Managing risk in regulated provisions

Identifying risk and seeking out information on risks is a key part of the assessment process. Any evidence of previous risks, a history of falls, of choking or of recurrent Infections. Is the person frail what is the degree of frailty and what risks result from such frailty?                                                     

Golden rule number one throughout any risk management proceed is ASSUME NOTHING, base your decisions on evidence, not the lack of evidence. If in doubt talk to the person their family previous carers or carry out and record an appropriate review for example a Waterlow for skin integrity, hydration assessments, falls assessment etc this will provide the basic information for your risk assessment                                                     

Risk treatment - What can you do with an identified risk?                                                   

Once a risk has been identified and its priority (the likelihood and potential impact a likely risk with a potential of death will be treated with a higher priority than an unlikely risk with risk of minor harm) determined. The next step is to consider the options for managing (treating) the risk to either stop it from arising, or to minimise the impact should it occur.         

This involves either improving existing controls or developing and implementing new ones (via risk actions/mitigations) to minimise the likelihood of a risk event occurring, reduce the frequency with which it might occur and limit the severity of the consequences in the event that it does occur.         

There are many ways to treat risks, the main ones being: allocating responsibility for managing the risks to specific staff, reporting risks to an appropriate body, introducing procedures and guidance, staff training, checks and inspections (internal and external stakeholders), and implementing physical security controls.         

There are three main categories of ways of dealing with a risk once it has been identified.         

• Put in place mitigating actions that will reduce the risk:

1. the probability of the risk occurring. Make it less likely to happen.
2. reduce the probable impact (the degree of severity of harm) should the risk occur.

• Decide that given the evidence you have the reasonable probability of harm occurring is so low that no actions are required, and you simply accept the risk, as seen in the following example:

Mrs Smith has no history of choking and no indicators of choking. Following assessment, the risk of choking would fall within the “Normal range,” as it would do for you or me. In such a case it is reasonable to decide that no additional action is required (note, it is important for assurance and governance reasons that there is evidence that you have thought about this and checked that there is no other evidence available that could indicate there is a significant choking risk (assume nothing.)         

• You Identify the risk and hand it over (transfer) to someone else to deal with. Taking out insurance for a lift repair contract is an example of ‘risk transfer.’ In the Care Sector different parts of the risk may be delegated to different people or different organisations to manage. In such instances, always ensure you have a clear record of these roles and responsibilities and that the other party is in agreement with what they are expected to do.

Areas of risks that you need to consider         

The areas of potential risk you need to consider, and address are:         

• Those risks that impact on your ability to continue to provide services to those who are dependent on you in the event of a disruptive incident. These risks fall under the category of business continuity management and examples include IT failure, IT hacking, severe weather, fire, flooding, power cuts and pandemics. See Provider’s business contingency (leeds.gov.uk) .
• Risks that impact on those receiving care, e.g. the risk of falls, choking, meds incidents, pressure injuries, infection control etc.
• Environmental risks such as fire, legionella, hazardous chemicals and unsecured stairwells, dangerous dogs in the community
• Risk that impacts on your staff, e.g. lone working, moving, and handling injuries, infection prevention and control.
• Risk to persons entering your premises e.g. families and visitors.

The process always starts with identifying the risk, the harm that could happen and who is at risk        

Remember RULE 1 ASSUME NOTHING:        

A good idea is to screen for all possible risks and look at whether there is evidence for the risk existing or not. If there is any doubt check. If there is no evidence identified, (after appropriate and due diligence) of a particular risk note this and no risk assessment is required.’ Recording this evidences that you have thought about the risk and looked for any relevant information, but the evidence you have managed to collect indicates that no risk exists. No evidence does not mean no risk review and monitor continuously        

Otherwise, if there is any indication of risk you must undertake a risk assessment.        

Like any defensible decision you must be able to demonstrate that you have diligently sought out any relevantevidence.        

There have been several examples where an individual in hospital has had a SALT assessment indicating a risk and that information has been “lost” between the hospital and care home resulting in deaths of the individuals.        

CQC are also finding that staff are not always aware of mitigating actions required when asked by inspectors.        

RULE 2 Ensure all staff are fully aware of mitigating actions         

A key CQC failure point for providers is they (CQC) read the risk assessment and/or care plan and then go and ask staff, what kind of diet does the service user/resident require? If staff are not aware of the correct diet, or other mitigation, this indicates a significant weakness in the risk arrangements and will impact on CQC Judgement for Safe and Well Led.       

An example:                                                

A SALT (Speech and Language Therapist) assessment identifies an individual is at risk of choking.                                               

Or                                               

the individual presents with a series of indicators of being at risk of choking.                                               

The person at risk is obvious in this case the service user and the potential harm from choking is potential death.                                               

There will be differences if the individual is in a care home to being in their own home. But the same process will apply in home care.                                               

That difference will be the degree of control you have. This control is less with someone living in their own home. It is important to remember that you will only be accountable for those areas you have accepted responsibility for; hence these should be clearly documented defined and agreed in the care plan and any risk assessment with family other professionals etc.                                           »                                            

Having identified that a risk exists the next stage is:      

What makes the risk for example choking more or less likely?      

Some examples might be: (Note not all will apply to all individuals and there are other factors that may apply in some cases)      

• Having the correct diet identified,
• Staff being aware of the dietary requirements of the individual
• Staff being observant and aware of the support required to eat - reminding to swallow, slow down eating, small mouthfuls etc
• Ensuring the individual is in an appropriate position, not lying flat in bed or being slouched in a chair.
• Ensuring the person has appropriate accessible drinks.
• Limiting access to inappropriate food e.g. via family and friends

What makes the risk of severe harm less likely?      

• Staff being close at hand and observant not just at mealtimes but at other times when the individual may have access to inappropriate foods to ensure rapid intervention. (Picking up a handful of biscuits or pinching sweets etc).
• Close monitoring of food stuffs and identifying safe alternatives for the individual

Contingency      

• What should the staff do if the individual starts to choke (including containing and protecting other service users if appropriate)
• Clear instruction on who should do what and when (It is important to be specific clearly stating who will do what and who is responsible for ensuring activities are carried out in line with the risk assessment.)
• Who to inform.
• Any post incident follow up.
• Review the risk assessment.

When asked staff should be able to confidently outline the above.      

Not all risks can be fully removed, there may be an element of ‘residual risk.’ The aim is reducing the risk of harm as much as reasonably possible.      

All risk decision making must be in the form of DEFENSIBLE DECISION:    

• In the care plan and any other documents, record defensibly
• These are the facts, Salt assessment, poly pharmacy, dehydrations other indicators
• This is my analysis in my professional opinion given the facts I have
• My decision is that these are the things we can do in this case to mitigate potential harm by making the risk less likely to occur (reduce the chance of Mr Miggins fall or choke or become entrapped in bed rails and reduce the impact should it happen 
• This is what staff need to do, the actions very clearly stated what to do when to do it and if necessary how to do it
• These actions for the staff need to be communicated to staff to ensure that staff are fully aware of the actions they should be taking and can clearly explain these things when asked.

The way risks are managed should be reviewed    

• If the risk occurs
• On receipt of any new or different information
• On a regular basis – the time span for reviews being dependent upon the rate of change for the individual

1. In a respite unite or a recovery unit where peoples condition is less well known or may change more rapidly more frequent reviews for example in a rehab unit you may review weekly
2. If someone is very stable you may review 6 monthly

The aim of any review is to prevent a re-occurrence to the individual but also to identify any learning to prevent a similar thing happening to someone else in the future to prevent a reoccurrence through trying to identify learning. This should form part of your continuous improvement cycle    

The types of risks within a care home vary greatly. We could expect to see risk assessments (e.g. those covering all staff and/or residents including if there are any specialist risks For example, around bottles of cleaning materials etc in a dementia unit where residents could mistake the pretty pink liquid in the bleach container for a nice drink).  

Some examples might be: -  

COSHH (Control of Substances Hazardous to Health) product risk assessment and under the Control of Substances Hazardous to Health (e.g. safe storage of cleaning products). Food safety (e.g. ensuring all food is prepared safely and that food preparation areas are also safe, hygienic). Lift use (e.g. safe use of any installed elevators/lifts)  

Fire safety, including Personal Emergency Evacuation Plans (PEEPs) Personalised in terms of communication needs, special support required and ways of containing anxiety and agitation during an evacuation.  

Lift and stair lift safety, also stairs and stair wells  

Maintenance and use of taps and shower/baths (e.g. this may include checks for legionella or ensuring that temperature control valves are in place for resident’s safety. This may also include risk assessments for use of bathrooms/wet rooms).  

Clinical waste safe disposal and safe handling (e.g. risk assessments containing information and guidance on how to use/dispose of contaminated pads/clothing or safe disposal of needles used in nursing care).  

Any building work taking place while the care home is still open, must be fully risk assessed with rigorous mitigating actions including induction of any staff not used to working in care homes e.g. don’t leave tools lying around.  

Please note, this is not an indicative nor an exhaustive list.  

There is useful information to be found on the internet, for example, HSE (Health and Safety Executive) have published a guide entitled health and safety in care homes . This was last updated in 2014 but is still relevant. 

The types of risks within home care are very similar to a care home. The difference in Home Care is that you do not have control over the working environment in someone’s own home.  

Though the risks may be present as in a care home hazardous to Health substances, fire safety issues, maintenance etc. You do not have the control to address these risks in a person’s home, but you must still assess the risk under duty of care but what you do with the assessment differs, you cannot make someone undertake changes in their own home, but you should make them or someone who can action them a family member etc aware of the issues.  

An individual has the right to make a risky decision however they do not have the right to put others at risk and you have a duty of care to your staff. Therefore, you must undertake a risk assessment of the working environment, for example lone working in areas of known high crime rates etc, and where required put in place mitigating actions to ensure your staffs safety. If there are issues regarding serious risk of harm that cannot be mitigated and providing a service would put staff at unacceptable risk, then social workers contracts etc should be involved to derive a solution.  

Services provided by your own staff as part of the persons care plan should be assessed as above to ensure that those services are provided safely. If someone is at risk of choking, then the process is the same as it would be in a care home with adaptations of not leaving until safety was assured and being clear where your responsibility ends, through agreement with other decision makes such as the individual family etc  

Where other potential risk risks are identified, for example an individual with COPD who smokes in bed throwing tissues into a bin that they also use for cigarette ends, is a real example.  

 If the person has capacity, then Duty of Care indicates that the risk should be assessed in the same way and the individual made aware of the risk and the actions that they and others can take identified. It is then up to them to take the actions as they wish or not, your responsibility is discharged if any actions for staff and agreed by the service user are carried out. You have identified the risk and made the person aware of that risk and done all you reasonably can to mitigate the risk. You have discharged your duty of care In someone’s own home you have no power to enforce any actions on the service user or institute any rules in the service users own home unless they freely agree.  

Given the potentially very serious potential impact of some risks we would suggest considering getting the individual to sign the risk assessment saying they understand the risk and its potential implications, and they are happy to continue, however. Effectively you have identified a risk but then transferred responsibility for the mitigating actions to the individual or the family and they have accepted them (You would need to ensure in the case of the individual that they have capacity to do this.)  

Where someone does not have capacity then there is the MCA (Mental Capacity Assessment) and BI (Best interest) pathway involving the family, friends and/or an advocate who also have a duty of care to the individual.  

Any risk assessment in relation to a service user must be discussed either with them, or their immediate family/representative, or made on a best interest basis. If no representative is available and the resident does not have capacity to be aware of the risk (following a mental capacity assessment) then an advocate should be considered via a referral back to social work.  

It is not possible to compile a full a list of potential risk assessments for residents as individual care and support plan vary massively as do the environments that they live in.  

Some examples are seen below:  

Entrapment within bed rails. A risk assessment regarding entrapment within bed rails would only be in place for a resident, where bed rails where being used to prevent the resident falling out of the bed and injuring themselves (following a risk assessment and potentially a best interest decision about the use of bed rails in the first place).  

Risk of slip, trip, or fall. However, like all risk assessments this should be specific to the individual and not a one size fits all generic risk assessment. What affects one person to have a risk of a slip, trip or fall would not necessary be relevant to another person. The risk assessment would include information to enable the person to be as mobile as possible whilst also being safe.  

Risk of choking on food. This risk assessment would be in place for anyone who had a history of choking on food. Advice and guidance from external professionals should be sought e.g. SALT (Speech and Language Team) would be involved, if there is a delay the team should be able to advise on what to do in the meantime to reduce the risk which should eb recorded. Recommendations from SALT may include cutting food into bite sized pieces, fork mashing food, only having a soft food diet, having a pureed diet, or even having a pureed diet and the use of thickeners as prescribed for the resident. There should also be information available to tell staff what to do in the event of a choking incident.  

Risk of medication, missing meds, overdose on meds, poly pharmacy.  

Use of wheelchairs, only of the person uses a wheelchair  

Skin Integrity if identified at risk.  

Behaviours in this case you may need to consider who is at risk other service users’ staff etc deepening on the behaviour  

Again, this is not an indicative nor an exhaustive list. It is important to confirm that you have identified all risks relating to an individual and noted all indicators that risks might exist  

It is important to note that every despite the best risk management something may occur despite all your careful planning and management, in some cases things happen out of the blue without any warning indicators. In such cases it is important to review in depth and see what can be learned if there is any way to prevent something similar happening to someone else in the future as part of your continuous service improvement. It is also important to review all incidents accidents etc for the same reason to see if anything can be learned that will prevent the same thing happening to others in the future.  

CQC have also published a guide around learning from safety incidents . To support this development  

There are two main things to remember when undertaking risk assessments. One is that at the heart of the support plan and risk assessment lies the resident.  

Secondly the resident may still have wishes, aims, goals and desires which to others may seem risky. The resident may want to go scuba diving, horse riding, parachuting etc.  

All of these have been undertaken by people who have care and support needs.  

There is no reason why, when weighing up the pros and cons of a situation, any resident should not be able to do whatever their heart desires if the improvement in wellbeing outweigh the risks and does not result in risk to others  

Person centred care is supported by the requirement that any risk management plan and any mitigations must represent the least restrictive option for that individual.  

If a service user or resident has a minor history of falls but it has been identified that a walk in the garden is very beneficial to her well-being, and the garden is a safe space with raised beds flat walking surfaces with no trip hazards, with lots of grab points then preventing the service user/resident going for a walk in the garden may not be seen as the least restrictive option, it may be that being accompanied by a staff member when available is a less restrictive option, or providing some walking aid.  

The first principle the of the Mental Capacity Act (2005) is to always assume that the person has capacity, and that every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise.  

The third principle states that people (who have capacity) have the right to make decisions that others might regard as unwise or eccentric. You cannot treat someone as lacking capacity for this reason. Everyone has their own values, beliefs and preferences which may not be the same as those of other people.  

You can find more information on sensible risk assessments here .  

In the case of people taking risky decisions especially if they live at home the recommended approach as outlined above is to carry out a full risk assessment and share it with the individual. The aim is to ensure they fully understand the risk they are taking and if they continue to undertake the behaviour they do so in the full knowledge and understanding of the potential consequences. Some examples may be smoking whilst using Oxygen, smoking and emollient fire risk are just two unfortunately common examples. Remember though that you have a duty of care to staff, and you would need to make it clear to staff what they need to do to keep themselves safe e.g. do not provide care if individuals are smoking, usually taken care of by a not smoking prior to or during care requirement  

Quality of evidence for the risk or for the lack of the risk:                       

Remember GOLDEN RULE NUMBER 1 (for risk assessments) ASSUME NOTHING and preferably get the details in writing.  

You should and anyone else CQC, Auditors family should be able to follow the risk management story how you sought out the facts and used them to identify the risks, how you analysed those risks to find mitigating actions this story should be clear in the recording – do the documents tell the story without leaving any questions unanswered from the evidence received and does the assessment flow into the actions agreed. An indicator of a really good risk assessment is that anyone should be able to read it and know what actions are required.  

A new member of staff or agency worker should be able to easily read a short document to clearly know what they needs to do and why:  

Then:  

What is the quality of analysis (How reasonable is it ) in deriving mitigating actions, (are they reasonable appropriate and least restrictive) will the actions actually reduce the probability of the risk, and where possible reduce the impact, reduce the likely degree of harm from the risk?  

The following steps should be clear  

• Identifying in the case of this individual what makes the risk more or less likely and how to manage this
• Is there anything that can be done to reduce the impact of the risk should it occur.
• How should this be managed
• Clear mitigating actions what needs to be done when and identifying who will do what when.
• Contingency what to do after the risk has occurred to minimise the impact with clear who will do what when details.

GOLDEN RULE NUMBER 2 for risk assessments, make sure all staff are aware of what they should be doing to treat the risk. If they don’t, then what was the point of doing the risk management process? During an inspection CQC inspectors will read through care plans and then on a visit they will ask both the manager and the staff what the mitigating actions should be for specific risks for individual service users if staff or even the manager doesn’t know CQC will deem the service not Safe, staff didn’t know the mitigating actions and not Well Led because the management didn’t make sure staff knew the mitigating actions