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Risk assessment
13.1 Person-centred approaches should be adopted in all risk
assessments. Using a person-centred approach helps professionals involved
in assessing risk to address significant issues of health and safety whilst
supporting choice by also taking into account things that are important to
people. A person centred approach can be one of the best ways to :
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Consider taking a particular risk or risks
Establish and improve capacity to make decisions
Make a best interest decision
13.2 As with all person centred assessments it will need to be holistic and
wide ranging, however unlike a more general assessment there will be a
specific choice or decision, or more than one choice or decision, to consider.
The Mental Capacity Act and the DH guidance “Independence Choice and
Risk” both support the use of person centred planning when considering the
above issues.
14
Information sharing and confidentiality
14.1 The gathering and sharing of information is important to the risk
assessment process, and helps to:
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Identify risk and potential risk
Assess risk
Plan for the management of risk
14.2 The use and sharing of information must be in accordance with the
Data Protection Act and the department’s Records Management and Data
Protection Policy: http://www3.hants.gov.uk/proc0607.doc.
14.3 When assessing and managing risk, staff should take a proactive
approach to confirm with the individual their wishes regarding sharing of
information, and support them to consider sharing of information which will
promote their independence while keeping them safe. Information should be
provided about the purpose of collecting information, how it will be kept, and
who it will be shared with. Consent to sharing of information, together with
any specific decisions about information or people who are excluded from this
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consent, must be recorded using recording systems and methods agreed by
Adult Services.
14.4
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14.5
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Clarification and agreement about the sharing of information will:
Support practitioners and the people they are working with in reaching
agreement about risk decisions
Enable practitioners and other involved professionals to deal effectively
with risk situations which arise which may or may not be foreseen.
Information may be gathered from a range of sources, including:
Directly from the individual
From significant others including family or friends, advocates, other
involved professionals, other statutory or voluntary agencies, the
police, probation service or courts, agencies involved in providing
services
From information in Adult Services’ records
14.6 It is essential that information gathered during the identification,
assessment and management of risk is recorded, and that recording
demonstrates the rationale and reasoning behind the decision made. This will
be achieved by:
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Demonstrating the evidence which is used to judge the severity of the
risk and the likelihood that it will occur
Evidencing the involvement of the individual and their carers in the
decision making, or if they are not involved, explaining the reasons why
Identifying conflicting opinions and interests
Explaining the rationale for actions taken or planned
14.7 Adult Services is currently developing improved systems for sharing of
information across agencies, through involvement in the Department of
Health’s Common Assessment Framework project. When this policy is
reviewed, Common Assessment Framework process and procedures which
have been agreed and adopted by Adult Services will be included.
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Recording
15.1 All risk assessments, decisions and management plans will be
recorded using Adult Services’ recording systems. The recording system for
most Adult Services staff is Swift (for exceptions, see below, section 15.5).
Recording is an essential part of good practice, and should always be
considered as recording for the person, with the information kept on their
record regarded as belonging to them. Information about risk assessments,
decisions and management plans should be included in the case chronology.
15.2 Risk assessments, decisions and management plans will be recorded
in a variety of ways. In many cases, risks are dealt with as part of the normal
process of assessment and delivery of support, using assessment and
support planning documents in Swift, and in profile notes which capture day to
day activity, which should be identified as:
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Risk event
Risk discussion
Risk decision.
15.3 In addition to this, risks may be identified outside these processes, as
identified at 16.6. Where documentation is created other than Swift
documents, these will be scanned into Swift, and will be referenced in profile
notes. To summarise, information about risk assessment and risk
management may be captured in:
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Profile notes in Swift
Swift assessments and support plans
Support plan evaluations
Safeguarding meetings
Best Interests decisions under the Mental Capacity Act
Planning meetings
Documents received from others
Letters sent and received
Casefile chronology
It is essential that where a number of different assessments have taken
place which include risk assessment, that these assessments and
related information are clearly linked in the recording and cross
referenced where appropriate.
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Recording should always evidence:
The risks identified
The potential benefits and harms and likelihood these will occur
The plan proposed
The rationale behind any decisions made
Who made the decision
When the risk assessment will be reviewed
The contingency plan
Who is responsible for any actions agreed
15.5 Although Swift is referred to in this policy as the main recording system
for Adult Services, it is recognised that staff working in integrated teams,
particularly Community Mental Health Teams, may be recording on health
systems and may not have access to Swift. Their recording must follow the
policies and procedures of the lead agency, but should ensure that the above
principles are followed.
16
What triggers a risk assessment?
16.1 As stated in this policy, risk assessment is included in all assessment
and planning for the provision of social care. Therefore all assessment
documentation should identify the types of risk assessed, and contain the
necessary information to enable a decision to be made which takes account
of the potential benefits and harms, and the likelihood of these occurring.
16.2 Risks identified during an assessment may be managed through
normal processes of assessment and care planning, or may need more
complex planning to ensure that they are assessed and managed in the most
effective way.
16.3 Risks may arise outside the assessment process, and may trigger a
review or a re-assessment if there has been a change in need or
circumstances which indicates that the person’s needs and/or services
currently in place need to be reviewed. Consideration should always be given
to using normal assessment and review processes.
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16.4 Risks may arise which need to be dealt with by specific actions to
resolve a risk situation, such as:
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Failure or potential failure of care delivery or support plan
Actions of the person or others are creating a situation of risk
16.5 When risk arise which need to be managed outside the usual
assessment and planning processes, staff should always involve their
line manager.
Triggers for involving managers in risk management
16.6 The following should be considered whenever a situation of risk is
identified, to ensure that managers are involved and can provide support and
supervision when appropriate:
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Is the person or are others at risk of immediate serious harm?
Is the person or someone closely involved in their situation
subject to MAPPA or section 37/section 41 of the Mental Health
Act? For further information see Section 17.12 and Section 17.13
Where steps have been taken to manage a presenting risk, is the
person or are others still at risk or potential risk of harm?
Is there disagreement or conflict about a decision/choice or
course of action to be taken?
Is the person vulnerable and at risk of harm due to e.g. self
neglect or self harm but reluctant or refusing to accept
intervention or support?
Has a high risk situation been ongoing for more than one working
day without resolution?
Has a risk situation which has been ongoing over time, with
several risk events, escalated to a situation of higher risk?
Is there a need to use a formal planning processes including
planning meetings in order to assess and manage the risk?
If the answer to any of these questions is yes, practitioners should seek
advice from their line manager immediately.
16.7 The District or Locality Service Manager should be informed
immediately if there is:
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A safeguarding risk
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Conflict about a risk decision
A situation which is not resolving or there is a significant increase
in risk
16.8 The District or Locality Service Manager will be responsible for all risk
decisions made by their staff in these circumstances. This may be delegated
to Team Manager, although the District Service Manager will retain overall
responsibility.
16.9 Managers will ensure that the response to risk situations is
proportionate to the level of risk identified. Managers may seek legal advice if
this is required to clarify any points of law which are relevant to the decision to
be made. It is the responsibility of managers to seek legal advice which will
support their decision making. Solicitors in the legal department will be able
to provide managers with advice which will support their decision making but
are not able to make operational decisions. It is therefore important that when
legal advice is required, this is accessed using agreed protocols. Access to
legal advice is covered in Adult Services procedure Scheme of Delegations
16.10 Practitioners may be delegated to retain responsibility for risk decisions
and risk management, provided that they have access to support and
supervision from managers when required. Senior practitioners also have a
key role in supporting practitioners in decision making, through supervision
and support.
16.11 Decisions about delegation of decision making in these cases should
be recorded on case files, and in supervision records.
16.12 Ownership of decisions. Decisions must always be recorded and the
recording should be clear about who made the decision and who is
responsible for any actions agreed, as described at 15.4. It is important that it
is clear who owns any decisions made, and is therefore responsible for any
outcomes associated with those decisions. This could be:
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The key worker
Other involved professional or staff from another agency
Team or Service Manager from Adult Services or another agency
A multi-disciplinary decision made as a result of multi-disciplinary
planning or more formal procedures
The individual
A member of the individual’s support network, e.g. a family member
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16.13 Where a decision has been made as a result of a multi-disciplinary
process, and where a view is held which is different from the one agreed
upon, it is important to record this alternative view and why it was not taken.
This would also be the case where decisions are made collaboratively with
the service user and others involved in their support.
16.14 The decision maker will be responsible for recording the decision.
If the decision maker is not a member of Adult Services staff, the
involved practitioner must ensure the information about the decision is
recorded on the case file.
17
Assessment
17.1 Risk assessments may be carried out for specific purposes, including
those described here. In addition, a risk assessment may be carried out in
response to a specific event, in which case the factors described here should
be considered. In some cases there will be a number of assessments which
need to be considered, for example where there is a safeguarding concern,
together with other non-safeguarding risks, and mental capacity also needs to
be considered. Where a number of assessments are undertaken, it is
essential that these are cross referenced in the case file. A chronology of
events and assessments will assist in providing a summary of all the relevant
information available.
Fair Access to Care Services
17.2 Adult Services arranges support to meet the needs of people who have
needs which have been assessed as eligible needs, under guidance issued
by the Department of Health. The eligibility criteria used by Adult Services is
found in the Care Management Practice Manual, Chapter 6, and provides a
risk assessment framework which focuses on the risks arising from the needs
of the person which mean that they are at risk of losing their independence.
Once eligible needs are identified, Adult Services is obliged to arrange
support which will meet those needs. All risk assessments should take
account of eligible needs, and all support plans and action plans agreed to
manage risk should ensure that eligible needs are met. The Fair Access to
Care Services guidance has been reviewed by the Department of Health and
new practice guidance was issued in February 2010
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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPo
licyAndGuidance/DH_4009653.
Mental Capacity
17.3.1 Whenever a risk assessment is undertaken, once the decisions to be
assessed have been clarified, the person’s capacity to make those specific
decisions must be considered before the risk assessment is undertaken. This
will inform the nature of the assessment, and will determine whether the risk
assessment will require Supported Decision Making or Best Interests
Decision Making, or a combination of both where several decisions need to
be made. The 5 principles of the Mental Capacity Act must be followed in all
assessments. These are:
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People are assumed to have capacity, unless it is proved otherwise. If
there is doubt about the person’s mental capacity to make a decision,
capacity must be assessed about that specific decision
No-one should be treated as unable to make a decision unless all
reasonable steps have been taken to support them to make the
decision
People should not be treated as being unable to make decisions just
because they make “unwise” decisions
Decisions made about someone who lacks capacity must be made in
their best interests in accordance with the best interests checklist
contained in the MCA code of practice
When best interests decisions are made, regard should be given to all
alternatives which are “less restrictive” of the person’s rights and
freedoms, whilst still allowing the original purpose of the decision to be
met. We should aim to restrict a person’s freedom as little as possible
while still acting in their best interests.
17.3.2 Practitioners should follow the practice guidance in the Care
Management Practice Manual, Chapter 9, and should, in discussion with their
manager, seek the advice of the Mental Capacity Act Development Manager
when required.
Safeguarding
17.4.1 In circumstances where there is evidence or suspicion that a person is
being abused, or at risk of abuse from others, Adult Services Safeguarding
Procedures must be followed. Any evidence or suspicion of abuse of a
vulnerable person must be determined as an eligible risk under Fair Access to
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Care Services guidance. Safeguarding procedures ensure that people are
protected, whilst promoting their choice and freedom of action as far as
possible.
http://www3.hants.gov.uk/0308-procedure.htm
17.4.2 Practitioners should always notify their manager immediately if a
safeguarding risk is identified, and should seek advice from their
Safeguarding Co-ordinator when required.
17.4.3 When carrying out a risk assessment in cases where there is evidence
or suspicion of abuse of a vulnerable adult, Adult Services safeguarding risk
tool should also be completed as part of the risk assessment.
17.4.4 When considering risk in safeguarding, potential benefits and harms
associated with relationships must be considered.
Domestic abuse, stalking and honour based violence
17.5.1 Adult Services is working with the Hampshire Domestic Abuse
Partnership Board to introduce the CAADA (Co-ordinated Action Against
Domestic Abuse) Domestic Abuse, Stalking and Honour Based Violence
(DASH) risk assessment tool and risk management model in Hampshire. This
falls within the safeguarding remit, and links to the Multi Agency Risk
Assessment Conference (MARAC) which is accessed for cases where a high
risk is identified. It is intended to roll out a framework for DASH, to include
Independent Domestic Violence Advisors who will work directly with people at
high risk and can support with completion of the DASH risk assessment. This,
together with information, resources and support for people at medium or
standard risk, will promote self determination for people and help them to
reduce and manage risk in their situation. Training will also be available for
practitioners. A referral pathway is planned for publication in September.
17.5.2 Further information will be included in this policy when available,
meanwhile further information can be accessed at
http://www3.hants.gov.uk/domestic-abuse-forum-bulletin.htm. Practitioners
should discuss any cases where domestic abuse, stalking or honour based
violence may be happening with their team manager and safeguarding coordinator.
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Human rights
17.6 The Human Rights Act and all of the guidance available to practitioners
requires them to work in a way which respects the individual’s human rights.
Risk assessment and risk management should be approached in the same
way.
Carers
17.7.1 Carers are entitled to an assessment of their needs and may need
support in their own right, to enable the caring relationship to continue and to
support their own wellbeing. Practitioners should follow practice guidance in
the Care Management Practice Manual, Chapter 10
http://www3.hants.gov.uk/care-management.htm
The carer’s assessment should identify any risks to the carer resulting from
the caring relationship, so that appropriate support may be considered.
17.7.2 When risk assessment is carried out with the cared for person, risks to
carers must be considered, and may influence the determination of eligibility
and the way in which support is provided for the cared for person. Where
there are disagreements or conflict between the choices of the person and
their carer, this should be dealt with in an open and transparent way which
enables those involved to reach agreement wherever possible about the risks
and how they will be managed.
People who refuse or resist intervention
17.8.1 Where people are resisting or refusing intervention from Adult
Services, and they have capacity to make that decision, they may continue to
be at risk and the decision to refuse help may be considered an unwise
decision. Often these situations are brought to the attention of Adult Services
by others who consider the person to be at risk, such as referrals from:
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Family
Friends or neighbours
Other professionals or agencies.
17.8.2 It is essential that the decision making about such people
demonstrates a balance between respecting their independence and right to
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make their own decisions, and ensuring that Adult Services meets any
obligations arising from a duty of care. Even when an individual is indicating
that they wish to accept a high level of risk, this should not prevent
practitioners from involved agencies meeting to share information about the
risk and agree any available actions which will reduce or monitor the risk. In
such circumstances the reasons for sharing any information, including
personal information, should be documented following adult services records
management procedure http://www3.hants.gov.uk/proc0607.doc
17.8.3 There may be circumstances in which an individual does not wish to
have involvement from Adult Services or other agencies, but a decision is
made that involvement should continue. This decision may be taken in one or
more of the following circumstances, where there is evidence from a number
of sources that:
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Failure to act may result in greater harm to the person or others,
including carers and care workers, for which Adult Services may be
responsible
The level of risk is high and likely to continue, resulting in greater harm
as above
There is a need to carry out further work to clarify the person’s mental
capacity, the level of risk, the person’s understanding of the risk and
the options open to them to manage the risk
The person does not have all the information they would need in order
to make an informed decision
The person would not understand what to do if they decide in the
future that they wish to have help
It is not possible to agree with the person that they will take
responsibility for their decision and any outcomes arising from it.
This is not an exhaustive list, and the particular circumstances of the person
must be considered.
17.8.4 There may be circumstances in which, even though there is a level of
concern from others, a decision is made that Adult Services will not take
further action. This decision may be taken in one or more of the following
circumstances where there is evidence from a number of sources that:
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It is clear that the person has the capacity to make the decision and
understands the consequences of the decision
No harm will occur to others, including carers and care workers
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The person is able to take steps to manage and reduce the risks
themselves or with the support of others
The person knows what to do and who to contact should they decide
they want help in the future
It is agreed with the person that they will take responsibility for any
outcomes of the decision they make not to have support.
Again, this is not an exhaustive list, and the decision must be based on a
consideration of the particular circumstances of the person.
17.8.5 These decisions can be difficult to judge and there is no clear “right or
wrong” answer, as the circumstances for each individual will need to be taken
into account along with all the available information. It is essential therefore
that such decisions clearly evidence that the balance between the individual’s
choice and the need for continued intervention has been considered, and that
a defensible decision has been made, in consideration of all the
circumstances. Such decisions must be:
Made as far as possible in collaboration with the person, and clearly
evidenced with reasons and justification, if not
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Made in collaboration with other involved professionals
Made with the involvement of managers
Justifiable as in the person’s best interests, or in the best interests of
others
Justifiable under Adult Services duty of care.
Managers should take into account all available legislation which could
assist in protecting an individual from harm. A synopsis of a wide range
of legislation is available in section 10.1 of Adult Services Safeguarding
procedure.
17.8.6 These decisions should be recorded and shared with the individual and
other involved people, including the referrer. The recording should follow the
principles described at 15.4 and 16.12.
Risk assessments for providers and Occupational Therapy
referrals
17.9 Risk assessments are required for providers prior to the
commencement of services which are directly commissioned, or to provide
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information when requesting an Occupational Therapy assessment, and
should be completed using the Care Provision Risk Assessment in Swift. This
assessment should contain any known information which may affect the safe
delivery of services, and is required to inform the risk assessment which will
be completed by the provider or occupational therapist. These assessments
will have a health and safety focus.
Quality Outcomes and Contract Monitoring Framework
17.10 A risk assessment is required prior to consideration of placement with
any provider which has a Care Quality Commission rating of 1 star or 0 star,
or any provider for which a caution has been indicated in the QOCM
database. The risk assessment should take account of the wishes of the
person and the reasons why the placement is being considered, but must
focus on whether the proposed placement will safely meet the needs of the
service user, and a risk management plan will be required to ensure that, if
agreed, the placement is supported and that risks will be managed to ensure
that the person is safe. Authorisation from the appropriate manager will be
required before placement can be agreed. The QOCM procedure should be
followed: http://www3.hants.gov.uk/ 0309-procedure.htm
Health and safety
17.11 There are situations in which a health and safety assessment is
required, for example when assessing and managing the safety of staff in
their working environment, who may be practitioners, care workers, other
professionals or members of the public. The procedure for risk assessment
(health and safety) should be followed:
http://www3.hants.gov.uk/proc2106.doc
Further procedures and guidance relating to health and safety can be found
at:
http://www3.hants.gov.uk/ socialservices-deptprocedures-health-safety.htm
Mental Health Act
17.12 Practitioners working with risk situations must follow requirements of
the Mental Health Act where this applies, and may be required to take specific
actions for example where the person is subject to Section 37 or Section 41.
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Practitioners must ensure that any requirements of the Act are followed. The
requirements of the Act will take precedence over any guidance in this policy.
There may be areas of the person’s life and support needs which fall outside
the Mental Health Act and practitioners should follow the principles of positive
risk taking in this policy where this is safe to do so for the person and for
others, and where doing so will not impact on any requirements of the
legislation.
Multi Agency Public Protection Arrangements
17.13 People subject to Multi Agency Public Protection Arrangements
(MAPPA) are dealt with under specific procedures and in some circumstances
may not be consulted when decisions about risk are made, and their views
may not be taken into account when making the decision.
18
Risk management
18.1.1 Following the key steps outlined at 7.7, whenever a risk is identified,
action must be taken to address it. Risk management will be incorporated
into all assessments and support plans.
18.1.1 The response should be proportionate to the level of risk, and recorded
appropriately. Where risks are dealt with and managed by straightforward
actions such as a telephone call to a person or another practitioner or agency,
or simple advice from a manager, these may be recorded as part of day to
day recording activity on the person’s file, using appropriate headings.
18.1.2 More complex risks which need further assessment and planning, may
be managed through discussions and meetings which include the person,
their carers and other involved agencies. Records must be kept of this
planning, as described at 15.2,15.3 and 15.4, and must be scanned into Swift.
18.1.3 Managers should be directly involved in the evaluation, planning
and management of risks which are described at 16.6 and 16.7, and
decisions about delegating risk management decisions should be
clearly recorded.
Evaluating risk
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18.2 Risks should be evaluated using the information gathered, to determine
the balance of potential benefits and harms associated with the decision or
risk to be taken. This balance can only be assessed if the likelihood of
benefits or harms arising are also evaluated, using the principles described
above in sections 6 - 7, in order to support best practice in decision making.
The use of risk assessment and recording tools, as described in section 24,
can promote discussion with the person and their support network, and help
with decision making which is shared and owned by all those involved. This
evaluation should be clearly linked to the decision making, and evidenced in
recording. Wherever possible, the person should be encouraged to think
about their own evaluation of the risks. The risk tool at Appendix E may help
them to do this.
Risk management action plans
18.3 People should be involved as far as possible in setting out plans for the
management of risk, and should be encouraged to be active in managing
risks themselves. With good collaborative planning, people may take
responsibility for managing risks themselves, whilst knowing how to access
appropriate support where this is necessary. Where actions are agreed which
will increase the likelihood of benefit being achieved, and reduce the risk of
harm occurring, these should be recorded in an action plan which clearly
describes the actions to be taken and who will be responsible for them, and a
contingency plan which describes actions to be taken in the case of
foreseeable and unforeseeable events taking place. The action plan must
also address risks for which it has not been possible to identify any way of
managing or mitigating the risk, and include information about how these risks
will be monitored and reviewed within the overall plan. The action plan may be
incorporated into assessment and support planning for self directed support,
or where risks arise which need to be managed outside the self directed
support process, using documentation which is scanned into Swift. These
may include:
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Minutes of meetings with the person and others involved, including
other practitioners and agencies
Letters which confirm actions agreed verbally in person or by telephone
Agreeing risk management plans
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18.4.1 Risk management action plans should be agreed with the individual
and should be signed by all involved parties, wherever possible. Where this
has not been possible, the reason should be explained and recorded.
18.4.2 Risk management action plans should be shared with the individual
and involved parties. The plan should evidence that information has been
provided to the individual and their carers which explains what to do and who
to contact should any unforeseen events occur, or there are any difficulties
with the agreed plan which cannot be managed within the contingency plan.
Reviewing risk decisions and action plans
18.5.1 Whenever a decision is made about a risk, or an action plan is put in
place to support risk taking and manage any identified potentially harmful
risks, this should include a date when the decision or plan will be reviewed.
This should be agreed with the individual, recorded and arrangements made
for the review to take place as agreed.
18.5.2 The decision about when to review a risk decision or risk management
plan should be made in the context of the overall support plan or care plan for
the individual, in accordance with Fair Access to Care Services guidance.
Risks should also be reviewed within the review carried out of the person’s
support plan or care plan, and the level or complexity of the risks will be
considered in deciding when the review should take place. It may also be
necessary to review specific risk decisions separately outside the review
process, particularly where the risk situation is unstable or ongoing, or where
an earlier review of a particular risk or risks is essential to the success of the
overall risk management plan, or to ensure the person’s safety.
18.5.3 When reviewing risk, practitioners and managers should re-evaluate
the information from the risk assessment and approach the evaluation of the
level and likelihood of harm with an open mind. Assumptions about the level
of risk should not be based on previous risk assessments. This will guard
against any tendency for potentially serious levels of risk to become accepted
as tolerable or acceptable. Equally, a re-evaluation of the risk decision which
reviews all previous information together with any new information available
may enable the person’s choice to be supported.
Independence and Choice Policy
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