RELATED CHAPTER

Promoting Wellbeing

Mental Capacity

This chapter was added to the MAPP in November 2018.

1. Introduction

Risk taking is part of daily life and does bring benefits, including wellbeing (see Promoting Wellbeing). The evaluation and management of risk, therefore, is an essential part of the assessment process and is a necessary for identifying an adult’s level of need and eligibility for services. Not all risks can be eradicated, but they can be managed to prevent or reduce the impact of harm.

Some risks are general and some specific, but in each case risk should be defined in relation to a specific situation, that is, what is the presenting risk and /or who or what is the risk. Undertaking a comprehensive risk assessment involves collating evidence based information, evaluating that information – balancing possible positives of a course of action against potential drawbacks – and using professional judgment to ascertain the potential for the occurrence of harm.

Adequate risk assessment can rarely be done by one person alone and a coordinated approach is required. Good relationships between professionals, the adult and their carers makes the assessment easier and more accurate, and may indeed reduce risk.

A risk assessment needs to identify and balance different perceptions of risk, including the adult, their carers and professionals; the adult’s right to make informed choices about taking risks should be safeguarded and encouraged. Decisions about risk, however, do need to balance any risk to the public and the needs and wishes of the adult.

If the adult lacks capacity to make decisions (see Mental Capacity), the risk assessment must take account of the views of family members or friends important to the adult and who have an interest in their welfare or, where appointed, their Attorney or Independent Mental Capacity Advocate (see Independent Advocacy).

2. Roles and Responsibilities of Staff

The professional undertaking the assessment must be supported throughout the process by their manager, to ensure all aspects of the situation have been understood, evaluated and the views of the adult, their attorney and / or advocate where appointed and other agencies and service providers have been considered. The professional undertaking the assessment should ensure a referral for an IMCA is made, where appropriate, to protect an unsupported person who lacks capacity to make a decision.

Staff undertaking risk assessments should be competent and able to evaluate and act upon a risk of danger, harm or abuse. Staff should therefore know how to reduce or remove risk. Ongoing risk management tasks include staff supervision.

In high risk situations staff should be debriefed on the outcomes of the assessment, enabling them to gain insight into their work, their personal stress, their decisions and the appropriate plan of action.

Lines of accountability with other agencies should be established for high risk areas and a clear management reporting structure should be in place.

3. Risk Assessment Process

The adult should be involved as far as possible in the process and their independence should be the main focus. Their attorney and / or advocate, where appointed, should also be involved (see Mental Capacity and Deprivation of Liberty Safeguards).

A multi-disciplinary approach should form the basis of the risk assessment process. Information should be collated from a variety of sources and agencies. Contributions from agencies such as the police, probation and the adult’s GP should always be considered at each stage in the process.

The professional/s undertaking the risk assessment should be aware of the different types of risk that may exist. These may include risks in four main areas:

  1. physical health;
  2. mental health;
  3. emotional wellbeing;
  4. social circumstances.

Risk should be considered in terms of the likely risk to:

  • the person;
  • others including care staff, carers, visitors and social workers;
  • the wider community including neighbours or other residents of the area or care home.

Types of risk may include the following:

  • the physical environment, for example an unsafe home conditions
  • mental health issues which result in, for example confusion, wandering, leaving the gas on
  • the adult’s behaviour, for example fire setting or aggression;
  • major life changes, such as bereavement / loss, moving to residential care;
  • health issues refusing medication;
  • a poorly managed service;
  • sharing accommodation or services with people who have violent behaviour;
  • relationships including emotional, physical, financial or sexual abuse or neglect.

Risks that involve the allegation or suspicion that an adult may be experiencing, or at risk of, abuse or neglect should be dealt with under the local safeguarding adults procedures (see Safeguarding Enquiries). For example in the immediate aftermath of an incident, or interpreting signs of distress which have built up over a period leading to a decision that serious concern is warranted.

In assessing the likelihood of the risk occurring, the professional should consider the:

  • history;
  • patterns of behaviour, which may help identify triggers for risky situations;
  • severity of the risk;
  • motivation of the adult or their carer to manage the situation;
  • different judgements about the level of risk within the agencies involved, the adult and / or the carer;
  • interdependence of risk factors;
  • timescales – and whether the risk can be contained during particular timeframes or whether it is ongoing and likely to deteriorate;

It should be noted, risk assessment forms and screening checklists may vary between different service areas.

Other factors to be considered by the professional include:

  • previous incidents of harm;
  • history of falls;
  • poor social relationships;
  • poor compliance with services;
  • presence of substance or alcohol misuse;
  • family history of harmful behaviour;
  • significant life events;
  • home circumstances or places where incidents have occurred;
  • home environment and housing;
  • disturbances in the individual’s mental state caused by brain damage, dementia or mental illness;
  • fears and threats made by the individual;
  • challenging behaviours;
  • health and physical state;
  • frailty and general health condition;
  • effects of any medication, including side effects.

Risk assessments should be subject to frequent review, as an adult – or their carer’s – circumstances may change. Interventions can increase risk as well as decrease it.

Recording of the risk assessment should be structured with the identification of each risk in order of priority, and the likelihood of the realisation of the risk and its impact. Each risk should have recommendations to control, reduce or remove the risk (see also Record Keeping).

4. Vulnerable Adult Risk Management (VARM) Guidance

See Leicester, Leicestershire and Rutland Vulnerable Adults Risk Management

The guidance seeks to provide front line professionals with a framework to facilitate effective working with adults who are at risk due to self-neglect, where that risk may lead to significant harm or death and the risks are not effectively managed via other processes or interventions. The VARM guidance is used when the adult refuses to engage with services and yet the risk is significant. It is essential to note that the adult must be considered to have a potential need for care and support as well as self-neglect. If the risk from self-neglect is not at the level which may lead to significant harm or death then the VARM process would not be followed. Link to VARM guidance.

5. Multi-Agency Meetings

Multi-agency meetings may be required where:

  • there are concerns about potentially serious outcomes;
  • previous experience indicates a probability of high risk and resulting harm;
  • several agencies need to be involved to manage the risk;
  • there is conflict between key individuals or agencies;
  • consideration is being given to using legislation to restrict liberty and freedom of choice;
  • the adult departs from an agreed plan of action aimed at managing risk;
  • several agencies, acting in isolation, have withdrawn services in response to an adult’s behaviour and where a coordinated response needs to be re-established.

6. Decision Making and Risk Management Plan

The professional should conclude how serious the risk is, how specific it is and its immediacy.

Not every adult will require a risk management plan, but where there are concerns, a plan should be developed.

The risk management plan should:

  • identify each risk and detail the measures taken or services applied to remove or reduce it;
  • identify who is responsible for each aspect of the required monitoring;
  • identify and plan the frequency of reviews;
  • identify who is responsible for coordinating reviews;
  • identify the role and contribution of each agency in the management of the identified risk/s;
  • contain a contingency plan in case of emergency or in response to risks identified.