Risk management in social care: new guidance in 2007

November 29, 2006 in Adults, Children

New guidance could be set to alter social workers’ thinking on the delicate question of service users’ exposure to risk, an issue close to the heart of the service user movement. Anabel Unity Sale reports

How much risk are you willing to personally take? Now think about the clients you work with: how much risk do you think they should be exposed to? Is it more or less than you would like in your personal life? The question of risk lies at the core of social care’s drive to enhance clients’ independence and it affects how practitioners help users to make their own choices.

The white paper Our Health, Our Care, Our Say had a strong focus on enabling adults to live independently by giving them a choice of services, such as individual budgets. Inevitably this will involve an element of risk to the user in some situations; a risk that their family or social worker might be unhappy about them taking.

To help care providers deal with issues connected with risk, the Department of Health is due to publish a draft best practice guidance document in the spring.

The guidance – or supporting decisionmaking tool as it is likely to be referred to – has already been subject to consultation with users and practitioners around the country. The DH is also being advised by an external steering group which includes the Association of Directors of Social Services, the NHS Confederation, Mencap, Carers UK, and Better Government for Older People.

The guidance will include examples of:
● Potential risk issues, with details on how some care providers have tackled them.
● Conflict resolution by practitioners.
● Advice on documenting decisions and how to ensure that users understand their responsibilities and decisions, so that they appreciate the implications of their choice if things go wrong.

The relationship between risk, responsibility and regulation is of growing importance in public policymaking. The prime minister charged the Better Regulation Commission (BRC) with looking at the debate and last month it published its first major report on the subject.(1) Lynne Berry (pictured), chief executive of the General Social Care Council, headed the BRC sub-committee that oversaw the report’s creation. She says more needs to be done to challenge the prevailing assumption that government can and should manage risks.

“We wanted to create a new understanding between government, regulators, the media and the public that we all share a responsibility for managing risk and that, within the right circumstances, risk can be beneficial and should be encouraged,” Berry says.

Social workers are trained in risk assessment and risk management. Berry says staff are realistic and aware that “all risks cannot and should not be eliminated”.

Berry herself became embroiled in the debate when she suggested earlier this year that registration should extend to personal assistants working for direct payments users to protect them from abuse. While a well-meaning intention, many disabled people feel that this will restrict who they can employ, therefore reducing choice and control. They want those who are employed through a direct payment to have the choice to register, not an obligation.

More recently at the National Children and Adult Services conference, Berry said no decision had been made, adding “it will need to be driven by what users want. My guess is we will be talking about some sort of voluntary registration”.

Clients often undergo a risk assessment and it is sometimes the result of this that proves problematic, says John Winkler, head of independent living services for disability charity Scope. He says practitioners are often concerned by clients’ resistance to the constraints imposed after assessments.

“A risk assessment may say a person’s wheelchair is not suitable for transportation in a particular type of vehicle. Service users occasionally complain when risk assessment constrains activity for health and safety reasons.”

The real and perceived risks clients face may also influence how professionals work with them. Chris Hampson, director of strategy and service delivery at Look Ahead Housing and Care, says staff in supported housing schemes are often placed in risky situations because schemes are in “less than ideal” locations and there is a high level of alcohol and drug use among sme clients.

Consequently, he adds, this can affect practice: “It can result in poor service delivery and a loss of innovative ways of working and achieving successful outcomes with vulnerable clients.”

Clients often lack insight into their situation and what their vulnerabilities may be, leading to a distorted perception of risk, Hampson adds. To help combat this, Look Ahead has produced a good practice guide to help supported housing providers plan for risk management.(2)

Social care practitioners know more than most about the blame culture. No professional wants to see their face in a tabloid newspaper when their client is injured or dies, but this happens to social workers. So are staff really concerned they will be blamed if something goes wrong because of a decision the client made?

Berry says the BRC found evidence of those working in public services feeling “increasingly under pressure” about the consequences of their decisions. “That’s one reason we wrote the report.” However, she adds social workers have an excellent resource in managing risk in the form of the GSCC codes of practice.

Winkler says that as long as suitable staff are recruited, trained and supported and robust risk assessment policies are in place practitioners should not fear blame. He adds that balanced risk-taking occurs where risks are properly evaluated by all those concerned and where there are good person-centred planning processes in place.

So how can practitioners improve risk management without curtailing their clients’ freedom and stifling their choices?

Winkler advocates staff and users have an “open and frank” exchange that is recorded in the support plan and risk assessment documentation. He adds that if a serious breach is made on either side it must then be discussed and a further review conducted.

Hampson says practitioners in supported housing are used to balancing individual rights with the desire to minimise risk to staff, clients and the community on a daily basis. But he says: “As we increase choice in service provision the stakes will be higher for our clients. We need to ensure mechanisms are in place to support clients to assess the risks they make.”

Berry says social care workers must respect the rights of service users while seeking to ensure that their behaviour does not harm themselves or other people. This includes, she adds, recognising that service users have the right to take risks and helping them to identify and manage potential and actual risk to themselves and others.

Berry adds: “If we are to have a vibrant society in which people are able to make their own choices, in which we challenge notions of vulnerability and dependence and replace them with ideas of autonomy and interdependence, that’s something to be celebrated, not avoided.”

● If you wish to comment on or inquire about the DH guidance, e-mail adultsocialcare@dh.gsi.gov.uk

(1) Risk, Responsibility and Regulation – Whose Risk is it Anyway?, Better Regulations Commission, 2006
(2) Positive Risk Taking: A Good Practice Guide for Supported Housing Providers, Look Ahead Housing and Care, 2006