Exceptional, affordable healthcare.
Safety is a priority for everyone and leaders embed a culture of openness and collaboration. People are always safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. Their liberty is protected where this is in their best interests and in line with legislation.
Where people raise concerns about safety and ideas to improve, the primary response is to learn and improve continuously. There is strong awareness of the areas with the greatest safety risks. Solutions to risks are developed collaboratively. Services are planned and organised with people and communities in a way that improves their safety across their care journeys. People are supported to make choices that balance risks of harm with positive choices about their lives. Leaders ensure there are enough skilled people to deliver safe care that promotes choice, control and individual wellbeing.
Care service managers must make sure that their people who use the care service are always kept safe and well protected. They contribute to people who use the care services’ safety and protection by being aware of any risks to them, continuously assessing these and making plans to minimise any risks that could threaten their welfare.
Risk assessments predict how people who use the care service might be affected by their or others’ behaviour or situations that could harm or injure them, by their staff or in some cases by the public. Having assessed the risks, managers can act to prevent any vulnerable persons from being harmed or injured by drawing up a risk management plan (often referred to as “risk control”).
Risk assessments and management plans are required in several areas, eg nutrition, environment, fire prevention, health and safety, etc. The risk areas that are identified in this topic are mainly those that must be considered in relation to individual needs assessments and care plans.
It should be remembered that everyone is continuously assessing risks to their safety and wellbeing throughout the day, often unconsciously, for example, when crossing a road, driving a car or talking to strangers. In doing so a person will often calculate the benefits of taking the risk against the possible costs and act accordingly on their judgment.
Physical and emotional risks will be considered in most risk assessments, often with more emphasis on one type over the other. Helping people who use the care service to assess the risks to their safety and wellbeing, including assessing possible costs and benefits, requires empathy and should take place as a relationship building process with their full involvement. It is not a checklist exercise.
Risk assessments and management plans have been key tools for care services during the Covid-19 pandemic, eg in relation to:
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the fundamental standards) require care providers to assess and manage different sorts of risk. The key regulations are:
Regulation 9.3(c): Person-centred Care requires care providers to enable and support the users of their service: “to understand the care or treatment choices available … and to discuss, with a … competent person, the balance of risks and benefits involved in any particular course of treatment. In a medical context, this requirement is clear. In social care it could refer to a social worker or registered care manager (as competent persons) discussing the risks and benefits of say someone staying at home or moving into a care home.
Regulation 12.2(a & b): Safe Care and Treatment requires care and treatment to be provided in a safe way, by, for example:
The intention of this regulation is to prevent any avoidable harm or risk of harm to people who use the care service from unsafe care and treatment. Any breach of this regulation is a prosecutable offence, which means that the Care Quality Commission (CQC) could prosecute without first serving a warning notice (depending on the severity of the breach).
However, the CQC has recognised that there may be inherent risks in carrying out some care and treatment. Therefore, if providers can show that they have taken all reasonable steps to ensure the health and safety of people who use the care service and to manage any risks, they might not be in breach of the regulation, or if in breach, at least not prosecuted for the offence. They could still be required to improve their practice.
Of these regulations, it is 12: Safe Care and Treatment that CQC inspectors will mainly refer to when assessing if people who use the care service’s risk assessments and management plans meet the required standards.
CQC requirements are succinctly expressed in the Quality Statement, “Involving people to manage risks”, which the CQC will use once it rolls out its single assessment framework in late 2023 or 2024.
We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.
This statement indicates that inspectors will look for evidence from all sources on how well the service addresses different areas of risk taking under the key question “Is it Safe?”
How a service assesses and manages risk is relevant to the other key questions also, contributing to it being effective, caring, responsive and well-led. Thus, in overview, inspectors will be looking for evidence that:
Examples of the ratings characteristics for each of the four rating levels are given as follows.
Outstanding
The service:
Good
The service:
Requires Improvement
The service:
Inadequate
The service:
The Regulated Services (Service Providers and Responsible Individuals) Regulations 2017 developed under the Regulation and Inspection of Social Care (Wales) Act 2016, now used by the Care Inspectorate Wales (CIW) in their inspections of registered services, reflect the importance of risk assessments to ensure that people receive safe care that promotes their wellbeing. Risk assessments ae integral to needs assessments, including provider assessments, and in care and support planning and reviews.
The key regulations are:
Care providers must achieve the national health and social care standards set out in the national health and care standards, My Support, My Life, particularly Standard 2: “I am fully involved in all decisions about my care and support”, which includes the following.
Care providers assess risks to predict the chances of people who use the care service being harmed by the decisions and actions taken while receiving care. They must then manage any identified risks to reduce or avoid any adverse effects from the care being provided.
For example, a person with a history of falling is highly likely to continue having falls unless appropriate actions are taken to control or prevent their occurrence. Accordingly:
In any of the above events, the care service could be criticised for failing in its duty of care.
Domiciliary care providers will not be responsible for assessing and managing all the risks that might be present in an individual’s home environment and circumstances, but should assess and manage fully all risks for which they have a duty of care.
Even where the risk of something occurring is low, the consequences of a single occurrence might be so serious that it is just not worth taking. For example, if a person using the care service falls from a window they could suffer serious injury or be killed. Therefore, managers must ensure no person is exposed unnecessarily to the consequences of falling by adopting all the measures possible to avoid people who use the care service from falls (eg installing window protectors and checking on their condition).
Risk assessments often require fine judgments, particularly concerning the level of risk to which an individual might be exposed. This applies to care services provided to people in their own homes as to any other service.
In the current climate, where accidents might result in charges of negligence and litigation, managers and care workers understandably tend to opt for a safety first, low risk or even risk averse approach. However, it is important that managers are not averse to the idea of the people who use their care service taking risks. Risk assessments are usually made with a view to preventing certain behaviour or events from occurring. But assessments can also emphasise positive risk-taking that encourages greater choice and independence. For example, there are people who might need to:
(See Positive Risk Taking for People Receiving Care Policy and Positive Risk Assessment and Management Framework and Record Form with a Worked Example.)
In all risk assessments, managers must balance their responsibilities for ensuring people who use the care services’ safety and protection with their rights to make their own choices and decisions. They need to appreciate that the consequences of failure because of taking a risk are not always physical, but are emotional also, which can be just as damaging to a person.
Risk assessments resulting in potential restrictions on choice, freedom, service provision or facilities should be discussed and agreed with the prospective person receiving care and recorded on the care plan.
People who use the care service, particularly younger adults in care homes or supported living, should be supported to take risks as part of an independent lifestyle, and to avoid limiting any preferred activity or choice. They should be able to take responsible risks providing that:
Autonomy is the freedom to choose, and is a key concept in the human rights that should be accorded to people who use the care service. But, with choice comes risk and these ideas must be balanced.
Balancing risk and freedom
Managers should follow these principles in developing and applying their risk assessment and management policies and procedures.
For any risk area or subject managers should ask the following.
(See the Resources section for examples of risk assessment and management tools based on these common principles and key questions.)
The outcome of a risk assessment is a risk management plan, which should form part of the individual’s care plan. A risk management plan requires consideration of:
Managers should build such risk assessment and management processes into their needs assessments, care planning and reviewing procedures. (See Worked Examples for a model risk management plan.)
“Personal safety and risk” must be covered in a needs assessment. In making their assessments, care managers and staff must consider acceptable and unacceptable risks facing people who use the care service in their daily activities. “Personal safety and risk” should also include emotional risk assessments in situations where, for example, people are vulnerable; for example, if likely to suffer from a panic attacks when in a crowd or strange place. A person with a fear of heights will need help to assess the risks before going to the top of a building or, if claustrophobic, to assess the risks before entering an enclosed space. Assessment of such risks is particularly important when supporting a person with autism for example.
Managers should ensure that all risks to be assessed and managed are agreed, recorded, monitored and reviewed as part of the continuous assessment and care services planning procedures.
Managers should focus on differences of views, for example, between the person using the care service, care staff and relatives on what are acceptable and unacceptable risks. These should always be recorded together with any conclusions about the possible consequences of any risk-taking and who accepts responsibilities for this. For example, informal carers and relatives might act against professional advice. The manager must then make sure that they accept responsibility for any harmful consequences and record this.
Managers should refer to the following general checklist when assessing “personal safety and risk” for any individual.
Managers must also consider the resource situation in deciding to implement any risk management plan, particularly where the risks are high or the consequences of failure could be serious. They should consider these questions.
Mental capacity refers to the ability to take decisions. The Mental Capacity Act 2005 sets out who can take decisions, in which situations, and how they should go about this. It also protects people who use the care service against being exploited and abused because of any lack of decision-making capacity.
Needs assessments should include assessments of people who use the care services’ decision-making capacities and any risks that result from lack of capacity. Decisions taken under the Act must be in the person’s best interests and be the least restrictive option.
(See Mental Capacity and Human Rights and Deprivation of Liberty topics.)
The Health and Safety Executive (HSE) guidance, Sensible Risk Assessment in Care Settings, relates to the autonomy of people who use the care service and their right to live their lives as they wish, taking the risks that they consider acceptable.
In health and social care settings this right must often be weighed against the duty of services to care for people and to protect them from danger.
The results of getting the balance wrong may result in an overprotective environment where a person’s independence and autonomy is affected.
The guidance states that the provision of care and support should be tailored to meet the needs of the individual and should encourage them to do what they can for themselves. Where an activity is seen to put a person at some level of risk, then a balanced decision must be made weighing up the needs, freedom and dignity of the individual and their safety.
Care service managers must pay attention to specific risk areas in making their individual needs assessments and care plans.
These include risks relating to:
See:
Risk assessments for individuals should complement those that also must be made in line with more general environmental health and safety issues such as fire safety, equipment and appliances, etc. Risk assessments and contingency plans should also be made for emergencies, including outbreaks of infectious illnesses such as Covid-19, disasters or extreme weather conditions. (See the Emergency Planning in Social Care topic for further information.)
It is possible that some more vulnerable people who use the care service will be at risk from accidental burns because of contact with hot surfaces. Care staff should be aware of this possibility and assess any risks accordingly. The HSE has issued guidance on the need to assess people who could be at risk from being burnt from contact with hot surfaces. These include people who cannot move away from a heat source (eg hot water pipes, radiators or other forms of space heating devices) quickly enough and who may therefore sustain serious burns. This often occurs because they have fallen and are physically unable to move due to their mobility or are trapped by the furniture arrangement.
The HSE points out that the risk of burns from hot surfaces can be reduced by:
Vulnerable people who use the care service should be assessed for any risks from possible exposure to hot surfaces. Factors to assess include:
The results of such risk assessments and any management plans should be recorded on individual care plans.
The HSE recommends that risk assessments should be carried out to identify potential scalding risks from hot water temperatures and to assess the vulnerability of those who have access to bathing and washing facilities.
The risk factors involved include:
The results of the risk assessment and any risk management plan should be recorded on the person’s care plan.
(See the Safety section for detailed information on Health and Safety risks including Fire Safety, and Infection Control for risks relating to the spread of infectious illnesses including Covid-19.)
Care staff must understand the service’s risk assessment policies and procedures and plans relating to individuals. They should receive supervision and training in all types of risk assessment and management plans used in the service.
Training should begin with induction and continue with refresher and further training (see Staff Training and Qualifications).
Staff new to care work will need to achieve the relevant standards for the Care Certificate that include risk issues, particularly Standard 13: Health and Safety.
Staff competences in assessing and managing risks should be regularly checked in supervision and appraisals.
Training in most areas of practice involving risk assessments including health and safety will need to be regularly refreshed.
More advanced training covering different areas in which risk issues occur should include:
Care services could develop some staff members as “risk assessment specialists” or “champions”, whose roles are to advise and train other staff on the different risk issues, eg safe working practices, challenging behaviour, risks to people with dementia.