App ...................................................................................................153
Home Screen & selecting your rota ...............................................................................154
First time logging in instructions.....................................................................................155
Logging Arrivals and Departures....................................................................................156
Confirmation Pop up’s Following Scanning....................................................................157
Feedback for next 48 Hours...........................................................................................158
MISCELLANEOUS GUIDANCE AND INSTRUCTIONS ...................................................159
..........................................................................................................................................159
Confidentiality ................................................................................................................160
Involvement with Service User’s financial and private affairs.........................................160
Receipt of purchases made on behalf of a Service User ...............................................161
Record of Receipts of Purchases Made on Behalf of a Service User ............................162
Financial Guidelines Supporting Service Users to Attend Paid Venues.........................163
Use of Service User Debit / Credit and Prepaid Cards...................................................164
PROFESSIONAL PRACTICE AND CONDUCT ...............................................................165
INAPPROPRIATE BEHAVIOUR.......................................................................................165
MAINTAINING BOUNDARIES..........................................................................................165
Recruitment....................................................................................................................166
Communication ..............................................................................................................167
Supplier Performance and Stock Control .......................................................................167
Gifts and gratuities .........................................................................................................167
Withdrawal of service .....................................................................................................167
Assessment and review .................................................................................................168
Risk taking and restraint.................................................................................................168
Accessibility of management..........................................................................................168
Staffing Levels ...............................................................................................................169
Involvement of Service User and Carer in service provision ..........................................169
Partnership working with key agencies ..........................................................................169
Key Holding....................................................................................................................169
Key Safes & Coded Door Locks.....................................................................................169
Insurance .......................................................................................................................170
Telephones ....................................................................................................................170
Security of Company Vehicles and Load .......................................................................170
Driver Responsibility ......................................................................................................170
Am I responsible for Roadworthiness?...........................................................................171
Social, Environmental and Ethical Issues ......................................................................171
Green Housekeeping .....................................................................................................172
Culturally Appropriate Care............................................................................................173
Training ..........................................................................................................................173
HUMAN RIGHTS ACT 1998 .............................................................................................174
Policy Statement ............................................................................................................174
Human Rights and Homecare........................................................................................174
'Whistle-Blowing .............................................................................................................178
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Bullying, Harassment and Coercion ...............................................................................180
Harassment....................................................................................................................180
Bullying ..........................................................................................................................181
Examples of Bullying......................................................................................................181
Code of Conduct ............................................................................................................182
POLICY ON SEX AND SEXUALITY .................................................................................182
ATTENDANCE MANAGEMENT POLICY.........................................................................183
COMBATING VIOLENCE AGAINST CARE STAFF/SAFER PLACES ............................184
VALUING PEOPLE / PERSONALISATION POLICY, ......................................................187
POLICY & PROCEDURE SERVICE USER REQUIRING MEDICAL ATTENTION. .........191
a) Calling 999 For Urgent Medical Assistance ...............................................................191
b) Calling 111 To Seek Guidance for Advice from a Health Advisor ..............................192
c) Finding a service user has fallen and found on the floor. ...........................................192
d) Calling GP for advice or to book an appointment for service user. ............................194
POLICY CARE OF THE DYING........................................................................................195
POLICY ON SECURITY OF THE HOME ..........................................................................199
Entering a Service Users Home.....................................................................................199
Leaving a Service Users Home......................................................................................199
Action to be taken if entry cannot be gained ..................................................................200
HEALTH & SAFETY AT WORK ACT 1974 ......................................................................202
Policy Statement ............................................................................................................202
Introduction ....................................................................................................................202
Explanation of Health & Safety ......................................................................................202
Responsibilities for Health & Safety ...............................................................................203
Investigation of Accidents ..............................................................................................204
COVID-19 – CORONAVIRUS POLICY AND PROCEDURE ............................................208
INFECTION CONTROL COVID-19 SARS- COV-2 ...........................................................210
COVID- 19 Infection Control Rules For homecare workers............................................210
Donning and Doffing a Guide to Safely put on and remove PPE ...................................215
COVID-19 Infection Control Rules for all Employees and Visitors .................................217
MOVING & HANDLING.....................................................................................................222
MANUAL HANDLING POLICY.........................................................................................223
RISK ASSESSMENT ........................................................................................................224
What is Risk Assessment?.............................................................................................224
Carrying out a risk assessment......................................................................................224
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Work Environment Assessment .....................................................................................225
Individual risk assessments ...........................................................................................225
Method of Assessing Risk..............................................................................................226
PROCEDURE FOR RECORDING ACCIDENTS AND REPORTING NOTIFIABLE
OCCURRENCES ..............................................................................................................228
Reporting & Recording of Minor Accidents ....................................................................228
R.I.D.D.O.R. ...................................................................................................................228
C.O.S.H.H. Policy ..........................................................................................................228
Assessment of Health Risks ..........................................................................................229
Definition of Substances Hazardous to Health ...............................................................230
Safe Access & Egress Policy .........................................................................................230
Wheelchairs ...................................................................................................................230
Corridors and Fire Exits .................................................................................................231
Falling objects ................................................................................................................231
Contractors Working on Site ..........................................................................................231
Floors and surfaces........................................................................................................231
Paths and Driveways .....................................................................................................231
Awareness .....................................................................................................................231
CONTROL OF INFECTIOUS DISEASES .........................................................................232
EMERGENCY PROCEDURES .........................................................................................233
Procedure in the event of not gaining access to a Service User's home........................233
Procedure in the event of a fire ......................................................................................234
Procedure in the event of accident.................................................................................236
Procedure in the event of an accident to yourself ..........................................................237
Procedure in the event of discovering a Service User has died .....................................237
Procedure in the event of a failure in the electricity supply ............................................238
Procedure in the event of a suspected gas escape .......................................................239
Procedure in the event of a burst water pipe..................................................................240
Procedure in the event of a Service User Suffering Food Poisoning .............................241
Procedure in the Event of a Member of Staff Suffering from Food Poisoning ................242
Illness Exclusion ............................................................................................................242
Procedure for dealing with a reported accident or emergency .......................................244
Procedure for recording an accident on company premises ..........................................245
PRIORITISING OF TASKS ...............................................................................................245
Procedure for Recording Accidents and Reporting Notifiable Occurrences ...................246
Reporting and Recording of Minor Accidents.................................................................246
R.I.D.D.O.R. ...................................................................................................................246
Incident report Form.......................................................................................................246
CONTRACT OF EMPLOYMENT ......................................................................................249
DISCIPLINARY PROCEDURES .......................................................................................251
DISCIPLINARY APPEALS PROCEDURE........................................................................252
GRIEVANCE PROCEDURE .............................................................................................253
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WORKING TIME REGULATIONS ....................................................................................254
EXCLUSION AGREEMENT “THE 48 HOUR WEEK” ......................................................257
EXCLUSION AGREEMENT “WEEKLY REST DAY” .......................................................258
STAFF RECRUITMENT POLICY......................................................................................259
Aims ...............................................................................................................................259
Objectives ......................................................................................................................259
Recruitment Procedure ..................................................................................................260
RACE RELATIONS AND EQUAL OPPORTUNITIES ......................................................261
EQUAL OPPORTUNITIES................................................................................................262
JOB DESCRIPTION REGISTERED MANAGER ..............................................................265
JOB DESCRIPTION AREA MANAGER ...........................................................................268
JOB DESCRIPTION DOMICILIARY CARE WORKER.....................................................271
EMPLOYMENT QUALIFICATIONS & REQUIREMENTS ..............................................273
TRAINING AND DEVELOPMENT PLAN..........................................................................274
PERFORMANCE APPRAISAL & ASSESSMENT............................................................276
Training Evaluation and Feedback form.........................................................................277
Training feedback form ..................................................................................................278
Staff Supervision Form...................................................................................................279
FALLS PREVENTION.......................................................................................................280
Falls Chart......................................................................................................................281
Falls Prevention Checklist..............................................................................................281
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted by any
means electronically, mechanical or chemical without the specific written permission of the publisher.
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Mission Statement
We believe all people, regardless of ability and capacity, should be in control of their own
lives, live within the community, have freedom of choice and control, make informed
decisions and take responsibility for associated risks.
It our mission to provide quality care and support services that will assist people to realise
these aspirations and expectations
Aims and Objectives
We aim to provide services that are caring, safe, effective, responsive and well led. These
services aim maximise independence to enable people to live at home and be a part of their
local communities
The directors and managers aim to provide: -
high quality integrated and dependable services for as long as they are required.
care and support this is person centred
services that are inclusive and available to all regardless of age, disability, gender,
gender assignment, marriage, civil partnership, race, religion or belief sex or sexual
orientation.
matched carer characteristics to the Service Users assessed needs.
a broad range of services at varying intensity that maximise independence.
integrate services into seamless packages of care with minimum disruption to
Service User's day to day routine.
services that actively promote the health and wellbeing of the Service Users.
services that maximise independence and minimise the effects of any disability or
incapacity.
In order to achieve these aims, the management objectives are to: -
Promote within Service Users self help, independence and community presence.
Monitor and respond to the changing needs of Service Users
Assist with the formulation and commission of personal care plans.
Liaise with all relevant groups including Service User and other providers.
Recruit and employ suitable personnel.
Achieve staff competence through training and communication.
Ensure that services provided are pertinent, effective and efficient.
Develop Service User confidence through reliability, consistency, flexibility and
communication.
Be sensitive and receptive to all those concerned.
Aims of Reablement Service.
The Reablement Service forms part of the transitional care pathway which is a range
of integrated services and supports the promotion of independence and faster
recovery from illness. The Service aims to prevent unnecessary acute hospital
admission, premature admission to residential care, support timely discharge from
hospital, to minimise, delay or avoid the need for long term domiciliary supports and to
maximise independent living. Evidence shows that timely periods of social care
reablement, focusing on skills for daily living, can enable people to live more
independently and reduce their need for ongoing support
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Dignity in Care Charter
All about you care services Ltd. is a signatory to the Lancashire
Dignity in Care Charter, this charter outlines what a person can
expect as a minimum when receiving our services. In addition, the
company is committed to championing dignity and promises to
promote the values of the 10 point dignity challenge.
The charter is a joint initiative between Lancashire County Council and the ‘Health and
Social Care Partnership’ – the partners being the Lancashire Care Association and the
Lancashire Domiciliary Care Providers Forum representing independent providers
throughout Lancashire. The Charter is a public statement that care providers and
commissioners of services have agreed to.
The Charter underlines what a person can reasonably expect when they need and use care
and support in Lancashire.
We will:
Dignity
Respect each individual for their uniqueness and make each individual feel that they
matter
Have a zero tolerance to all forms of abuse
Promote and encourage positive and respectful attitudes
Respect
Support people with the same respect you would want for yourself or a member of
your family
Treat each person as an individual with their own needs wants, desires and
expectations
Respect people’s rights to have relationships
Privacy
Respect people’s rights to privacy and autonomy
Independence
Enable people to maintain independence, choice and control whilst managing any
risks
Ensure that services are provided in a way that meets an individual’s likes and
dislikes
Act to alleviate people’s loneliness and isolation
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Choice
Provide a personalised service and treat each
person as an individual
Listen and support people to express their
needs and wants
Engage with family members, carers and care
partners where this is appropriate
Rights
Help to maintain all entitlements associated
with citizenship
Ensure that people feel able to complain
without fear of repercussions
Fulfilment
Assist people to maintain confidence and a
positive esteem
Support them in the realisation of personal
aspirations and abilities in respect of daily life
Nutrition
Adhere to guidance on nutrition in homes and in the
community and encourage nutritional screening
Staffing
Those who commission the service and those who
provide the service have a responsibility to ensure
services are properly staffed and funded and are
properly trine, vetted, supervised and supported.
Policies and Procedures
Policies and procedures will be in place to support
dignity in care, to challenge discrimination and
inequality, and to respect individual needs, covering:
Whistle blowing / Equal opportunity
Complaints and complements / Safeguarding adults
Commissioning
Involve all stakeholders and partners, including users, carers and providers, to commission
high quality personalised care.
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The Dignity Challenge
10 Dignity Do's
Have a zero tolerance of all forms of abuse
Support people with the same respect you would want for yourself or a member of
your family
Treat each person as an individual by offering a personalised service
Enable people to maintain the maximum possible level of independence, choice and
control
Listen and support people to express their needs and wants
Respect people's right to privacy
Ensure people feel able to complain without fear of retribution
Engage with family members and carers as care partners
Assist people to maintain confidence and positive self-esteem
Act to alleviate people's loneliness and isolation
All About You Care Services will endeavour to promote awareness of these 10
points to everyone connected with health and social care.
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Service User’s Charter
Your Rights
As an All About You Care Services Ltd. Care Rehabilitation Service User you have the right
to:-
Independence and choice Individuality and autonomy
Dignity and personal respect Privacy for your own affairs
Involvement with the planning of Have all your needs accepted and
your service respected
Involvement with Your Affairs
Under no circumstances should any member of staff be involved with your financial and
legal affairs, this specifically includes wills and legal documents. It may be necessary,
however, under certain circumstances for a member of staff to handle your money. On
these occasions you will be made fully aware of all transactions. Members of staff will not,
under any circumstances, borrow money from or loan money to you. Assessment and
Review
As rehabilitation Service User you will be assessed with regard to the service you require.
Your assessment is designed to identify specific goals towards independence and forms
the basis of your rehabilitation plan. In order to monitor progress your plan will be
continuously reviewed. You will, whenever possible, be involved in all aspects of the
planning of your service.
Independence
You will, at all times, be encouraged to be independent and make your own choices.
Equality
We are committed to ensuring that no forms of discrimination are practised within our
organisation. Equally we are committed to ensuring that our Service Users and staff shall
be entitled to equality of opportunity irrespective of age, class, race, religion, gender, sexual
orientation, culture, disability or any other factor.
Confidentially
It is the responsibility of all personnel to ensure they do not divulge information of a
confidential nature gained through the course of their work either directly or indirectly to a
third party, unless that person has a legal consent to receive the information. This includes
information appertaining to staff and service users alike.
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The management of the company will ensure no information of a confidential nature gained
through the course of the company's activities will be divulged to a third party, unless that
person has a legal right to the information without the prior explicit consent of the individual.
Non discriminatory Practice
All About You Care Services Limited operates a non discriminatory policy and will provide
services to any Service User irrespective of gender, race, sexual orientation, age, cultural
background, disability or religion.
Extent of Services
The services provided will be:-
Of a type and frequency as identified to meet a Service Users assessed needs,
Sensitive to personal circumstances.
Quality of services
In order to achieve the provision of high quality services all personnel will be aware that
each Service User, irrespective of gender, race, sexual orientation, age, cultural
background, disability or religion, is entitled to all the normal rights associated with citizen
ship including:-
The right to be in control of their own services
Dignity and personal respect including being valued as an individual.
Individuality and choice within the scope of the service provided including
preferences for timing, food, etc.
Fulfilment of personal aspirations and involvement in the planning of their own
services.
Have all their needs, physical and emotional, accepted and respected.
Privacy for their own affairs and to be alone or undisturbed.
Refuse a service or services.
Be given the opportunity to think and act independently without reference to another.
Principles of Service
Although the following principles are expressed in terms of what the service should achieve
for the individual, the fundamental requirement for services is that they should be shaped
around the Service Users unique circumstances.
Competence
All About You Care Services Limited will take all reasonable steps to ensure that:-
All legal requirements regarding the employment of staff and the provision of
services are complied with.
Prospective employee’s, have been interviewed and satisfactory references sought.
16
Staff employed, do not have a previous history that would be detrimental to their
position or inconsistent with their profession.
Personnel within its employ are capable of performing their delegated duties to a
high standard. This will include induction and ongoing training.
All necessary insurances are undertaken.
Routine business financial procedures and audits are undertaken.
Reliability
All About You Care Services Limited will always endeavour to deliver services as agreed;
this will include timing, frequency and intensity. Specific procedures regarding the
distribution of service information to Service Users and staff will be initiated and maintained.
Responsiveness
All About You Care Services Limited will always endeavour to respond to individual needs
and involve both the Service User and carer in service provision details. This will include a
comprehensive comments, suggestions and complaints procedure.
Co-ordination
All About You Care Services Limited will ensure that all relevant personnel are adequately
briefed regarding Service Users individual needs, preferences and wishes. This information
will be obtained at the commissioning of a care plan and kept current by regular
consultation with Service Users and other groups.
Planning of care
Person centred care is established practice within the whole of our service, our person
centred approach within our service ensures care and support is clearly focussed on those
we are supporting, as a result many elderly people live safely in their own homes with
emphasis on individual choice and control.
As part of support planning we encourage service users to involve others to contribute to
their support plan such as a family member, a friend, existing carer or someone who is
close to them. Our experience confirms we get additional information of a person’s
preferences, likes and dislikes when prompted by someone who knows them well, however,
we do not let the opinions of others remove choice and control, this remains with the
service user. Where people lack capacity to make decisions during support planning we will
refer to the advocacy service who introduce an independent advisor to represent the
person’s views, when drawing up the plan the following items are discussed:
what works / doesn't work in their lives at the moment
what is important to them and what they like to do
what support they want and when they want it
ideas about how to make these things happen
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Complaints, grievances and suggestions
All About You Care Services Limited will maintain a comprehensive complaints, grievance
and suggestions procedure for the specific benefit of Service Users. This procedure will
seek to clarify and resolve any problems arising the provision of services. Ultimately if the
problem cannot be satisfactorily remedied by the company, then it will be referred to an
independent arbitrator, or local authority. Complaints alleging non-compliance with the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 will be reported to
the Care Quality Commission.Service Users, personnel and other interested groups will be
notified of this procedure.
If
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Complaints Procedure
The Director and Managers of All About You Care Services Ltd. endeavour to ensure that all
Service Users receive the service and attention they expect. In order to achieve this, it is
important that all those concerned are aware of Service Users needs and expectations. If a
Service User, or their representative, should feel dissatisfied with any aspect of the service or their
treatment then they should inform a member of staff as soon as possible. Such representations
may be made at any time to any member of staff or management either verbally or in writing. It is
expected that, in most instances, problems will be resolved at the time they occur by open and
honest discussion between the Service User or their representative and the member of staff
concerned.
Occasionally, the response from the member of staff may not be seen to be adequate, in which
case it is important to seek an answer from the management at the earliest possible time. The
management will then investigate the circumstances and attempt to resolve the problem as soon
as possible (within 28 days). All complaints, whether brought to the direct attention of the
management or not, will be treated seriously and positively.
In the event of the problem being unsatisfactorily resolved by the management, the issue may be
serious enough to involve the registering authority. The Service User or their representative or the
company may make representations to Lancashire County Council Safeguarding Adults, the
regulating body CQC or the local Commissioner for Administration (Ombudsman).
Lancashire County Council Telephone number on 0300 123 6721
Safeguarding Adults
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The regulating body is: Care Quality Commission
CQC Online contact form CQC National Customer Service Centre
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Telephone: 03000 616161
Fax: 03000 616171
www.cqc.org.uk/content/contact-us-using-our-
online-form
Policies
In developing these policies and by their regular review and update it is intended that we,
the proprietors, will be able to achieve the highest levels of care and service for our Service
Users.
We will ensure that all relevant policies are shared with and understood by the staff team,
including updates as required.
The policies will be used during staff induction training and as an ongoing working tool. We
will endeavour to ensure the policies are not ‘left on the shelf’ but brought into all aspects of
the day to day operation of the service.
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© All About You Care Services Limited 2016
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Personalisation
All about You Care Services is committed to continual improving the way adult social care
is provided to users of its services. It is the policy of the company to continually develop a
person centred culture within its workforce and across the organisation. Four years ago we
set out on a journey to introduce personalised support that is more responsive to those who
use our services and our carers who provide the service.
In line with the Putting People first concordat, the transformation from prescriptive services
to person centred approaches, and the development of a person centred culture within the
organisation we endeavour to support people to:-
live independently.
stay healthy and recover quickly from illness.
exercise maximum control over their own life by assisting people to take charge of
their own care and support.
plan their own care and support.
have the best quality of life, irrespective of illness or disability.
retain maxim dignity and respect.
explore, innovate ways and new types of services to achieve out comes.
promote independence, good health and wellbeing.
focus on prevention, early intervention and Reablement
gain access to voluntary and community supports.
promote community integration and participation as equal citizens.
As part of this commitment we will:
Promote self-directed support in our administration systems and training, this will
lead to service users having more choice and control over planning and managing
their support and thereby promote their independence, health and wellbeing.
Provide service users with information about self-directed support, their right to
receive direct payments and taking their personal budgets either as cash payments
in lieu of services paid directly to them or a third party.
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Support and assist service users to obtain direct payments if specifically requested.
Where engaged directly to provide services we will introduce PCP’s (person centred
plans) these plans will be flexible and put the service user at the heart of the service,
PCP’s will be innovative and looking for new ways of meeting outcomes, including
the use of voluntary and community supports.
Ensure the service is delivered in person centred ways even when care plans
provided by the local authority are not person centred.
Ensure services are person focussed fitting in and around people’s lifestyles
respecting individuality, intrinsic values and promoting diversity.
Undertake ongoing reviews to establish ‘what’s working’ & ‘what’s not working’
where things are working well we will seek to build and further improve this part of
the service. Where thinks are not working we encourage the service user to look
alternative ways of meeting outcomes.
Train our staff to deliver personalised care and to understand the benefits of putting
people in control of their own care and support.
To continue to develop a person cantered culture throughout the organisation.
we support people to gain
access to voluntary and
community supports.
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Safeguarding Adults Policy and Procedure
All About You Care Services adopts Lancashire County Council Multi-agency policy &
procedure “Safeguarding Adults”. The aim of is to ensure we work in partnership to
establish best practice guidelines and outcomes in safeguarding adults at risk of abuse. We
are all responsible for protecting and safeguarding adults through the work we do on a daily
basis, the overall responsibility for safeguarding adults within the company rests with the
Managing Director Mr. J Lee.
As a Partner agency to the authority we agreed to work to the following principles:
Everyone has the right to live their life free from violence, fear and abuse.
All adults have the right to be protected from harm and exploitation.
All adults have the right to self-determination, which involves a degree of risk.
Staff who wishes to obtain a full copy of the County Council policy can request one through
the office; alternatively, a copy can be obtained on the internet at the following address:
http://www.lancashire.gov.uk/corporate/web/viewdoc.asp?id=22666staff
Definition of Abuse
It is the policy of the company to take all possible precautions and actions to prevent any
event of abuse in the workplace. In order to do this, and for the benefit of its employees and
Service Users, the company defines abuse as:
“………………a violation of an individual’s human and civil rights by a person
or persons who' have power over the life or well being of any individual
It may be the physical, emotional, or psychological
abuse of an individual by any person.”
The scope of this policy applies to all vulnerable adults and children whilst within the care of
the company be it in their own homes, a residential home or when receiving community
support in other locations.
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Base Values
It is the policy of the company to afford the following base values to all individuals, these
values underpin the basic human rights of all those in our care. Any infringement or denial
of these base values will be considered by the company as ABUSE of the individual:
Privacy The right of individuals to be left alone or undisturbed and free from
Dignity intrusion or public attention into their affairs.
Independence Recognition of the intrinsic value of people regardless of
Choice circumstances by respecting their uniqueness and their personal
Rights needs; treating with respect.
Fulfilment
Opportunities to act and think without reference to another person
Types of Abuse including a willingness to incur a degree of risk.
Opportunity to select independently from a range of options
The maintenance of all entitlements associated with citizenship
The realisation of personal aspirations and abilities in all aspects of
daily life
For the avoidance of any doubt the company has identified the following categories of
abuse for the benefit of staff and has given some examples of indicators (this list is not
exhaustive) that may identify a victim of abuse:
Physical Abuse
An act resulting in the victim’s body or bodily functions suffering pain or impairment. Being
refused medication, receiving too much or too little medication or receiving medication
improperly. Denial of access to appropriate medical care.
Indicators of Physical Abuse:
Visible signs include: Bruising, finger marks burns, cuts and bruises found at different
stages of healing, malnutrition. Bed sores, ulcers and being left in wet clothing
Other indicators include: Excessive requests for repeat prescriptions or under use of
prescribed medicines. Reluctance to seek help from GP or other services. History of
agency or GP hopping.
Financial or Material Abuse
The misuse, deprivation, extortion or denying the right of a person to their money, property,
possessions, pensions, allowances or insurance. Denying the right of a competent person
to handle their own financial affairs.
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Indicators of Financial Abuse:
Unexplained or sudden inability to pay bill unexplained withdrawals from accounts,
pressure by carers or family to sign over assets.
Sexual Abuse
Sexual harassment, involvement of a person in a sexual activity against his or her will, to
which he or she has not given consent.
Indicators of Sexual Abuse:
A change in the individual’s behaviour, withdrawal and isolation, overt sexual behaviour,
self inflicted injury, disturbed sleep pattern, difficulty in walking or standing, torn stained or
bloody undergarments, love bites, bleeding torn rectal and vaginal area.
Psychological Abuse
The inappropriate exercise of power to violate the human or civil rights of a person. Making
a person feel ashamed of involuntary behaviour. Blaming a person for attitudes, actions or
events beyond their control. Making behaviour, attainment or physical appearance a target
for ridicule. Intimidation of a person by name calling, threats, continued shouting or the use
of abusive language. Racist comments. Depravation of normal, social contact and cultural
identity. Racial or religious harassment, lack of provision to dress, diet, language or
specific religious observances relating to a person’s background or culture. Withdrawal
from normal social interaction or exposure to excessive or inappropriate stimuli.
Psychological Abuse Indicators:
Insomnia or need for excessive sleep. Isolation and withdrawal, Carer always being present
during an interview or conversation.
Individual features: Very eager to please and appear to be subservient, change in appetite,
unusual weight gain or loss, tearfulness, paranoia, low self-esteem, excessive fears,
ambivalence, confusion, resignation, agitation, inappropriately dressed unkempt and
unwashed.
Neglect or Acts of Omission
A vulnerable person may suffer abuse by acts of omission this is when the act of neglect or
omission leads to deterioration in their well-being or development is impaired as a result
of the abuse, examples of neglect and acts of omission are: -
Lack of:
• adequate food or liquids,
• heating and lighting
• appropriate medical care
Being allowed to take unwanted / unreasonable risks
Lack of attention to:
• toe and fingernails
• teeth natural or false
Indicators of Neglect or Acts of Omission
• Inadequate food, fluids, heating, lighting.
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• Poor physical condition, poor hygiene, varicose ulcers, pressure sores.
• Clothing dirty or in a poor condition
• Failure to seek medical advice or summons assistance as required.
• Failure to access dentistry, chiropody services etc.
• Refusal to allow access to appropriate callers or visitors.
Discriminatory Abuse
Inappropriate treatment of a vulnerable adult because of their race, colour, sex (or
sexuality), disability etc. these can include: racist remarks, sexist remarks, comments about
disability, other forms of harassment, slurs or similar treatment, depravation of normal
social contact and cultural identity.
Indicators of Discriminatory Abuse
Inappropriate remarks or comments poor quality care to certain types of Service Users,
Service User prefers not to be cared for by certain members of staff, staff members may
seem to avoid caring for certain groups of Service Users.
Institutional Abuse
The inappropriate care of a vulnerable adult in an institutional situation (residential home)
the following factors may be relevant: poor management of staff, poor care standards, lack
of positive response to complex needs, rigid routines, inadequate staffing, and insufficient
knowledge base within the service.
Indicators of Institutional abuse
The vulnerable adult, in an institutional setting displays any of the indicators mentioned in
all forms of abuse described above.
Mental Capacity Act 2005
The statutory principle aim of the Mental Capacity Act of 2005 is to protect people who lack
capacity and to help them take part, as much as possible in decisions that affect them.
Every adult (anyone over 18 years of age) has the right to make their own decisions if they
have the capacity to do so. As care and support workers we must assume that all of our
service has the capacity to make decisions, a wrong or bad decision made should not be an
indication that the person is not able to make their own decisions. The starting assumption
must always be that an individual has the capacity, until there is proof that they do not.
We have a legal duty to assist and empower all of our service users to make their own
decisions regarding choices, wishes, preferences or any decision that affect them.
In some circumstances it will be necessary to appoint an independent advocate for
someone who lacks capacity, the circumstances and procedure appointing an advocate are
detailed in the Mental Capacity Act Policy. Copies of the Act and the code of practice can
be obtained from the manager’s office; further information and advice can also be obtained
from your manager.
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How Does the MCA Define Restraint?
The law says that someone is using restraint if they:
• Use force – or threaten to use force – to make someone do something that they are
resisting, or
• Restrict a person’s freedom of movement, whether they are resisting or not.
It’s that second part that sometimes isn’t recognised. People who lack mental capacity to
make the decision to go out, for example, are very often restrained – in that their freedom of
movement is restricted, for example by a locked front door or garden gate. It is important to
understand that this is a restraint. But it isn’t true that this restraint is always wrong: if you
think the restraint is completely in someone’s best interests.
When an adult lacks mental capacity to give you consent for your actions, then anything
you do to that person, or on their behalf, must be in their best interests, and the least
restrictive of their rights that can be identified.
Extra Conditions for Restraint
Already we know that providers must always look for the ‘least restrictive option’: this is the
golden thread of the MCA, that we must never restrict people’s freedom to live as they
choose, with more than the lightest possible touch.
And we know that we get protection from liability, when someone lacks capacity to consent,
by being clear that we are making the decisions within the principles of the MCA.
The MCA explains what this means when we think we might have to restrain someone, in
their best interests. Alongside the rest of the best interest’s checklist, there are two extra
conditions that must be met for this restraint to be lawful – hence, for you to have protection
from liability.
These extra conditions are:
• The person taking action must reasonably believe that restraint is necessary to
prevent harm to the person who lacks capacity; and
• The amount or type of restraint used, and the amount of time it lasts, must be
a proportionate response to the likelihood and seriousness of that harm.
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Recruitment
Prior to commencement of employment all new employees will undergo a DBS check, if in
on receipt of the DBS check offences are recorded this will discussed with the company
care manager and company director who will their discretion to decide if the applicant can
be employed by the company. In addition, successful applicants will be checked against the
ISA Barring list. Anyone found to be included on the lists will not be employment by the
company.
Abuse Reporting Procedure
It is the expressed wish of the company that no person for whom it has a duty of care will
suffer any type of abuse at any time whatsoever. Therefore, any form of abuse made
against another person should be brought to the attention of the company management
immediately. If the circumstances are difficult to report you should refer to the company
"Whistle Blowing Policy", however, an incident of abuse must not remain unreported.
Following any allegation of abuse the company will immediately report the incident to the
lead body (Lancashire County Council Social Services) who will investigate the allegation,
further to this the company will also inform the Care Quality Commission of the allegation
immediately. Prior to undertaking work from a local authority the company will endeavour to
make available that authorities "Adult and Child Protections Procedures” available to all
care staff for their information.
If you suspect or witness any form of abuse you should inform your line manager, the
registered manager of the John Lee (Company Director) 01253 889982
If you feel it is not appropriate to report the company, then you can report to one of the
following authorities
Telephone: 03000 616161
Care Quality Commission
National Correspondence
Citygate, Gallowgate
Newcastle upon Tyne
NE1 4PA
or
Lancashire County Council Safeguarding Adults
Telephone number on 0300 123 6721
or visit online at www.lancashire.gov.uk/safeguardingadults
Abuse is a disciplinary offence, those found guilty of abuse will be subject
to summary dismissal, and furthermore, some forms of abuse may also be
a criminal offence and will also be investigated by the appropriate
authority for their action.
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Body Map Instructions (for recording evidence of abuse) Name of person completing form ………………
Date completed ………………………………….
In suspected cases of abuse please use gender specific body map marking accordingly Service user ID …………………………………...
to indicate where you have witnessed any bruising, scars, injuries, red marks etc. Give
as much detail as to size, colour and so on. Only complete if these injuries are clearly
visible during the course of your duty or have been shown to you freely.
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Reporting an Allegation of Abuse Flow Chart
Are you a Member of staff or a Service user?
Member of Staff Service User
Immediately You can choose several Immediately inform your
inform your line ways to report the alleged carer or contact the
manger abuse company Registered
manager
If line manager is If the company If the company is
party to abuse is complicit to complicit to the Julia Stockdale
Immediately the abuse abuse or, if you 01253 899982
contact company or, if you choose not to
Director J Lee by choose not to report to the If manager or staff are
telephone report to the company then party to the abuse
01253 899982 company then contact: Contact company
contact: Director by telephone
If the company is Commission for
complicit to Safeguarding Quality Care 01253 899982
abuse Adults
Contact telephone Telephone: Company Director John Lee
Safeguarding number on 03000 616161 who will establish details
Adults telephone 0300 123 6721 gather information on your
number on 0300 behalf and report to
123 6721
Safeguarding Adults
telephone number on 0300
123 6721
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Stage Activity Responsibility Timescale
• Everyone with a duty of
Stage 1 • Act to protect adult at risk Immediately, if emergency
• Deal with immediate care or within same working day
Raising an alert (this should be within four
needs hours)
• Report to registered
manager 01253 899982
• Consider reporting to the
police, if a crime
• Record
Decision • Take any immediate • Alerting manager
management action to Safeguarding Adults
identify and address the lead Member of staff if Immediately or within 24
risk appropriate hours
• Decide if a referral is
needed
Stage 2 • Refer to Safeguarding • Adult at risk (carer, Immediately or within 24
Adults referral point 0300 friend, relative) hours
Making a referral 123 6721 Registered Manager
• Report to the police, if a • Director
crime • Safeguarding Adults
• Notify CQC lead
• Gather initial information • Other professionals
• Any company staff
Clarify facts
Decision • Evaluate risk • Director
• Decide if Safeguarding • registered manager
• relevant partner Within 24 hours of referral
Adults procedures apply
• Agree interim protection organisations
plan
• (Police investigation may
have begun)
Stage 3 Strategy • Evaluate risk
discussion or • Director The same day or within five
meeting • Registered manager working days from receipt
• Relevant partner of the Safeguarding Adults
referral
organisations
• Adult at risk as
appropriate
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Stage Activity Responsibility Timescale
Decision
• Decide if • Director
investigation needed • Registered manager
• Agree investigation • Relevant partner
plan
• If not Safeguarding organisations
Adults agree appropriate • Adult at risk as
action
• If not Safeguarding appropriate
Adults close process at
this point
Stage 4 • Conduct investigation • Director Within 20 days from receipt
• Re-evaluate risk • Registered manage of referral
Investigation • Collate evidence and • Relevant partner
share with involved organisations
organisations
• Produce and distribute
Report
Stage 5 • Receive investigation • Director Within five working days
evidence • Registered manage from receipt/distribution of
Case conference • Relevant partner the safeguarding
and protection plan • Evaluate risk investigation report (or as
• Formulate protection organisations agreed at strategy
Decision • Adult at risk/family/ discussion or meeting)
plan
Stage 6 • Close Safeguarding advocate
Review of the Adults process • Director Within three months of
protection plan • Keep under review • Registered manage case conference or as
• Relevant partner agreed at case conference
• Agree outcome
• Agree review organisations
• Adult at risk/family/
• Review the protection
plan advocate
• Evaluate risk
Stage 7 • Complete Safeguarding Signed off by Registered On agreement with other
Adults process Manager /Director organisations and adult at
Closing the risk
Safeguarding Adults • Sign off Safeguarding
Adults process
process
• Review process continues
• Dissemination of lessons
learnt
• Process may also be
closed pending outcome
of prosecution
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Safeguarding Incident Report Sheet
Name, Name ……………………………………………………………..
address and
contact Address …………………………………………………………..
number of …………………………………………………………..
person
reporting Contact Tel Number ……………………………………………..
incident
Nature and
details of
alleged
incident
Date & Time Date …../…../….. Time ………………..
of alleged
incident
The place
incident was
alleged to
have taken
place
Details of Name ……………………………………………………………..
the allegedly Address …………………………………………………………..
abused
person …………………………………………………………..
Contact Tel Number ……………………………………………..
Was the alleged person a Service User (please tick ✓ box)
Was the alleged person a member of staff (please tick ✓ box)
Name and Name ……………………………………………………………..
details of the Address …………………………………………………………..
alleged
perpetrator if …………………………………………………………..
known
Contact Tel Number ……………………………………………..
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Reporting Name of person reported to …………………………………………….
details Date and time reported date …. /…../……. Time ………………….
Permissions I the undersigned give my permission to the following person/s to have
access to details of the above allegation of abuse directed against me.
Print Name …………………. Signature ………………….. Date ………..
Immediate Action
Action taken
to minimise
risk
Implemented by:
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Duty of Candour Policy & Procedure
Regulation 20 has been introduced under the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 (Part 3). This regulation defines what constitutes a notifiable
safety incident in adult services. This applies to providers when they are providing care and
support to people who use the service in the carrying on of a regulated activity.
To comply with the requirements of regulation 20 it is the policy of the company and
the responsibility of the registered manager to:
Act in an open and transparent way with those who use the services in carrying on a
regulated activity (providing personal care)
Notify the relevant person as reasonably practicable after becoming aware that a
notifiable incident has occurred, and provide support to them in relation to the
incident, including when giving notification.
Provide an account of the incident which, to the best of our knowledge. is true of all
the facts about the incident as at the date of the notification
Advise the relevant person what further action we believe is appropriate and intend
to take.
Offer an apology
Follow up the apology by giving the same information in writing, and providing an
update on the enquiries made following the event.
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Keep a written record of all communication with the relevant person
By acting in this way we aim to encourage a culture of openness and transparency in our
services. We will make all reasonable efforts to foster a culture that supports staff to be
open and transparent in the course of their work. We will take disciplinary action against
any employee who attempts to conceal reportable incidents through bullying tactics or the
use of threatening behaviour to conceal reportable incidents.
For the benefit of doubt, a ‘notifiable safety incident’ is any unintended or unexpected
incident that occurred in respect of a service user during the provision of a regulated activity
that, in the reasonable opinion of an adult care professional, appears to have resulted in:
The death of the service user, where the death relates directly to the incident rather
than to the natural course of the service user’s illness or underlying condition.
An impairment of the sensory, motor or intellectual functions of the service user
which has lasted, or is likely to last, for a period of 28 days.
Changes to the structure of a service user’s body.
the service user experiencing prolonged pain or prolonged physical harm lasting for
a continuous for a period of 28 days
the shortening of the life expectancy of the service user.
any injury to the service user which, if left untreated, would lead to one or more of
the outcomes mentioned in the paragraph above.
The responsibility for reporting notifiable safety incidents to CQC lies with the registered
manager or the registered provider.
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Independent Mental Capacity Advocates Policy
1. Policy statement
The Mental Capacity Act 2005 provides a statutory framework to empower and protect
vulnerable people who are not able to make their own decisions. It makes it clear who can
take decisions, in which situations, and how they should go about this. It also provides
options for those who may choose to plan and make provision for a future time when they
may lack capacity. Furthermore, the Act also specifies the principles that must be applied
by everyone who is working with or caring for adults who lack capacity. It is the Policy of the
company to work within the statutory framework of the act and follow the guidelines as set
out in the code of practice. The company will provide all staff working with vulnerable
people sufficient information and guidance to empower those they care for to make their
own decisions and where assistance is required this will be done within the framework of
the act.
The whole Act is underpinned by a set of five key principles:
a. A presumption of capacity - every adult has the right to make his or her own
decisions and must be assumed to have capacity to do so unless it is proved
otherwise;
b. The right for individuals to be supported to make their own decisions - people must
be given all appropriate help before anyone concludes that they cannot make their
own decisions;
c. That individuals must retain the right to make what might be seen as eccentric or
unwise decisions;
d. Best interests – anything done for or on behalf of people without capacity must be in
their best interests; and
e. Least restrictive intervention – anything done for or on behalf of people without
capacity should be the least restrictive of their basic rights and freedoms.
What does the Act do?
Whilst the Act sets out the legal framework, the Code of Practice provides guidance and
information for those acting under its terms and applying its provisions on a daily basis. A
copy of the Act and the Code of Practice is available from your manager and the company
will provide further information and training.
As there are many situations that can arise when caring or supporting for those who may
lack capacity, the Code incorporates good practice along with flexibility to apply the
principles to the particular circumstances of the situation.
A significant number of people suffer a degree of mental impairment, for a range of different
reasons, and therefore may lack capacity to take some decisions about the care they
receive at key stages in their lives, such as a change of accommodation or the need for
serious medical treatment. As a provider of care and support services there maybe
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circumstances where we have a duty to provide suitable independent specialist advocates
for people who lack mental capacity. These advocates must be able to identify as far as
possible the service user’s views and preferences, and present them to those responsible
for providing care and support.
An Independent Mental Capacity Advocate (IMCA) is someone appointed to support and
represent a person who lacks capacity, possibly because of dementia, a learning disability
or mental health needs, when they are faced with major decisions about their health and
social care but have no family or friends to represent them.
2. Purpose
This policy explains the circumstances in which an Independent Mental Capacity Advocate
must or may be provided, the process for referring and appointing one, their responsibilities
and our duty as a provider of care and support.
3. Scope
This policy applies to all staff who are involved in working with people with a mental
impairment who are eligible for the support of an Independent Mental Capacity Advocate.
4. Legal context
The role of Independent Mental Capacity Advocate (IMCA) was introduced in the Mental
Capacity Act 2005, with associated Regulations (2006) and Code of Practice, and
additional Regulations (Expansion of Role) 2006. The Act lays down the criteria for
assessing a lack of capacity and the situations in which an IMCA must or may be provided.
5. Mandatory Procedures
Circumstances in which an IMCA may be required:
The purpose of the IMCA role is to provide representation and support for particularly
vulnerable people who lack capacity and are facing important decisions about certain
serious, potentially life-changing situations.
The commissioners (this could be the local authority Social Services, the NHS trust or we
as private providers of care and support) have a statutory duty to provide independent
advocates for individual service users who meet the eligibility criteria in circumstances
where a decision needs to be made concerning a change of accommodation.
This may be a move for the first time from the community or hospital into residential
accommodation, or where a change of accommodation is being considered. It may be as a
result of changing care needs or a change in the current provision.
The duty is triggered when the proposed move in question is:
To or between hospitals for a period likely to exceed 28 days
To or between their home to care homes for a period likely to exceed eight
weeks.
If the placement is initially estimated to be for less than this period but later
needs to be extended, an IMCA should be appointed as soon as this
becomes clear.
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There is a similar duty where serious medical treatment may be provided, withdrawn or
withheld. The criteria for ‘serious medical treatment’ are:
there is a fine balance between the benefits and the risks
the choice between treatments is finely balanced
what is proposed would be likely to involve serious consequences for the patient.
The only situation in which the duty to seek advice from an IMCA could be dispensed with
is where the proposed treatment needs to be provided as a matter of urgency, for example
to save the person’s life or prevent a serious deterioration in his/her condition.
As the care provider we have the power to appoint an advocate in Adult Protection
procedures, where protective measures are being put in place and the person concerned
lacks capacity. Where these criteria are met, there is a duty to consider the provision of an
advocate. In addition, as the care provider we may refer a service user to an advocate for a
care review if the service user has lost capacity, and there is no one else appropriate to
consult.
6. Eligibility
In order to qualify for representation by an advocate (IMCA) the service user concerned
must:
a) be assessed as lacking capacity according to the criteria laid down in the Mental
Capacity Act 2005, in relation to the specific decision being considered
b) The service user will lack support, in that they will have no one who can help them
communicate their wishes or be consulted about their best interests other than
professional health or care staff who may be providing services to them.
Anyone not meeting these criteria should be referred to an alternative advocacy provider.
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Every adult has the right to
make his or her decisions, and
must be assumed to have
capacity
41
7. Attorneys, family and friends, existing advocates
In the following circumstances the individual would not be eligible for the provision of an
IMCA:
• Where a person who now lacks capacity in relation to a particular matter has
previously expressed a wish that a named person should be consulted in matters
affecting his/her interests, and that person is available and willing to be consulted
• Where there is an attorney appointed under a Lasting Power of Attorney
• Where there is an attorney appointed under an Enduring Power of Attorney, and
the attorney continues to manage the person’s affairs;
• Where a welfare deputy has been appointed by the Court of Protection
• There may be circumstances where family members or friends who would
normally be consulted are not appropriate. The reasons for this may be distance,
a lack of contact, their own ill-health or mental frailty, an unwillingness to be
consulted, or concerns about the safeguarding of the service user’s best
interests; an IMCA may therefore be appointed.
Where the person who lacks capacity and already has an independent
advocate they may still be entitled to an IMCA, in the following situations:
• where the person who lacks capacity has an independent advocate acting under
restrictions as to the areas where s/he is to be involved (which may include a
Mental Health advocate) and the person is now unable to give instructions. An
IMCA should be appointed, and should consult and work with the independent
advocate in supporting the person, particularly in ascertaining the person’s
wishes and feelings
• If an IMCA has already been appointed and the service user subsequently
becomes subject to the Mental Health Act, it may be appropriate for a Mental
Health Advocate to be appointed in addition. The two advocates would be
expected to work together, using their respective knowledge and skills to
represent the service user’s best interests.
• Where the person has previously appointed an independent advocate
him/herself, and has indicated that s/he wishes the independent advocate to be
consulted on all affairs and decisions which the person concerned lacks capacity
to make, the person lacking capacity would not be entitled to an IMCA. If however
that advocate is unable or unwilling to proceed in the changed circumstances, an
IMCA may be appointed.
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8. Referral to the Advocacy Service (N-COMPASS)
In any situation where a service user is known or believed to lack relevant capacity and a
decision is required where an IMCA may be involved, the decision maker should assess the
individual’s capacity according to the Mental Capacity Act guidance in relation to that
decision. The staff responsible for decision-making may include doctors, nurses, social
workers, care managers and domiciliary care providers.
When the decision maker has identified the need for an IMCA, they will confirm this with
their line manager and then contact:
N-Compass Advocacy Service
Wyre and Fylde
3 Errigal House
Avroe Crescent
Blackpool Business Park
Blackpool
FY4 2DP
Telephone 01253 362140
Referral should be made by telephone to the above number. This will avoid the potential for
breaches of confidentiality while allowing the sharing of appropriate detail.
The initial information required by the Advocacy Service will include:
Details of the service user
Confirmation of lack of capacity
Preferred communication methods
Brief background to the current situation
Timescale for the decision-making process
Indication of any family, friends or other people who may need to be
consulted.
43
9. Role and responsibilities of the referring staff member
a) A record will be made of the decision to appoint an IMCA and the people involved in
that decision.
b) The referring staff member will arrange preliminary contact with the Locality Manager
of the IMCA service or the designated IMCA, to confirm the basic arrangements and
give more detailed information.
c) In future correspondence case number will be used together with reference number
provided by the Advocacy Service to identify the service user concerned.
d) They will also confirm arrangements for a first meeting with the service user, at
which they or another staff member currently involved in the service user’s care, will
also initially be present.
e) Beyond these initial introductions, the IMCA and the service user will be assured of
privacy for their meetings.
f) They will ensure that the IMCA has access to all relevant information and practical
support which may assist them in working with the service user, in line with the
specific protocol between all parties regarding confidentiality.
g) They will facilitate contact between the IMCA and any other relevant individuals or
agencies.
h) They will maintain contact with the IMCA throughout the process and record any
problems and their resolution
i) They will discuss the final report with the IMCA and give it due weight when deciding
on a course of action.
10. Role and responsibilities of the Advocacy Service (N-Compass)
The Advocacy Agency must work in partnership with other agencies, both statutory,
independent and voluntary, assisting those who are likely to refer their service users to
understand the role of the Independent Mental Capacity Advocate and how and when to
access the service.
They must ensure that all IMCAs are suitably trained for the role, and have been CRB
checked as part of their duty in the protection of vulnerable people.
11. Role and responsibilities of the IMCA
44
An IMCA must not have any professional or paid involvement with the provision of care or
treatment for any vulnerable person for whom they may be appointed to act, and they must
be completely independent of the person responsible for making the decision or carrying
out the act in question.
The principal responsibilities of the IMCA include:
Representing and supporting the person who lacks capacity, so that the person may
participate as far as possible in any relevant decision
Obtaining and evaluating information
As far as possible, ascertaining the person’s wishes and feelings, beliefs and values,
or what these would be likely to be
Ascertaining alternative courses of action – for example, looking at different care
arrangements.
Obtaining a further medical opinion, if necessary;
Investigating the particular circumstances of the vulnerable person
Considering whether the principles set out in section 1 of the Mental Capacity Act
have been complied with
Considering the factors relevant to the service user’s best interests
The IMCA will respect the general principles of confidentiality, and in addition will abide by
the specific protocol between the company and the provider. They have the right to
examine, and take copies of, any records (such as clinical records, care plans or social care
assessment documents) which the person holding the record considers are relevant to the
IMCA’s investigation.
The IMCA will consult relevant people and records and meet with the service user as
required in order to make their assessment. They will keep in contact with the decision
maker throughout the process, to update them on progress or to report any problems. They
will present a report in the required format by the agreed date, which may be altered by
mutual agreement if particular difficulties occur. The IMCA may seek additional support, for
example if there are communication difficulties the company will assist in locating and
providing this.
11. Reports
The IMCA’s report will include the following, identified by an IMCA unique number:
• Summary of the decision required
• Summary of contact with the service user (dates, time spent etc)
• Summary of contacts with other people, as above
• Principal points arising from the contacts
• Recommendation based on this.
45
12. Disagreements
If the decision maker opts for action which is different from the one recommended by the
IMCA, the IMCA has the right to challenge this on behalf of the service user.
If the situation is not easily resolved, the IMCA may use the company’s complaints
procedure as someone having an interest in the service user’s welfare.
13. Complaints
If in the course of their assessment the IMCA comes across practice or conditions which
they believe to be unacceptable, they may use the Company’s complaints procedure.
If anyone involved with the process has a complaint about the IMCA or the Advocacy
Service, they should use the Advocacy Service’s complaints procedure.
14. Practice guidance
When assessing the capacity of service users to reach decisions on aspects of their
care staff should work to guidance based on the Mental Capacity Act 2005 and the code
of Practice. Copies of both of these documents are available and assistance is available
from your manager.
IMCAs will not be expected to assess capacity themselves but will need to have access
to records of any assessments of capacity, including the date of assessment and the
name and role of the person who carried out the assessment.
An IMCA may request a new assessment if they feel the service user’s level of capacity
has significantly altered since the most recent assessment.
15. Code of Practice
The IMCA should ascertain, as far as possible, the past and present wishes and feelings of
the person concerned, any beliefs and values that may influence the decision in question,
and the factors which the person would consider if able to do so. This is likely to involve
observation and communication with the person themselves, although there may be cases
where the person is unable to communicate at all, for example where they are unconscious.
It may also include talking to other professionals or paid carers directly involved in providing
care or treatment for the vulnerable person and examining health and social care records
and any written statements of preferences. Detailed guidance on ways of ascertaining the
past and present views of people lacking capacity is given in chapter 4 of the Code. Further
guidance on helping someone to make his/her own decisions, communication techniques
and choosing the best time and location is given in chapter 3 of the Code.
16. Advance directives and DNAR
If an IMCA engaged in relation to a decision regarding medical treatment discovers an
advance directive made by the service user, they must try to confirm its date and whether
any later directive exists, made while the service user had capacity. Similarly, if they
become aware of a ‘Do not attempt to resuscitate’ order (DNAR) they must check the
validity of the order with medical staff and the relevant Trust policy.
46
17. Security and confidentiality
Given the particularly sensitive nature of the information that will be gathered, reviewed,
and exchanged in the course of reaching a decision, confidentiality must be maintained by
all staff concerned. However, confidentiality must not be used as means to deny information
available, particularly in relation to relevant information about third parties.
18.The Deprivation of Liberty Safeguards (DOLS)
The Deprivation of Liberty Safeguards (DOLS) became is part of The Mental Capacity Act
2005 from April 2009. The Mental Capacity Act as previously explained is what the law says
should happen when people cannot make some decisions for themselves, this is called
lacking capacity.
DOLS are intended to ensure that confidentiality must be maintained
people receiving treatment and by all staff
support have as much liberty as
possible and as a care provider we
have duty to ensure that this is true
for everyone we support.,
Furthermore, we also have a legal
responsibility for operating and
overseeing the DOLS and for
applying to our local authority (LCC
Social Services) for a Deprivation of
Liberty Authorisation if it is required.
The person responsible for making
an application is the Responsible
registered person who is the
Company Director John Lee
DOLS is about protective care, they
are not about giving health and
social care professional’s arbitrary
powers of detention. Quite the
opposite: they put in place legal
safeguards to ensure that people are
not deprived of their liberty in
hospital or care home settings
unless it is absolutely necessary to
do so.
It is the responsibility of managers to
ensure training is provided to staff
and information is provided, in an
appropriate manner, to those in our care and their families. Staff have a duty to familiarise
themselves with this MCA/DOLS legislation and to share any relevant information and
cooperate with other professionals when legally required to do so.
DOLS are to be used as a last resort they are not to be used as a form of punishment, or
for the convenience of professionals, carers, or anyone else.
47
Valuing People Plan
As a provider of services to people with learning difficulties All about you care Services
Limited is committed to delivering high quality services that encompass the four key
principles and the objectives of Valuing People (A New Strategy for Learning Disability for
the 21st Century) white Paper.
By implementing these principles and objectives we aim to ensure that all of those we
support are valued and recognised as an individual’s, are given fair access and have the
opportunity to play their full part in society. We will work to ensure the people we support
have are directed to and given access to health and medical facilities, social activities and
all those things associated with everyday living.
Through Person Centre Planning we will put those who are receiving our support at the
centre of their services and provide them with information and assistance to enable them to
take control of their own lives and to make choices about all of the things that affect their
everyday lives. To further provide full and active lives we will endeavour to seek out and
provide new opportunities in social, recreational and work-based activities.
We will at all times endeavour to protect all of those we support from being pushed to the
margins of our society and ensure they are protected from prejudice, bullying and
harassment, insensitive treatment and discrimination.
In order to achieve all the above outcomes, we will continue to develop all of our
established skills, knowledge and activities, these include:
Staff training and development
Management training and development
Communication and participation with other professionals i.e. Partnership board,
Health service, local authorities, voluntary organisations and families.
Ensure existing Safeguarding policies and procedures are understood by all within
the organisation and practiced as routine.
Ensure the principles of capacity are practiced throughout the organisation.
Continue to develop Person Centred Planning.
Promote employment opportunities.
Provide assistance to access benefits including housing.
Assist with access to Advocacy services whenever required.
Annual review of Policies and procedures
It is the responsibility of the company Director to ensure information and resources are
made available to implement this plan, it is the responsibility of the Learning Disability
Manager to implement the plan. All staff will be made aware of their responsibilities through
training.
48
In order to ensure we all are aware and fully understand the key principles and objectives of
the White Paper they are detailed below, objectives 1 and 2 do not presently apply to the
our services:
Four Key Principles of Valuing People
Choice: Like other people, people with learning disabilities want a real say in where they
live, what work they should do and who looks after them. But for too many people with
learning disabilities, these are currently unattainable goals. We believe that everyone
should be able to make choices. This includes people with severe and profound disabilities
who, with the right help and support, can make important choices and express preferences
about their day to day lives.
Inclusion: Being part of the mainstream is something most of us take for granted. We go to
work, look after our families, visit our GP, use transport, and go to the swimming pool or
cinema. Inclusion means enabling people with learning disabilities to do those ordinary
things make use of mainstream services and be fully included in the local community.
Legal and Civil Rights: The Government is committed to enforceable civil rights for
disabled people in order to eradicate discrimination in society. People with learning
disabilities have the right to a decent education, to grow up to vote, to marry and have a
family, and to express their opinions, with help and support to do so where necessary. The
Government is committed to providing comprehensive guidance for electoral administrators
on helping disabled people, including those with learning disabilities, through the whole
electoral process – from registering to vote until polling day itself. All public services will
treat people with learning disabilities as individuals with respect for their dignity, and
challenge discrimination on all grounds including disability. People with learning disabilities
will also receive the full
protection of the law
when necessary.
Independence:
Promoting independence
is a key aim for the
Government’s
modernisation agenda.
Nowhere is it of greater
importance than for
people with learning
disabilities. While
people’s individual needs
will differ, the starting
presumption should be
one of independence,
rather than dependence,
with public services
providing the support
needed to maximise this.
Independence in this
context does not mean
49
doing everything unaided.
50
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