A Framework for Understanding and Responding to Risk

1. Summary of Key Principles Organisational Context

Organisations need to take into account the impact that any restrictive, safety led responses might have on the emotional well-being of the person they support.

The framework provides an approach to assessing and responding to risk from the perspective of the person concerned, the practitioner, and the organisation. It promotes an approach which steers practitioners and organisations away from 'protecting' to promoting human rights. It acknowledges that the 'solution' is not simply to prevent or stop risk.

'Notions of risk are socially constructed and context specific. However, they are often presented as a technical or scientific fact, which can be assessed by professionals through an opaque process which is invisible to critical analysis. If practitioners are able to relinquish their expert status, and view risk through the lens of human rights, they may be able to approach the use of risk assessment tools as a participative means of gathering information to inform decision making and take the role of advocate or facilitator in supporting the person to make difficult decisions about their situation. Organisations play their part in changing the language and understanding of risk, to support their staff in making good decisions instead of eliminating the risk altogether, and in moving away from seeing risk purely from the viewpoint of organisational liability'. (White, E 2017 pp125-126)

• Design a clear, transparent and simple risk assessment process which leaves space for comment, explanation or analysis;
• Approach risk assessment through a Human Rights lens - what are we doing through this assessment that supports the person's human rights? Are we balancing their view of their own wellbeing with safety?
• See risk assessment as a participative means of gathering information and use it to weigh up aspects of decisions alongside people;
• Organisations have a key role. They must develop the necessary culture and support staff in this work.

Care Act 2014 and Mental Capacity Act, 2005 as context - a strengths-based approach

The practitioner acts as facilitator and advocate rather than 'expert'; as promoter of shared decision making and promoter of shared responsibility.

The practitioner asks the question: 'What might lead the person to be able to cope within this situation? How can their strengths be maximised (perhaps with support of others)?'

The Care Act 2014 requires consideration of a person's own strengths and capabilities, and what support might be available from their wider support network or within the community to help.

Strengths based assessment focuses on the person's situation and factors that make them more vulnerable, not perceived deficits of the person themselves. It is important to understand why a person might not be practised at decision making and what personal qualities or abilities they have that can be developed or supported.

• Seek out and use all available support and resources; family, friends, community and professional;
• Recapture what has worked well in the past;
• Identify plans for the future (McNamara and Morgan, 2016) that are meaningful to the person and that set out steps towards a goal. Taking smaller steps or decisions may reduce what initially appears to be a big risk (White, E, 2017 pp113);
• Make sure steps take account of wellbeing as well as safety.

The role of the practitioner - where to start?

• Belief in the person's capacity for change;
• Focus on the role of ethics, morals, values;
• Focus on the underlying principles of the Mental Capacity Act (MCA), 2005.

The framework is compatible with the MCA 2005 leading the practitioner to consider wishes and feelings as paramount and proportionality in assessing and responding to risk. 'The concept of proportionality is used as a criterion for fairness and justice in law, and should apply to any rights-based view of risk' (White, E, 2017 pp114).

• Work collaboratively on understanding risk leading to relationships based on trust;
• Recognise the protective value of increased choice, increased self esteem and confidence, and develop techniques to detect abuse or make it more difficult for it to occur (Stevenson et al 2014)[5];
• Use proactive strategies and contingency planning within support plans to mitigate.

[5] Stevenson, M et al, "Risk, Safeguarding and Personal Budgets: Exploring Relationships and Identifying Good Practice", 2014, London, Kings College, NIHR School for Social Care Research

2. Steps Within the Framework

Step. 1

Understanding the person's wishes and feelings in relation to the risk

Listen to what they say about the situation. This listening can begin to develop trust and to establish a shared understanding and responsibility for safety.

Gather their biographical information, paying attention to past wishes and feelings.

Speak with others who know them or who are important to them.

Promote wellbeing by attending to psychological, social and physical aspects and account for this in an assessment.

Work with them to put different wishes or needs in order of preference (what is most important to or for them?).

Understand their view of the benefits in the situation.

Reflect the importance of them feeling or being listened to in the way the assessment is approached.

Step. 2

Understanding the impact of risks on the person

List the risks by speaking to the person and significant others.

Apply simple tests of likelihood and impact to understand the true extent of perceived risk.

What strengths or positive factors exist that might mitigate some of the risks?

How far do any of the risks contribute to the person's quality of life? (Benefits may outweigh risks).

Use this as a means of sharing information and challenging perceptions.

Use it as a basis for discussion with the person and with professionals. Not as a 'professional tool'.

The person may change their view by seeing the information set out in this way. It will help to see how far they understand the situation and the risks.

If there are limited benefits identified and yet the person remains unable to see the risks, then now is the time to begin to test their view and their understanding.

Step. 3

Enabling and responding to risk

Acknowledge practitioner and organisational concerns, opinions, experiences, culture, preconceptions, risks, legal responsibilities ... openly. This needs to be explored in reflective sessions with managers and peers.

There are four key questions to be answered at this stage:

• Can we promote the person's safety without interfering with the benefits they gain from the situation or infringing their rights?
• Are there ways in which we can help to change the situation to reduce the risk to acceptable levels whilst still respecting their choices and promoting their quality of life? (DH, 2010);
• Accepting that some things can go wrong – what could go wrong, and how could we respond in that case? Who can help support with the consequences and associated fear or guilt? (Morgan, S and Williamson, T, 2014)[6][7];
• Are we in a position where collectively the different people, professionals and organisations involved support a joined-up understanding of the person, what is important to them and what the risks are?

Step. 4

Planning and contingency

This step brings together findings from steps 1-3 into a support or risk enablement plan.

The plan will summarise the person's wishes and feelings, the risk assessment, enablement solutions and the agreed actions to respond to residual risk and contingency planning.

"Safety planning' really only has meaning for the person in the context of their personal life goals. That is what will engage the person and get them to be motivated to take part in the process…. a shared responsibility for promoting safety: what the person will do, what staff [across organisations] will do, what others who are important to the person will do…. Developing a negotiated safety plan facilitates careful experimentation and the opportunities for people to discover what works best for them" (Boardman and Roberts, 2014)[8].

[6] Morgan, S and Williamson, T, "How Can 'Positive Risk-Taking' Help Build Dementia-Friendly Communities?"
[7] Joseph Rowntree Foundation and Mental Health Foundation
[8] Boardman and Roberts, "Risk, Safety and Recovery", 2014, London, Centre for Mental Health and Mental Health Network, NHS Confederation

3. A Note on Risk Assessment Tools

'Over-reliance on tools can lead to a false sense of security and simplistic application of risk management techniques as well as a failure to engage and to take appropriate action.' 'Tools must be seen as a support to or a means of engaging with people about what is important to them and about risks. Tools support revealing 'truth' towards risk assessment'. (White, E, 2017 pp115).

What are we trying to achieve?

• Enhanced resilience;
• Improved capacity to respond to issues;
• Support through whatever the issues are;
• Shared decision making and collectively thinking through the options to get to the bottom of:
  • What does the person want?
  • Why?
  • Their strengths or abilities;
  • Any extraneous factors that are under consideration.
• Ownership and accountability across organisations and sectors and commitment to interventions/responses to risk;
• The right balance in enhancing safety alongside wellbeing;
• Awareness of competing views and interests (sometimes through methodologies such as FGC, mediation for example);
• Any good risk assessment recording tool should not lose sight of the above and must allow space for these areas to be recorded.

4. A Note on Organisational Culture

Developing a culture that will enable sensitive risk management - leadership has a vital role in changing the language of risk.

The framework emphasises the importance of trust and negotiating and agreeing responsibility and accountability between the person, the range of practitioners, and concerned interested parties such as family and friends.

This needs to be assisted by a culture where staff are supported, trusted and empowered to work alongside people to address risk in their lives.

Opportunities should be created for open discussion about risk issues through critical reflection; supervision; audit; Serious Incident Learning; appreciative inquiry, and then share the learning from mistakes (transparency is a pre-requisite for this).

Organisational concerns such as funding and public perception need to be a transparent consideration within the whole picture.

Endeavour to move away from a focus on efficient completion of a process to prevention of specified types of harm.

Review the language of blame or an over-emphasis on safety, towards a no-fault approach which encourages cooperation and learning.

Spell out what organisational values and principles mean in practice especially where these conflict.

5. A Note on Perspectives on Risk and Defensible Decision Making

Regulator, commissioner, employer, public, and media may all take different views about assessing and responding to risk. Nevertheless, identifying a common language for working with risk is vital, including a common understanding about information sharing.

The concept of defensible decision making supports and is helpful to all. It focusses on the quality of approach rather than on the eventual outcomes. This is a helpful starting point for developing a shared understanding of risk and agreeing accepted strategies and practices.

The Department of Health (2010) cites Kemshall (2009) in describing defensible decision making. Organisations should be able to evidence that:

• All reasonable steps have been taken to respond;
• Reliable assessment methods have been used to inform decisions;
• Information has been collated and thoroughly evaluated;
• Decisions are recorded, communicated and thoroughly evaluated;
• Policies and procedures have been followed and legal responsibilities considered;
• Practitioners and their managers adopt a proactive, analytical approach.

The above considerations should prompt organisations into thinking about moving beyond incident reporting and process to adopting an open culture not only within but between organisations. Discussing risk issues and sharing responsibility may create greater transparency and a more positive view of risk within the wider system as well as risk as it relates to individuals. (White, E, 2017 pp123).