Positive Risk Management Good Practice Guidance Supporting Individual Choice

positive risk management good practice guidance supporting individual choice and control social care and health

Positive Risk Management
Good Practice Guidance
Supporting Individual
Choice and Control
Social Care and Health, Social Work Services
Scottish Borders Council
and
NHS Borders
June 2011
Contents
Summary 3
Introduction 4
Section One – Background to Positive Risk Management
What is risk? 5
Key principles of working with risk 6
What is positive risk management? 6
Section Two - Practice Guidelines:
1.
Risk Identification 8
2.
Risk Assessment 8
3.
Risk Management 10
4.
Critical Incident Review
Appendices 12
1. Decision making and recording
2. Legislation and Legal Principles
3. Policy and Guidance
Scottish Borders Council/NHS Borders acknowledge the influence of the
risk management policies of Gateshead and Cumbria Councils in drafting
this document.
SUMMARY
This joint document has been produced by NHS Borders and Social Work
Services to provide good practice guidance to staff on risk
management.
National policy direction in health and social care promotes a rights
based and personalised approach. If we are to deliver health and
social care services that offer individual control and choice then we
need an approach to risk that is able to deliver this agenda.
Positive risk management is an approach that recognises the importance
of professional judgement, with assessment tools that inform this
judgement, and an understanding that ‘the sort of society in which
there is no risk is neither achievable nor desirable’.
Positive risk management must take into account duties placed on staff
such as the Multi-Agency Adults at Risk Protection Arrangements and
Health and Safety legislation.
For staff within NHS Borders, Social Work Services and partner
organisations positive risk management includes:
*
Working in partnership with people who use services and carers
*
Helping people to access and widen their opportunities and
understand the consequences of different actions
*
Recognising that people learn from risk and experience enhances
individual’s quality of life
*
Ensuring staff use the appropriate procedures and assessment tools
*
Ensuring staff receive appropriate support and supervision
*
Ensuring accurate recording and appropriate information sharing
A structured approach to the identification, assessment and management
of risk, and review of incidents is essential.
Identification of Risk- this needs a balanced approach, which looks at
what is and is not a manageable risk. Not every situation will entail
a risk that needs to be assessed or managed.
Risk Assessment – is a process of thinking through with the individual
and others who can contribute to the process – it involves weighing up
the potential benefits and harm and putting things in place to manage
and minimise the risks.
Risk Management –is the activity of exercising a duty of care where
risks are identified, and can entail a broad range of responses to
reduce the negative consequences of risk and promote the potential
benefits of taking appropriate risks. This will occasionally involve
more restrictive measures where the risks have an increased potential
for harmful outcomes. Decisions need to be negotiated and understood
between all parties.
Introduction
Within society generally, people are encouraged to travel widely, take
part in regular leisure and sporting activities, go to college,
develop careers and have families. These are all activities in which
people take risks to achieve their aspirations, and for many people
risk is an accepted part of life. People with disabilities, with
mental health needs and older people are often discouraged from taking
risks either because of their perceived limitations or fear that they
or others might be harmed, resulting in criticism or claims against
health or social care services.
‘Changing Lives’, the 21st Century Social Work Review recommends a
change in organisational culture in order to promote personalisation.
Central to this approach is greater user and carer empowerment and the
management of positive risk taking. Social Work operates in a risk
averse and litigious society, however, to be able to deliver more
personalised services Social Work and its partners need to manage risk
effectively and support creative approaches to managing risk which
enable individuals to live as full a life as possible.
The Scottish Government in ‘Delivering for Health’ promotes user
empowerment and responsibility as a way to of support people to take
more care of their health. Documents such as the NHS Scotland ‘Rights
, Relationships and Recovery: The National Review of Mental Health
Nursing in Scotland’ (July 2007) state the importance of a rights
based and person-focused approach to practice.
Within the next year the Scottish Government plan to introduce a
strategy and Bill on self-directed support. Self directed support
encourages` people to meet their needs in ways that best suit them.
This means that we need an approach to risk that is suited to
delivering this agenda, one that is proactive, that manages risk, is
about working with users and carers to build on their capacity and
skills, and is open to learning.
This guidance takes account of the 2007 Scottish Government ‘Effective
approaches to risk management in social work: an international
literature review-research findings’. A key finding is that the
relationship between worker and client is paramount to effective
working in risk assessment and management. Positive risk management is
an approach that recognises the importance of professional judgement,
with risk assessment tools that inform not replace this judgement, and
an understanding that ‘the sort of society in which there is no risk
is neither achievable nor desirable’.
The Council and NHS Borders will endeavour through commissioning
arrangements and Service Level Agreements to encourage agencies and
services they contract with to adopt a positive risk management
approach. The effective identification, assessment and management of
risk and review of incidents can be supported through policy,
procedures and practical tools that can be used by practitioners.
Social Work Services, NHS Borders and its partners recognise that any
positive risk management approach must be balanced with its
responsibilities to implement the Multi-Agency Adults at Risk
protection arrangements and takes into account the Management of
Health and Safety at Work regulations 1999 regulation 3 – the
statutory obligation to assess and record the significant risks.
This is joint guidance although each organisation recognises that they
have their own risk tools.
Scottish Borders Council’s General Risk Assessment Procedure and
Guidance and the SBC Health and Safety Policy govern how general risk
assessments are carried out in the Council. The principles adhere to
the Health and Safety Commission’s ‘Principles of Sensible Risk
Management’. The Health and Safety Executive’s ‘Five steps to risk
assessment’ should be referred to.
Within its ‘Guidelines for Management of Clinical Adverse Event
Recording’ (p5) NHS Borders states that ‘clinical risk events will
never be prevented altogether…the underlying principle of effectively
managing risks are based on valuing people, working in partnership
with each other, sharing information and experiences in order to learn
from each other and be open to changes in practice as necessary and
plan care in a way that reflects this learning within an open, fair
and just culture.’
Section One – Background to Positive Risk Management
What is risk?
Risk is the probability that an event will occur with beneficial or
harmful outcomes for a particular person or others with whom they come
into contact.
For example, an event can occur because of:
*
risks associated with everyday activities and might be increased
by a person’s frailty or disability e.g. falls
*
accidents, for example, in the community, during travel to work,
shops
*
the misuse of drugs or alcohol
*
the use of medication
*
behaviours resulting in injury, neglect, abuse, violence,
aggression and exploitation by self or others
*
suicide or self-harm
Risk is often thought of in terms of danger, loss, threat, damage or
injury. But as well as potentially negative characteristics,
risk-taking can have positive benefits for individuals and their
communities
The difference for many disabled adults and older people when they
take risks is that they may do so when being supported by a paid
support worker There will be times when a disabled or older person
might take risks on their own, but the service might be held
responsible if harm to them or others occurs.
A balance therefore has to be achieved between the desire of people to
make decisions about the level of risk in their everyday lives, the
duty of care owed by services and employers to their staff, and the
legal duties of statutory and independent services.
In this circumstance the risk to staff in terms of accountability for
outcomes also needs to be considered. It is recognised that the
support and trust of the employing organisation needs to be explicit
if staff are to promote a sensible risk management approach in respect
of their work with clients.
Key Principles of Working with Risk
A number of important issues need to be considered by practitioners
when carrying out risk assessments and risk management:
*
Practitioners should promote the independence and social inclusion
of users; this includes helping the person to understand the
consequences.
*
All stakeholders should be involved and whenever possible in
multidisciplinary meetings, with responsibility for actions agreed
and shared and joint accountability recorded.
*
Involvement of people who use services, their families, advocates
and practitioners from a range of services and organisations helps
to improve the quality of risk assessments and decision-making.
*
Decision based on clear reasoning, evidence and involving all
stakeholders, with recorded outcomes and care planning are
transparent and accessible to all
*
Risks change as circumstances change.
*
Risk can be minimised and/or managed, but not eliminated.
*
There are inherent risks in relation to record keeping in that
information may sometimes be incomplete or inaccurate.
*
Identification of risk carries a duty to do something about it
i.e. identify ways to minimise risk/risk management..
*
Managing risk should involve everybody working together to achieve
positive outcomes.
*
Confidentiality is a right, but not an absolute right and may be
breached in exceptional circumstances when people are deemed to be
at risk of harm or it is in the public interest.
*
The standards of practice expected of practitioners must be made
clear by their team manager/supervisor, and by organisational
policies and procedures, to give staff the confidence to be
involved in decisions to take risk.
*
Sensitivity should be shown to the experience of people affected
by any risks that have been taken and where an event has occurred.
What is positive risk management?
Positive risk management is: ‘weighing up the potential benefits and
harms of exercising one choice of action over another. Identifying the
potential risks involved, and developing plans and actions that
reflect the positive potentials and stated priorities of the service
user. It involves using available resources and support to achieve the
desired outcomes, and to minimise the potential harmful outcomes’.
(Steve Morgan, risk consultant, 2004)
For staff within NHS Borders, Social Work Services and partner
organisations, this means:
*
being empowering
*
working in partnership with people who use services and carers
*
developing an understanding of the responsibilities of each party
*
helping people to access and widen their opportunities
*
developing trusting working relationships
*
helping people who use services to learn from their experiences
*
understanding the consequences of different actions
*
making decisions based on all the choices available and accurate
information
*
being positive about potential risks
*
understanding a person’s strengths
*
knowing what has worked or not in the past
*
where problems have arisen, understanding why
*
ensuring support and advocacy is available to service users
*
sometimes tolerating short-term risks for long-term gains ie
people learn from risk, and experience enhances individuals’
quality of life
*
gradually withdrawing inappropriate services that are not
promoting independence
*
having an understanding of the different perspectives of clients,
carers, practitioners, advocates and services
*
ensuring staff use the appropriate procedures and assessment tools
and receive appropriate support and supervision
*
accurate recording and appropriate information sharing
Understanding the Purpose of Risk Assessing
YES 
NO
“If someone wanted to do something new which involved risks, I see my
job as being to help them understand the risks involved. I would work
with the person and others to minimise and manage the risks so that
the person is supported and enabled to make informed choices about
this and can do the things they want to do”.
“If someone wanted to do something new I would plan a risk assessment
to eliminate any risk of harm to the service user.”
It is the job of people involved in social and health care to manage
risk rather than to try to keep people safe at all costs. People
should be supported to think through the risks and to make informed
choices (see ‘informed choice’ within Section Two - Practice
Guidelines) It is important that organisational issues to do with
health and safety, policies and procedures, fear of litigation, etc.
are fully understood whilst promoting the goals and human rights of
individuals as citizens.
Section Two – Practice Guidelines
Risk Identification, Assessment, Management and Critical Incident
Review
A structured approach to the identification, assessment and management
of risk and the review of incidents is essential as the total
elimination of risk is impractical. It is vital that staff use the
procedures and assessment tools that have been developed and
implemented by their service and seek clarification from their
manager, if they are unsure of what is expected of them. Agreed joint
tools and procedures across partner organisations should be used where
possible.
1. Risk Identification
======================
Identification of a risk should involve a balanced approach, which
looks at what is and is not a manageable risk. It should be a view
based on an individual’s aspirations, which aims to support them to
get the best out of life. The views of adults who use services and
their families and family carers are equally as important as those of
practitioners.
Not every situation or activity will entail a risk that needs to be
assessed or managed. The risk may be minimal and no greater for the
adult concerned than it would be for any other person. For example,
does a person need to be assessed in relation to risk just by having a
disability?
2. Risk Assessment
Risk assessment is a process of thinking things through with the
individual and others who can contribute to the process. It involves
weighing up the potential benefits and harm and putting things in
place to manage and minimise the risks. The following should be
considered:
====================================================================
*
The service user should not simply be seen as the source of risk –
their view of risk and that of their families and carers have a
prominent place in the identification, assessment and management
of risk.
*
When gathering information staff need to emphasise the importance
of information that is accurate and identifies any concerns or
issues that may increase the probability of an event occurring.
*
There should be a focus on a person’s strengths to give a positive
base from which to develop plans that will support positive risk
management e.g. their abilities, social and family networks, the
diverse support and advocacy services available to them.
*
A person-centred approach should be used to identify, assess and
manage risk.
*
An assessment needs to be clear if it is to protect the individual
or others.
*
Every individual or agency directly affected should be involved in
the development of a positive risk management plan that agrees on
the approach to risk and how identified risks will be supported.
Consensus helps to support positive risk-taking and promotes a
person-centred response.
*
If anyone involved in the care plan does not agree with the
assessment, the reasons for this should be recorded, and any
concerns they have about the action being taken noted
*
The influence of historical information in any assessment should
be concerned with understanding what happened if risk-taking
resulted in harm rather than the stigma of the events themselves
Informed choice
Risk assessments will involve making judgements about a person’s
ability to exercise informed choice. Where it has been agreed the user
can make an informed choice i.e. has capacity, then the risk
assessment process should enable individuals to make their own choices
in the context of their own culture and values.
An ‘informed choice’ means that a person has the information and
support to think the choice through and to understand what the
reasonably expected consequences may be of making that choice.
Enabling people to make informed choices does not mean an abdication
of responsibility to ensure people have a good quality of life. We
have a responsibility to support people to understand that with rights
comes responsibility.
Where the individual lacks capacity they are unable to make an
informed choice, this may also be the case when the individual
involves themselves in drug/alcohol misuse to a degree that affects
their judgement and puts them in high risk situations. In these
situations there should always be a case conference to consider
appropriate choice and control issues.
3. Risk Management
Risk management is the activity of exercising a duty of care where
risks (positive and negative) are identified. It entails a broad range
of responses linked closely to the wider process of care planning and
may involve preventative, responsive and supportive measures to reduce
the potential negative consequences of risk and promote the potential
benefits of taking appropriate risks. These will occasionally involve
more restrictive measures and crisis responses where the identified
risks have an increased potential for harmful outcomes. Decisions need
to be negotiated and agreed between all parties, and clearly
understood. The following must be considered:
*
Decision making in relation to risk, and the process, must be
clearly evidenced on relevant documentation.
*
Managers / supervisors have a responsibility to ensure that their
approach supports practitioners in risk decisions.
*
Risk management is enhanced by working to shorter timescales, with
smaller goals. This is supported by having mechanisms to check on
progress and to quickly change previous decisions when needed,
including intervening in a more restrictive way where necessary.
*
Risk management should be part of a practitioner’s ongoing work
and reflected in people’s case notes.
*
Individual practitioners are expected to accept responsibility for
professional standards of conduct but it is the collective
responsibility of the team to share information, make decisions
and plan.
*
There may be a statutory responsibility e.g. when an individual is
assessed as ‘lacking capacity’ in relation to a specific decision
or ‘at risk’ - see appendix for legislation
*
Positive risk management needs to be underpinned by contingency
planning for any change in circumstance.
*
Where people are behaving recklessly, risk management may include
the setting of explicit boundaries to contain situations that are
developing into potentially dangerous circumstances for all
involved. If a person or their carer makes a decision to continue
behaviour that is reckless, a record should be made of their
decision and when it was taken. If staff are affected by this
decision, any support service being provided will be reviewed to
ensure that how it is delivered guarantees the safety of any
worker involved.
Information Sharing
Information gathering and sharing is an essential part of risk
assessment and management, and is key to identifying a risk in the
first place. However, the use and sharing of information must respect
the principles outlined in the Data Protections Act 1998 and Scottish
Borders Information Sharing Protocol 2008 (e-link to be added). When
collecting new data or information, it is important to tell the person
and their family carers the purpose of the data collection, why
information gathering is necessary, whom it will be shared with, and
wherever possible to get written consent to share.
Decisions need to be transparent and evidence based as good practice
and to allow for scrutiny by external agencies. Therefore during the
identification, assessment and management of risk, practitioners must
ensure that information shared or gathered is properly recorded to be
able to evidence the:
*
Formulation of a logical, informed multi-disciplinary opinion as
to the severity of risk.
*
Involvement of the adult, their family and any health, education,
social care, advocacy or independent sector professional involved.
*
Inclusion of the adult and their family in decision-making
*
Identification of conflicting opinions and interests.
*
Evidence of reasons for actions
4. Critical Incident Review
In the context of this policy, an incident is when an event occurs
that results in physical, emotional or psychological harm to an
individual in receipt of services, practitioner or other. This also
includes ‘near misses’ with the potential for harm.
If things go wrong and the risk management results in a negative
outcome for the individual, there is no doubt that the risk taking
process will come under scrutiny and the way in which this process
worked to minimise the foreseeable risks will be considered. Those
scrutinising what happened will be looking at whether those involved
in the risk assessing process acted appropriately and in accordance
with risk policy.
The way in which staff followed policy and procedures, evidenced their
consideration of risk, utilised their training, and acted reasonably
and responsibly will be given due consideration and regard when
investigations are made into the risk management process.
Scottish Borders Council and NHS Borders recognise that the point at
which a risk becomes an incident is a traumatic time for
practitioners, as well as everyone else involved and that there is a
need to support staff after an incident and to undertake the duty of
care to staff.
To report and investigate an incident refer as appropriate to:
NHS Borders ‘Policy document; Mental Health and Learning Disability
Network; the Conduct of Critical Incident Reviews.’
NHS Borders ‘Guidelines for Management of Clinical Adverse Event
Recording’, 2007
NHS Quality Improvement Scotland ‘Fatal Accident Inquiries’. A Guide
for NHS staff’, 2007
Request for Inter-Agency Practice Review- form
SBC Accident/Incident Procedures and Arrangements
Adult Support and Protection Significant Case Review procedures
(draft)
Appendix 1
----------
Decision Making and Recording
-----------------------------
The decision-making involved in the assessment of risk and its
management is generally effective in avoiding harmful situations but
it is not infallible and it should be open to scrutiny. An open and
transparent decision is one where:
*
All reasonable steps have been taken to identify risks and put in
place a care plan that will maximise choice and independence and
minimise risk.
*
Reliable, agreed and joint assessment methods have been used.
*
Information has been collected and thoroughly evaluated.
*
Decisions are recorded and subsequently carried out.
*
Policies and procedures have been followed.
*
Practitioners and their managers adopt an investigative approach
and are proactive.
Risk Enablement Panel
A risk enablement panel is a tool that can be used by any organisation
to ensure that staff and individuals feel supported in seeking
positive solutions and outcomes in the process of making a difficult
decision. Risk decision making can be shared. The panel should ideally
be multi-professional and can meet in exceptional circumstances where,
for example, the risks identified are perceived as exceeding what is
reasonable; there is conflict in the decision making process
Appendix 2
Legislation and Legal Principles
When approaching the identification, assessment and management of
risk, knowledge of key legal principles and legislation will help
practitioners to make informed decisions and promote best practice.
Where there is doubt about a legal issue expert advice should be
sought from the organisation’s Legal and Corporate Services.
Legislation
a) Human Rights
These are rights and freedom to which every human being is entitled
e.g. the right to liberty and security. The Human Rights Act 1998
brought the European Convention on Human Rights into domestic law for
the UK in 2000.
b) Disability Rights
A legal framework has developed in the UK to protect those affected by
disability discrimination. See in particular the Disability
Discrimination Act 2005 and Disability Equality Duty 2006.
c) Adults with Incapacity (Scotland) Act 2000
Should there be any concern about the capacity of the individual in
assessing risk there should be discussion with line manager/mental
health team/GP/consultant psychiatrist.
For information go to:
www.scotland.gov.uk/justice/incapacity
d) Adult Support and Protection (Scotland) Act 2007
This Act introduces new duties to support and protect individuals who
fall into the category of ‘adults at risk’. Any intervention should
benefit the individual and should be the least restrictive option of
those that are available.
For further information:
www.scotland.gov.uk/Topics/Health/care/adult-care-and-support
e) Safety at Work
The Health and Safety at Work etc Act 1974 places requirements on
employers to ensure their employees' health and safety, and a duty on
employees to take reasonable care for their own health and safety.
The Management of Health and Safety at Work Regulations 1999 contain
the requirement, purpose and principles of risk assessment for
significant health and safety risks. Employers have a responsibility
to others for health and safety. NHS Borders and Social Work Services
staff should contact their organisational health/wellbeing and safety
advisors for professional advice and support.
Legal Principles
a) Duty of Care
===============
This is a requirement that a person acts towards others and the public
with the watchfulness, attention, caution and prudence that a
reasonable person in the circumstances would use. If a person's
actions do not meet this standard of care, then the acts may be
considered negligent. Professional workers owe a specific duty of care
to the people they work with. The standard of conduct and behaviour
expected of people in their professional role is higher than for an
ordinary person because of the professional training they have
received and the level of responsibility they assume.
b) Negligence
=============
Negligence is carelessness amounting to the culpable breach of a duty,
such as failure to do something that a reasonable person (i.e. an
average citizen in that same situation) would do, or doing something
that a reasonable person would not do. In cases of professional
negligence, involving someone with a special skill, that person is
expected to show the skill of an average member of his or her
profession.
Appendix 3
Policy and Guidance for reference
NHS Borders ‘Consent to Treatment’, Sept 2008
Public Protection Agency Guidelines
Codes of Practice for Social Service Workers and Employers: SSSC
SBC Health and Safety Policy and guidance
See also documents referred to within this guidance
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