Awareness Raising on the Adult Support and Protection (Scotland)

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Awareness Raising on the Adult Support and Protection (Scotland) Act 2007

Aims To recognise and acknowledge the shared responsibility for promoting a safer service To raise awareness and understanding of adults who may be at risk of harm To enable staff members to respond appropriately to concerns

Objectives Having completed the programme participants will: Understand the terms ‘adult at risk’ and ‘harm’ Be aware of the types of harm to which adults may be at risk and the situations in which harm may occur Know what principles should be followed and how to deal with some of the dilemmas around the issue Be able to recognise signs and symptoms which may indicate that an adult is being harmed Know who to go to and what to do if there are concerns about an adult Know how to record key information Be aware of relevant organisational procedures and policies

Let’s Agree Some Ground Rules: Think about the kinds of things that would make you feel at ease in this group Think about what you would not like to see happen in this group

Let’s Agree Some Ground Rules: to speak your mind to contribute to respect other people’s contributions one singer one song to keep what we say here confidential to switch off mobile phones don’t use jargon

Working Ground Rules We all share responsibility for learning We need to recognise that we will be discussing emotional and difficult issues. We need to acknowledge differences of experience and knowledge Everybody’s contribution is valuable and will be respected If we disagree or need to challenge another’s opinion we will endeavour to do it with good grace

Working Ground Rules Confidentiality is complex – if the trainer hears that an adult is at risk he/she will need to discuss with you how to protect them Some of us may have our own experiences of harm. We need to remember this as a group If the training raises personal issues and you would like to speak to someone please speak to the trainer or email them in confidence Awareness brings hindsight! We may have missed harm in the past, but we did not know then what we know now. We can now move forward with new knowledge

Being Safe and Secure What Adults Say Being respected as an individual Being able to ask questions and having them answered without being patronised or bamboozled Not using my first name but addressing me by my title and surname if that’s what I choose Having my friends visit when I want them to Having choice over what I eat Privacy when bathing, washing or going to the toilet Following my religious beliefs Ref: Health Care Commission 2004,

Definition Who is an adult ‘at risk’? The Adult Support and Protection (Scotland) Act 2007 defines Adults at Risk, through a 3-Point Test as adults aged 16 years or over, who: 1. are unable to safeguard their own well-being, property, rights or other interests 2. are at risk of harm; and 3. because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected

The Overarching Principle “any intervention in an individual's affairs should provide benefit to the individual, and should be the least restrictive option of those that are available.”

Guiding Principles The following guiding principles must be taken into account when any parts of the Act are put into place. These are: the wishes and feelings of the adult at risk (past and present); the views of other significant individuals, such as the adult's nearest relative; their primary carer, guardian, or attorney; or any other person with an interest in the adult's well-being or property the importance of the adult taking an active part in the performance of the function under the Act

Guiding Principles The following guiding principles must be taken into account when any parts of the Act are put into place. These are: providing the adult with the relevant information and support to enable them to participate as fully as possible the importance of ensuring that the adult is not treated less favourably than another adult in a comparable situation; and the adult's abilities, background and characteristics (including their age, sex, sexual orientation, religious persuasion, philosophical belief, racial origin, ethnic group and cultural and linguistic heritage)

Who Might be an Adult at Risk? May include individuals who: live in shared accommodation settings and may have little or no sense of privacy are unaware of their rights and who are not confident enough to complain when something happens which they do not like or who don’t know how to complain may have mental or physical impairments may have limited life experience are socially isolated

Who Might be an Adult at Risk? May include individuals who: have communication difficulties and may find it difficult to make their views or concerns known have learning disabilities have alcohol or drug misuse have little or no sex and personal relationship education and awareness have a poor or limited understanding of personal risk and safety

Who Might be an Adult at Risk? May include individuals who: have a history or pattern of family violence have low self esteem do not understand certain decisions or transactions have experienced discrimination on the grounds of their age, race or ethnicity, sexual orientation, gender, religion or belief or disability have limited access to health care have limited access to statutory agencies such as social services or criminal justice professionals are dependent on other people for personal and basic care needs

Definition of Harm The Adult Support and Protection (Scotland) Act 2007 says: “harm” includes all harmful conduct and, in particular, includes: a) b) c) d) conduct which causes physical harm; conduct which causes psychological harm (e.g. by causing fear, alarm or distress) unlawful conduct which appropriates or adversely affects property, rights or interests (e.g. theft, fraud, embezzlement or extortion) conduct which causes self-harm N.B - “conduct” includes neglect and other failures to act, which includes actions which are not planned or deliberate, but have harmful consequences

Definition of Harm “For the purposes of the Act, 'harm' includes all harmful conduct and, in particular, includes: conduct which causes physical harm conduct which causes psychological harm (e.g. by causing fear, alarm or distress) unlawful conduct which appropriates or adversely affects property, rights or interests (e.g. theft, fraud, embezzlement or extortion); and conduct which causes self-harm.”

Risk Refers to a situation or behaviours which present a real or potential threat of harm to a person’s health, development, safety or well being

Categories of Harm Sexual Harm Neglect Physical Psychological/emotional Institutional Verbal Finance or Material Discriminatory Self Harm

Harm Type Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People - National Centre for Social Research, King’s College London - June 2007 Note: The prevalence estimates are almost certainly lower than the actual level of mistreatment More men (5.2%) than women (3.6%) in Scotland – different from other UK countries

Who may Potentially be Perpetrators of Harm: Family members – partners, husbands, wives, sons, daughters and ex-partners Professional and paid carers – managers, front line staff Social care staff Medical or health professionals Volunteers Neighbours

Who may Potentially be Perpetrators of Harm: Friends and acquaintances Visitors Other users of services, residents and those at risk People who deliberately exploit vulnerable people and those at risk Strangers Anyone!

Harm Source Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People National Centre for Social Research, King’s College London - June 2007 Note: Respondents could mention more than one person

Some Research has Indicated that there is an Increased Risk or Possibility of Harm Occurring if the Carer: Has mental illness Has drug /or alcohol misuse Has a past history of offending Is financially dependent on users of service Is socially isolated Suffers from external stress – mainly associated with house sharing and work But anyone can end up harming!

Where Harm may Take Place? An individual’s home Care homes Day centres College Public transport Hospital The community A fellow residents room or friend’s house Anywhere!

Where Harm may Take Place? Answer (UK Figs)– percentage of the survey population: Source: Audit of calls to the AEA help line House of Commons Health Committee. Elder Abuse. Session 2003–04

What Makes Harm More Likely? Families where there is a culture of violence High levels of personal care needs or physical needs – moving and handling, toileting, dressing etc Family dynamics Loss of familial relationships Being in a minority There are several people who need care in the family Over protection Families where there are other issues, mental illness, addiction, misuse of drugs Where the cared for individual manifests behaviour which is challenging The natural and main communication partner is no longer around Where there are poor care practices in organisations

Sexual Harm Inappropriate sexual contact, touching, kissing Sexual assault, rape, non consensual contact, sexualised conversation/comments Indecent exposure Being made to listen to or watch pornography without consent Voyeurism

Indicators of Adult Sexual Harm Include: Significant changes in sexual behaviour, language or outlook Pregnancy in a woman who is unable (legally/mentally) to consent to sexual intercourse Wetting or soiling Unexplained responses to personal/medical tasks Signs of withdrawal, depression and stress

Indicators of Adult Sexual Harm Include: Overly sexualised language Unusual difficulty in walking and sitting Pain or itching, bruises or bleeding in the genital area Sexually transmitted disease, urinary tract/vaginal infections Psychosomatic disorders – stomach pains or excessive period pains Full or partial disclosure or hints of sexual abuse

Neglect and Acts of Omission Inadequate heating or nutrition, isolation and abandonment, withholding key essentials Denying access to social or educational services Person alone and at risk Failure to give privacy and dignity Failure to take an adult at risk to medical appointments or to correctly administer medicines Neglect of accommodation, self neglect Not re-setting a night alarm or buzzer

Indicators of Adult Neglect Include: Inadequate heating and/or lighting Inappropriate, old or shabby clothing or being kept in nightclothes during the day Sensory deprivation e.g. not being allowed to have a hearing aid, glasses or other aids to daily living Poor physical condition eg bedsores and unwashed ulcers Clothing in poor condition eg unclean, wet and ragged

Indicators of Adult Neglect Include: Inadequate diet Untreated injuries or medical problems Inconsistent or reluctant contact with health or social care agencies Failure to engage in social interaction Malnutrition when living alone Failure to give/offer prescribed medication Poor personal hygiene

Physical Harm Slapping, pushing, hitting, kicking, misuse of medication Pinching, biting, shaking Forcible feeding Improper use of medication Restraining or holding an individual back – locking in a room, tying to a bed or chair Inappropriate moving and rough handling Inappropriate touching Being threatened with a weapon

Indicators of Adult Physical Harm Include: Injuries inconsistent with the lifestyle of the Adult Bruises and/or welts on the face, lips, mouth, torso, arms, back, buttocks and thighs Clusters of injuries forming regular patterns or reflecting the shape of the article use Burns especially on the soles of the feet, palms of the hand, on the back, signs of immersion in hot water, friction burns, rope or electrical appliance burns

Indicators of Adult Physical Harm Include: Multiple fractures Lacerations or abrasions to the mouth, lips, gums, eyes and external genitalia Marks on the body including slap marks and finger marks Injuries at different stages of healing Medication misuse Inappropriate restraint

Psychological and Emotional Harm Threats, manipulation, inappropriate treatment Humiliation, intimidation, overt control and dominance Isolation and abandonment Bullying and intimidation by word or act Access to person being denied Misuse of power or influence 37

Psychological and Emotional Harm Deprivation of communication Threats of harm or abandonment Putting down, ignoring someone Controlling behaviour Taking away privacy Withdrawal from supportive services and networks Constant criticism

Indicators of Adult Psychological Harm Include: Changes in appetite Low self-esteem, deference, passivity and resignation Unexplained fear, defensiveness and ambivalence Emotionally withdrawn Sudden changes in behaviour The person providing care uses bullying, intimidation or threats to induce desired behaviour The person providing care has a punitive approach to bodily functions or incontinence

Institutional Harm Indicated by the repeated instances of unsatisfactory professional practice, pervasive ill treatment or gross misconduct indicating a harmful climate Removal of individuality within an institution by strict inflexible regimes and routines, lack of accommodation to individual choice, lifestyle etc.

Indicators of Institutional Harm Include: Inappropriate or poor care Misuse of medication Inappropriate restraint Sensory deprivation eg denial of the use of spectacles, hearing aids etc Lack of recording on client files Lack of respect shown to the person Denial of visitors or phone calls

Indicators of Institutional Harm Include:- Restricted access to toilet or bathing facilities Restricted access to appropriate medical or social care Failure to ensure appropriate privacy or personal dignity Lack of flexibility and choice e.g. restricted mealtimes and specified bedtimes and a restriction on the choice of food Lack of personal clothing and possessions A lack of privacy

Financial or Material Harm Fraud, theft of belongings, financial exploitation, misappropriation of belongings Undue pressure to sign documentation such as a will, power of attorney Pressure to hand over monies or benefits Misuse of property or possessions

Verbal Harm Inappropriate use of language, disrespect, name calling, shouting, sarcasm, inappropriate use of humour, using language to confuse or exclude

Indicators of Financial Harm Include: Unexplained sudden inability to pay bills or maintain their previous lifestyle The person lacks belongings or services that they can clearly afford Recent acquaintance expressing sudden or disproportionate affection for a person with money or property A lack of records and accounting for where money was spent

Indicators of Financial Harm Include: Unusual or inappropriate bank account activity Power of attorney or enduring power of attorney obtained when the person is unable to comprehend and give consent Withholding money Recent changes of deeds or title of property Unusual interest being shown by family or others in the person’s assets

Indicators of Financial Harm Include: The person managing the financial affairs of the adult is evasive or uncooperative The selling or offering to sell the possessions of an Adult who does not have the capacity to consent or know the full value of those possessions

Discriminatory Harm Racist, homophobic, ageist, sexist behaviours, harassment and any other discriminatory acts e.g. trans phobia. Preventing someone from accessing appropriate sexual support/education Denying someone the right to exercise their religion or belief Forcing an individual to participate in a religious or belief practice Denying someone access to culturally appropriate meals Inappropriate “nicknames or personal slurs”

Indicators of Discriminatory Harm Include: A lack of respect shown to the individual A failure to respect dietary needs A failure to respect cultural and religious needs Signs of a substandard service offered to an individual Exclusion from rights and services offered to citizens e.g. health, education, employment, access to the criminal justice system and civic status Assumptions being made about a person’s sexuality

Self Harm Refusal to eat or drink Drug/alcohol misuse Cutting, burning, scalding or hitting parts of own body Calculated and dangerous risk taking Banging head or other parts of the body Swallowing harmful substances Overdosing Drug or alcohol misuse 50

Patterns of Harm Planned, calculated, systematic Opportunistic Reaction to provocation or perceived provocation Being over-stressed Poor training Poor supervision or management Over-worked Institutions attempts to cope with limited resources

Potential Increased Risk of Harm Carer or Adult at risk abuses alcohol or drugs CARER Has given up work, social life etc to care for person Are under financial, emotional stress e.g. illness, bereavement, loneliness Perceive the person as being deliberately awkward Aggressive/defensive ADULT AT RISK Has recently increased dependency Has hit out at carer Disturbs the carer at night Lacks purposeful activity Exhibits odd or embarrassing behaviour Has difficulty in communicating

How an Individual Adult at Risk may Respond to Harm? They may: Seek attention Become resigned Deny what is happening Become angry Withdraw from activity Have difficulty communicating Evidence marked changes in behaviour Form inappropriate attachments Appear to become confused mentally and psychologically Become frightened

Responding to Initial Disclosures/Allegations Do Stay calm and try to respond without showing shock or anger Listen carefully and take what is being said seriously Re-assure the person that you are there to listen Explain what you will do next – you may need to share information to keep the individual or others safe Report to team leader, duty manager, adult protection lead or local social services team immediately In an emergency protect the individual Preserve evidence – e.g. leave the environment as it is, ask the person (very sensitively) to wait for a wash or bath if a sexual assault is suspected

Reporting Your Concerns If your manager is not available or is implicated then you should seek to speak to another manager If this is not possible you can contact social services directly or the Adult Protection lead person for your area

Reaction of affected adult to harm Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People - National Centre for Social Research, King’s College London - June 2007 Note: Respondents could give more than one answer; Reaction questions were not asked for neglect

Responses to Initial Disclosures/Allegations Don’t Don’t begin an investigation. Concentrate on asking questions about how the person is feeling and their safety Don’t make comments or judgements about the situation Don’t contaminate evidence Don’t promise to keep secrets Don’t give sweeping assurances, including about confidentiality Don’t confront the perpetrator Don’t keep the information to yourself

Record the following: The Incident The context in which it happened The evidence

Recording Should be immediate (i.e. as soon as you can after the incident or disclosure) All records should show whether the adult at risk was seen and spoken to and who accompanied them if anyone Record date, time, situation, who else was present and any discussion that took place Complete an incident form

Recording Identify fact and opinion Use the adult's own words Be clear and specific Record the incident, the context and the evidence Record action taken (even if none is taken) Print your name and role and sign and date the report Show your manager/on call manager Ensure the record is kept confidentially and securely in line with guidelines

Protection Orders an assessment order a removal order or a banning or temporary banning order.

Remember It is NOT your responsibility to decide whether or not an adult is being harmed It IS your responsibility to act if you have any concerns

The Human Rights Act (1998) Convention Rights: the right to life freedom from torture and inhuman or degrading treatment or punishment freedom from slavery, servitude or forced or compulsory labour the right to liberty and security of person the right to a fair and public trial within a reasonable time freedom from retrospective criminal penalties and no punishment without law the right to respect for private and family life, for home and for correspondence freedom of thought, conscience and religion

The Human Rights Act (1998) Convention Rights: freedom of expression freedom of assembly and association the right to marry and found a family prohibition of discrimination in the enjoyment of convention rights the right to peaceful enjoyment of one's possessions the right to education the right to free elections the right not to be subjected to the death penalty

Other Key Legislation/Guidance Adults with Incapacity (Scotland) Act 2000 Mental Health (Care and Treatment) (Scotland) Act 2003 Regulation of Care Act (Scotland) Act 2001 National Care Standards

An Adult Care and Protection Framework Recruitment Policy, including the recruitment of ex-offenders Disclosure Policy and procedures Health and Safety Policy Code of Conduct Adult Protection Procedures, including Adult Protection Statement, any leaflets for users of services etc Lone Working Policy Complaints Policy Grievance Policy

An Adult Care and Protection Framework Disciplinary Policy Whistle-blowing Policy Information Handling and Sharing Policy Use of Medicines Policy Managing Behaviours that Challenge Policy Wandering Technology Policy Control and Restraint Policy Equality and Diversity Policy

Incident Report Form should contain the following information (as far as possible): Personal details – name, address, date of birth, ethnic origin, gender, religion, GP, type of accommodation, family circumstances, support networks, physical and mental health, any communication difficulties The referrer’s name, job title, agency, contact details and reason for involvement The nature/substance of the allegation Details of care givers/significant others Details of alleged person(s) inflicting the harm/current whereabouts and likely movements within the next 24 hours, if known

Incident Report Form should contain the following information (as far as possible): Details of any specific incidents, e.g. dates, times, injuries, witnesses, evidence such as bruising What was said and by whom – where possible in the words used by the adult Background of any previous concerns Whether the adult is aware/has consented or not to the report being made Actions already taken, if any Information given to the adult, expectations and wishes of the adult if known Person responsible: staff member / line manager

In Recording Information You Should Record information promptly and accurately Record information in plain language Only record what you have been told and in the precise words used, as far as possible Respect any confidentiality in accordance with legal constraints Only record information relevant and necessary to the allegation or incident Indicate whether information has been visually observed or is verbal assertion Make opinions evident

Assisting the Council Officer Sit in and support the individual by being present Provide empathy Help to communicate the wishes of the individual, especially if there are communication difficulties Help in the use of any communication aids, or act as a lip speaker, signer, translator etc. Assist in building trust and co-operation between the individual and the Council officer Provide advice and expertise for the statutory agencies during inquiries, especially where medical examination has to take place

What Should You do if You Suspect Harm? Remain calm Try not to over-react Ensure no one is in immediate danger Call emergency services if urgent help is required Report concerns without delay to the manger or another Never try to investigate Do not challenge or speak to the person you suspect Record facts Do not wait until you have all the information Do not disturb any potential evidence

Disclosure Good Practice Try to: Ask what has happened Listen Ask precise questions – who, what, where, when? Avoid leading questions Do not make suggestions or try to put what someone is saying into your own words

Disclosure Good Practice Try to: Do not press the individual for more details and information than they are willing to give to you Stay calm Show sympathy and support Make the person feel safe and secure Remember that this may be the only time someone wants to talk about it Take notes of the key points. Do not try to rely on your memory Tell the person that they did right to tell you and that it was not their fault

Disclosure Good Practice Try to: Tell them what you are doing Explain what action you will take Reassure the person where ever possible their views will always be sought and considered Do not make judgements and dismiss what someone has told you Act immediately Report to your line manager

Disclosure Good Practice Try to: Do not tell anyone else Assess immediate risk to the adult who has disclosed to you and take appropriate action to ensure their safety Immediately write up what the person has told you Never confront or make contact with the alleged perpetrator Never remove any evidence from someone’s room or any evidence which may be used in an investigation. Indeed it is important to preserve any evidence of harm e.g. locking a door, taking the adult at risk to another room, not cleaning clothes or bed linen etc.

Grooming Grooming is when an individual perpetrator tries to ‘set up’ and ‘prepare’ another person to be the victim of harm, often sexual abuse. It can be perpetrated by someone who is a family member, friend or acquaintance of an individual as well as someone who is a stranger

A Perpetrator may “Groom” by: Giving an inappropriate level of attention to the adult Telling the adult that he/she is ‘special’ Giving the adult ‘special’ treatment, favours and privileges Offering, promising and/or giving gifts Offering to help family/carers to gain access to the adult Manipulating the adult through threats or coercion Openly or ‘accidentally’ exposing the adult to nudity/sexual material Sexualising physical contact Having inappropriate boundaries (e.g. sharing ‘problems’)

Physical Harm Cuts/injuries which seem to be unexplained and are repeated frequently Weight loss due to malnutrition (especially if the individual is fed by others) Physical marks such as slaps, finger or pressure marks, kick marks, pinching, bite marks A history of unexplained injuries caused by falls or accidents Bruising on parts of the body which are well-protected, not normally prone to injury and possibly evidence of repeated striking Broken bones Bed sores and body ulcers

Physical Harm Fatigue and drowsiness Excessive sleep and lethargy Injuries caused by protective responses – to arms, hands etc An injury for which the explanation seems inconsistent or denial of injuries Fear of parents/carers being approached for an explanation Aggressive behaviour or severe temper outbursts Carers do not readily seek help for injuries Flinching when approached or touched

Physical Harm Withdrawn behaviour Running away from home Distrust of adults, particularly those with whom a close relationship would normally be expected An adult at risk claims they have been hurt by another or have had lots of unexplained accidents The adult is prevented or restrained e.g. kept in own room, limited to certain areas etc Reluctance to get changed or covering up e.g. wearing long sleeves in hot weather Depression

Sexual Harm Changes in behaviour, weeping, anger, violent reactions, withdrawal and self isolation Self harming behaviour Physical damage, torn rectal/vaginal tissue, anal pain Signs of ‘grooming’ Bleeding Inappropriate or unusual personal attachments Unexplained pregnancy Pain, irritation or bruising in intimate areas Evidence of inappropriate restraint Over sexualised behaviour, language and expression Changes to posture, stiffness and difficulties in sitting Withdrawal of contraception or initiation of same

Sexual Harm Changes in routine, fear of dark and new places Suspicion of strangers and groups of people SIDs Vaginal discharge or infection Stained personal garments and bedding Stomach pains Self-harm or mutilation, sometimes leading to suicide attempts Bedwetting Fear of being left with a specific person or group of people Having nightmares Saying they have secrets they cannot tell anyone about Eating problems such as overeating or anorexia

Neglect Constant hunger, sometimes stealing food from others. Presenting as dirty, unkempt or ‘smelly’ Lack of food Loss of weight, or being constantly underweight Inappropriate dress for the conditions or time of day Complaining of being tired all the time Not requesting medical assistance and/or failing to attend appointments Medication is withheld

Neglect Body sores Denying access to personal aids, e.g. glasses, stick etc Having few friends Mentioning their being left alone or unsupervised Rushing a person with eating or personal care tasks Inadequate heating, lighting Unsafe living conditions Dirty living conditions

Psychological/Emotional Harm Self isolation Changes in sleep patterns – either excessive or sleeplessness Deterioration in physical presentation – unshaven, untidy, unkempt, unwashed etc Changes in psychological health, increase in phobias, paranoia Confusion, nervousness, excessive pattern of manners, agitated behaviours Sudden speech disorders Neurotic behaviour e.g. hair twisting, rocking Fear of making mistakes Self harm Fear of family/carer being approached regarding their behaviour

Verbal Harm Withdrawal from group interaction, introversion and self isolation Feelings of submissiveness and sense of fear around certain individuals Changes in behaviour resulting in aggressive verbal responses Inappropriate use of language

Financial or Material Harm Loss of financial ability Loss of material property – property or items in home goes missing for unexplained reasons Pressure to sign power of attorney or wills or actual changes to wills and deeds Visitors who only come when benefits are cashed Individuals who ‘help’ adult by withdrawing funds Lack of congruity between living conditions and assets Removal of access to benefits by family members Unexplained alterations to accounts Unexplained debt or inability to pay bills Unplanned and unanticipated sale of property and possessions Confused or irregular signature on credit cards or cheques

Institutional Harm Rigid and inflexible routines Individuals indicating a lack of choice Changes in behaviour, lack of involvement and interest in normal activities Self isolation, passivity and withdrawal Inadequate staffing User of services restricted to own rooms Lack of attention to complex needs Lack of understanding of individual communication needs Fear of another person Jokes at the expense of the user of services

Discriminatory Harm Loss of self esteem which is unexpected Bullying incidents on basis of an individual’s race, age, gender etc Offensive remarks or harassment based on the adult’s age, gender, disability, race, colour, cultural background sexual or religious orientation Changes to the adult’s mental state and behaviour e.g. fearful, anxious, withdrawn, angry, frustrated Providing unacceptable food/diet Failure to provide for cultural needs Isolation e.g. due to barriers to communication ‘Hate crime’ Not allowing for individual choice or difference Social isolation and exclusion The adult is refused access to services or is excluded inappropriately

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