Adult support and protection (G120)

The Adult Support and Protection (Scotland) Act 2007 is part of a suite of legislation intended to protect adults in Scotland. The other legislation are:

• Adults with Incapacity (Scotland) Act 2000
• Mental Health (Care and Treatment) (Scotland) Act 2003/2015

Everybody has the right to be safe and well-looked after. The Adult Support and Protection (Scotland) Act 2007 (the Act hereafter) is there to protect adults who may be vulnerable to harm/abuse. Most adults, who might be considered to be at risk of harm, live their lives without ever experiencing harm. However, some will, including for example physical harm, psychological harm, sexual harm or exploitation of finances or property.  This may be due to action or inaction by themselves, or others, or with or without intent.

This policy outlines the roles and responsibilities of NHS staff under the Act.

The purpose of this policy is to assist in the prevention of harm occurring to adults who may be at risk of harm by raising staff awareness of the Act and their statutory roles and responsibilities.

The policy will set out:

• Clear definitions of the criteria for invoking the Act and what ‘harm’ means
• A brief summary of the main elements of the Act
• The roles and responsibilities of health staff in protecting adults who may be at risk of harm
• Key points relating to the duty to report concerns and to cooperate with relevant inquiries and investigations
• How to access training and further information.

This policy is relevant to all NHS Ayrshire and Arran staff in all roles, areas and departments and is intended to benefit:

• service users
• carers
• NHS Ayrshire and Arran staff
• partner agencies.

4.1 Criteria

The Act provides criteria to define an adult at risk of harm.  This is an adult aged16 years and over, who:

1. Are unable to safeguard their own well-being, property, rights or other interests; and
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.

All criteria have to be satisfied to meet the definition in the Act. However an assessment that intervention under the Act is not necessary or appropriate because criteria has not been met does not absolve authorities of responsibility to consider intervention under other legislation or to offer other services.

Being unable to safeguard is not reliant on an adult’s capacity: both adults with and adults without capacity may meet the criteria for support and protection under the framework of the Act.

(N.B. ASP criteria is frequently referred to as the 3 point test)

4.2 Harm

The Act also provides guidance in relation to the definition of harm. An adult is at risk of harm when:

• Another person’s conduct is causing (or likely to cause) the adult to be harmed.

• The adult is engaging (or likely to engage in conduct that causes (or likely to cause) harm to themselves or others.

Harm includes all harmful conduct including the following examples:

• conduct which causes physical harm;
• conduct which causes psychological harm (for example by causing fear, alarm or distress);
• unlawful conduct which appropriates or adversely affects property, rights or interests (for example theft, fraud, embezzlement or extortion);
• conduct which causes self-harm.

The list is not exhaustive and no category of harm is excluded simply because it is not explicitly listed. In general terms, behaviours that constitute harm to a person can be physical, sexual, psychological, financial, or a combination of these. The harm can be accidental or intentional, as a result of self-neglect, neglect by a carer or caused by self-harm and/or attempted suicide. Other forms of harm can include domestic abuse, gender-based violence, forced marriage, female genital mutilation (FGM), human trafficking, stalking, scam trading and hate crime. Some such cases will result in adults being identified as at risk of harm under the terms of the Act, but this will not always be the case.

4.3 Council officer definition

Adult Support and Protection cases are investigated and managed by a council officer. The Act defines a council officer as an individual appointed by a council who:

• is registered in the part of the SSSC register maintained in respect of social workers or social service workers or is the subject of an equivalent registration;
• is registered as an occupational therapist in the register maintained under article 5(1) (establishment and maintenance of register) of the Health Professions Order 2001;
• or is a nurse [registered]; and
• the person has at least 12 months' post qualifying experience of identifying, assessing and managing adults at risk.

The Act introduced a duty on public bodies including the NHS to report known or suspected adult harm. It also introduced powers for councils (designated to social work services) to undertake inquiries and investigations into an adults circumstances if there are concerns and take action to support and protect that adult if appropriate.

In addition the Act places a duty on public bodies to co-operate with social work services who, in response to concern, undertake an investigation into an adults circumstances.  Also the Act provides a number of protection orders which can be used. For information about protection orders please see the ASP Code of Practice 

The Act also requires the formation and operation of a local multi-agency Adult Protection Committee. For more information about Adult Protection Committees please refer to the Scottish Government guidance 2022 

The general principle of the legislation is:

• any intervention in an individual's affairs provide benefit to the adult, and
• be the least restrictive option of those that are available to achieve a positive outcome. 

Interventions should also take account of the wishes and feelings of the adult and other supportive significant persons, encourage participation by the adult and take account of the adult’s abilities, background and characteristics.

All NHS Ayrshire and Arran staff have a duty and responsibility to:

•  Comply fully with this policy
• Undertake mandatory training including 3 yearly refresher training
• Ensure they know how to access this policy and the Adult Protection Referral (APR) form on the Adult Support and Protection page on AthenA
• Submit a referral if they know or believe that a person is an adult at risk of harm
• Co-operate with a council making inquiries under Section 4 of the Act and Adult Protection Committees (APCs) to assist them to carry out their functions
• Ensuring adherence to the principles of the Act, participate in co-ordinated multi agency support and protection planning.

In Ayrshire referrers have a choice of making an adult concern referral or an Adult Support and Protection referral (the same form is used for either – APR form ):

Adult concern referral: this is a lower level concern that can be used when a referrer is unsure if all criteria are met but they consider it necessary to share information.

Adult Support and Protection referral: is used when the referrer believes the criteria are met. An ASP referral triggers the social work statutory duty to inquire.  Remember in an emergency the appropriate response would be to request the assistance of emergency services such as the police.

It is your professional judgement that guides your decision which referral route you use. Please refer to appendix 1 for further guidance.

When an APR is submitted the referrer will receive a receipt of referral email the same day. This assures staff that the referral has been received and will be processed. If however this receipt is not received staff are advised to contact the relevant social work office to check the referral has been received. Due to confidentiality it is not always appropriate for referrers to receive feedback about their referral. If it is felt that feedback would be useful in terms of ongoing care planning and intervention but no feedback has been received staff are advised to contact the relevant social work office to discuss.

It is preferable that the adult is aware of a referral but submitting an ASP referral is not dependent on explicit consent.  Employees/officers of public bodies including NHS Ayrshire and Arran have a legal duty to report concerns about situations which suggest an adult is an adult at risk of harm under the Act. Sometimes it is not possible to advise the adult that a referral is being submitted because there is a risk that this would jeopardise any subsequent investigation or cause further risk of harm and this should be noted on the referral.

Information should only be shared which is relevant to the particular concern identified and the amount of information shared should be proportionate to addressing that concern.  An entry of the events surrounding the referral should be documented in the adult’s health record along with a copy of the APR form. This is useful information for other health professionals who may also have involvement with the adult.

It is possible for a health professional to have concerns about an adult and be concerned that there is potential for harm to occur but consider that ASP criteria has not been met. In these circumstances decision making should be fully noted in the adults file recording the judgement on each criterion.  This information serves as baseline information from which to compare any future improvement or deterioration in the adult’s circumstances.

Whilst adults with capacity have the right to consent or otherwise, there is a lawful basis to share information under the 2007 Act without consent. Practitioners can rely on the legal obligation and public task lawful basis for sharing information about concerns.

There is a difference between medical consent and data sharing consent. It is important to be open and transparent with the adult where possible, and vital that all decisions and rationale are recorded.

Why do we need to share adult protection information?

Organisations need to share safeguarding information with the right people at the

right time to:

• prevent death or serious harm;
• coordinate effective and efficient responses;
• enable early interventions to prevent the escalation of risk;
• prevent abuse and harm that may increase the need for care and support;
• maintain and improve good practice in safeguarding adults;
• reveal patterns of abuse that were previously undetected and that could identify others at risk of abuse;
• identify low-level concerns that may reveal people at risk of abuse;
• help people to access the right kind of support to reduce risk and promote wellbeing;
• help identify people who may pose a risk to others and, where possible,
• work to reduce offending behaviour;
• reduce organisational risk and protect reputation.

Where someone is suspected of being an adult at risk of harm, an Adult Support and Protection referral should be made to the council within 24 hours – any delay should be recorded with reasons.

Once you have made a referral this places a duty on the council to make inquiries where they know or believe that an individual may be an adult at risk of harm.

NHS staff will be invited to attend ASP multi-agency meetings and it is important that these are well attended. These meetings may be referred to as Planning Meetings, Professionals Meetings, Initital Case Conference and Review Case Conference meetings.  Whatever they are called the attendance of health professionals is crucial.

If it is not possible to attend it is recommended that either a deputy attends or a report is submitted providing relevant health information for the meeting. 

The multi-agency nature of ASP means that robust decision making can only take place when all relevant agencies are present or represented. Meetings should be as inclusive as possible, wherever practicable involving the adult at risk, their carers or advocates and all those people with a relevant contribution to make.

The purpose of such meetings includes the sharing of information relating to possible harm, the joint assessment of current and ongoing risk and the need to agree a specific detailed protection plan with timescales for addressing risks and providing services to support and protect the adult and any children living in the household.

At each key stage (inquiry, investigation, case conference etc.) different staff may be involved, but for every stage the multi-agency discussion and decision should be fully recorded, proportionate and relevant information exchanged, and decisions implemented.

If a concern involves a member of staff as an alleged perpetrator of harm this must be brought to the immediate attention of a senior manager.

Consideration must be given to the safety, well-being and needs of an adult at risk of harm who may also be a perpetrator of harm.  It may be appropriate to submit referrals concurrently but separately for both parties.

Where it is suspected that a criminal offence may have been committed, or if there is uncertainty that something may be a criminal offence, Police should be contacted for advice/to report the incident at the earliest opportunity.

It is an offence to prevent or obstruct any person from doing anything they are authorised to do under the Act.

It is also an offence to refuse, without reasonable excuse, to comply with a request to provide information made under the provisions for the examination of records. Information shared should be in relation to the adult at risk of harm only.

Section 10 of the Act permits council officers to request records relating to an adult known or believed to be at risk of harm.  As health records can only be examined by a health professional such as a doctor or nurse a council officer may request assistance to extract relevant health information from an adults records.

Section 9 of the Act allows a health professional to conduct a medical examination of the adult at risk of harm in private. A medical examination includes any physical, psychological or psychiatric assessment or examination.

A medical examination is useful to:

• Consider the adult’s need of immediate medical treatment for a physical illness or mental disorder;
• Provide evidence of harm to inform a criminal prosecution under police direction or application for an order to safeguard the adult;
• Assess the adult’s physical health needs; or
• assess the adult’s mental capacity.

Examples of circumstances where a medical examination would be useful include:

• the adult has a physical injury which he or she states was inflicted by another person;
• the adult has injuries where the explanation (from the adult or another person) is inconsistent with the injuries and an examination may provide a medical opinion as to whether or not harm has been inflicted, or whether there are concerns around self-harm;
• there is an allegation or disclosure of sexual abuse and the type of assault may have left physical evidence (following local procedures for liaison with the police);
• the adult appears to have been subject to neglect or self-neglect; and is ill or injured and no treatment has previously been sought.

An adult must be advised of their rights not to answer any questions or refuse to be medically examined.

The Act places a duty on the council to have ‘regard to the importance of the provision of independent advocacy services to the adult concerned’. Independent advocacy aims to help people by supporting them to express their own needs, gain access to information, understand the options available and make their own informed decisions. Anyone can make a referral to advocacy services with the consent of the adult. The independent advocacy services available in Ayrshire can provide further information including how to make a referral and a quick internet search will produce relevant contact details.

An Adult Support and Protection Learning Review is a means for public bodies with responsibilities relating to the support and protection of adults at risk, to learn lessons by considering the circumstances where an adult at risk has died, or been significantly harmed. An ASP Learning Review is usually carried out by an Adult Protection Committee or sometimes by an independent reviewer. For more information about significant case review please refer to the Adult support and protection: learning review guidance 

Similarly an adverse event is defined as an event that could have caused (a near miss), or did result in, harm to people or groups of people. Although review processes can run in tandem it is often the case that duplication should be avoided.  Due to the multi-agency nature of adult protection an ICR/SCR is likely to yield the most comprehensive results where circumstances are clearly linked to adult protection. For this reason the question of possible triggering of adult support and protection processes is raised early in the adverse event process.  For more information please refer to the Adverse Event Policy and the Adverse Event application guide.

The Act makes no reference to large scale investigations (LSIs), but these have become increasingly prevalent across Scotland since the implementation of the Act. Many partnerships have their own procedures, sometimes across a number of partnerships (e.g. within one Health Board area). LSIs frequently involve other agencies including the Care Inspectorate, the NHS and the police, but there are no nationally agreed definitions of what warrants an LSI, or guidance for conducting LSIs or for governance arrangements locally.

An LSI may be required where there is reason to believe that adults who are residents of a care home, supported accommodation, an NHS hospital or other facility, or who receive services in their own home may be at risk of harm due to another resident, a member of staff, some failing or deficit in the management regime, or in the environment of the establishment or service. In such circumstances this means that there is a belief that a particular service or alleged harmer may be placing more than one of its residents or service users at risk of harm.

Harm in a care setting may include:

• financial, physical or sexual abuse;
• neglect or omission of care;
• exploitation, coercion or undue influence to the detriment of the adult;
• psychological abuse, however subtle;
• undignified or degrading treatment.

A large scale investigation is an extension of the normal investigation process and as such NHS Ayrshire and Arran, as a statutory partner, may be invited to provide input. For more information on large scale investigations please refer to the Ayrshire guidance.

Caring often has a significant impact on a carer’s health and wellbeing. It may be that the adult’s carer requires support to sustain their caring responsibilities (thus preventing any unintentional stress related harm) and to lead a life alongside caring. It is well evidenced that caring, particularly without appropriate support, can have a significant impact on carers’ health, wellbeing and quality of life. It will therefore be important to recognise and acknowledge these strains on the carer and explore what support could be provided to them or to the adult which may alleviate these. With the consent of the adult the views of carers should be taken account of throughout adult protection processes.

Not all people with substance dependencies will be considered at risk of harm under the Act. However, many such people will find themselves leading difficult and at times chaotic lives. The longterm and cumulative nature of these problems can include periods when the person would not be regarded as being able to take authentic decisions affecting their health and wellbeing, and this can have serious consequences for their health and safety. They may then be more vulnerable to harm than others without such issues.

The problematic use of drugs or alcohol may take place alongside (and on occasions contribute to) a physical or mental illness, mental disorder or a condition such as alcohol related brain damage. If this is the case, an adult may be considered an adult at risk under the Act. It may also be that the impact of a person’s dependency renders them subject to physical or mental infirmity, and places them at risk of harm.

The concept of “executive capacity” is relevant where the individual has addictive or compulsive behaviours. This highlights the importance of considering the individual’s ability to put a decision to safeguard themselves into effect (executive capacity) in addition to their ability to make a decision (decisional capacity). Thus, for such a person an assessment of mental capacity would rarely be as simple as “yes” or “no.”

It is not appropriate to use the existence of substance misuse to conclude that a person would not fall within the scope of the Act. All the circumstances in a person’s life must be considered together when applying the three-point criteria.

Gender based violence (GBV) is an umbrella term encompassing the spectrum of abuse experienced disproportionately by women and perpetrated predominantly by men and may manifest in many ways including but not limited to domestic violence, forced marriage and sexual exploitation. Key factors such as being female, age, poverty, disability and other health issues e.g. mental health and substance misuse may heighten their vulnerability to abuse. Disabled people and women with learning disabilities in particular are at a greater risk of experiencing GBV.

Many survivors of GBV make contact with NHS services at some point meaning NHS staff can be the first point of contact when a disclosure takes place. There can be a number of ways NHS staff can offer support and more guidance on available options can be found in the GBV flowchart.  Staff responding to situations of GBV are asked to be alert to ASP criteria and if these are met follow ASP referral processes.

In August 2022 Ayrshire Multi-agency risk assessment conference (MARAC) was implemented.  The aim of MARAC is to safeguard adult victims of high risk domestic abuse and link in with other agencies to safeguard children and manage perpetrator behaviour.  A MARAC is a meeting where information is shared on the highest risk cases between representatives of local Police, Health, Social Work, Local Authority, Independent Domestic Abuse Advocates (IDAA's), and other specialists from the statutory and voluntary sectors. There is no single agency or individual that can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety.

If unsure, staff are encouraged to seek advice from their line manager.

Staff are asked to pay particular attention to the needs and risks experienced by young people in transition from youth to adulthood, who are more vulnerable to harm than others. As other legislation and provisions exist which include persons up to 18 (and sometimes up to age 25), support under these other provisions may be more appropriate for some young persons. Young people may already be receiving services from a range of children’s services, or as 'looked after' children. This is not to say that they will or will not become 'adults at risk' in terms of the Act simply because they have reached a particular age. Each case will need to be considered individually.

A number of key pieces of legislation and Scottish Government guidance documents linked to this policy have recently been revised:

• Adult Support and Protection (Scotland) Act 2007 Code of Practice 2022 
• Adult Support and Protection (Scotland) Act 2007 Guidance for Adult Protection Committees 
• Adult Support and Protection Guidance for General Practice 
• Scottish Government National Guidance for Adult Protection Committees Undertaking Learning Reviews 

All guidelines and policies require review using the NHS Ayrshire and Arran Impact Assessment Toolkit by staff trained in this process.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This Guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional Equality & Diversity issues were identified.

For some individuals the complexity, severity and persistence of post traumatic reactions may impact to the extent that they repeatedly take decisions that place them at risk of harm.  Equally, issues with their sense of self and interpersonal relationships can severely compromise their ability to safeguard. These safeguarding challenges can be associated with patterns of chronic difficulties in experience of emotions, emotional expression and/or regulation, and associated coping strategies such as self-harm, care-seeking and use/misuse of alcohol and drugs. Consideration should be given to any factors that may have impacted upon the adult with the effect of impinging on, or detracting from, their ability to make free and informed decisions to safeguard themselves. This could therefore mean that, in some circumstances, they should be regarded as unable to safeguard themselves.

The principles of trauma informed care of safety, choice, trust, empowerment and collaboration should be applied wherever possible and particularly when an adult is hesitant about accepting support. Examples may include:

• Providing information about adult support and protection processes in an accessible way
• Supporting an adult to recognise the harm they may be experiencing
• Offering to advocate/support or refer to advocacy for support throughout ASP processes when necessary
• Consider options available which promote the principles above

Practitioners with responsibilities under the Act should be trained to the appropriate levels, as noted in The Scottish psychological trauma training plan (page 22). This is to ensure their adult support and protection practice reflects the in-depth knowledge and understanding required to intervene in the lives of those affected by trauma.

Capacity and consent interactive learning 

Seen something Say something short film 

Tricky Friends short film 

NHS Ayrshire and Arran ASP resource folder

Mandatory Learnpro module – ASP: Essentials

TURAS Learn – ASP Practice Level 1 informed

TURAS Learn – ASP Practice Level 2 skilled

CPD Learnpro module – ASP: Advanced

Multi agency training – level 1and level 2 – check training calendar on AthenA

• North Ayrshire website 
• East Ayrshire website 
• South Ayrshire website 
• Out of hours - call 0800 328 7758

1. Staff identifies adult at risk of harm.
2. Assess which is most suitable referral route - Adult Support and Protection or an Adult Concern Referral.
3. Consider the criteria - Adults (over the age of 16) who:
   1. Are unable to safeguard their own well-being, property, rights or other interests
   2. Are at risk of harm
   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.
4. • If the answer is YES to ALL three, the adult does meet the criteria for an Adult Support and Protection referral.
   • If the answer is NO to ANY of the three questions above please submit an Adult Concern Referral.
5. Please complete the referral form providing clear information about the concern and your contact details for possible follow-up.
6. Please email the referral form immediately (with 24 hrs) to the relevant ASP email address. Remember all sensitive information should be in the attached referral form and not in the body of the email.

East Ayrshire H&SCP                  H&SCPCustomerFirst@east-ayrshire.gov.uk

North Ayrshire H&SCP                adultprotection@north-ayrshire.gov.uk

South Ayrshire H&SCP                ASP@south-ayrshire.gov.uk

Out of hours contact:                 0800 328 7758