Risk assessment process and key points to risk identification in virtual interactions

Virtual interactions with people that access care and support are here to stay, in one form or another. Where it is appropriate and proportionate to interact with an individual in a way other than face to face, it is necessary to be confident and competent to practice in a way that recognises and works effectively with risk.

This guide will help social care practitioners to understand:

• The key principles of how to gather evidence and information, so they are able to identify and assess risks virtually when it is not necessary or appropriate to do so through face-to-face contact.
• The importance of being aware that our professional decisions may become more reliant on assumptions or information provided by others, as we may have less ability to observe and draw conclusions from direct observation. However, as with any social care practice, it is essential that we are able to defend any decision made with the evidence that underpins it.
• That regardless of the method of interaction we should always be mindful of situations that present risk and should try to gather as much information as possible about the individuals’ circumstances to ensure any risks are identified and looked at properly.
• The importance of clearly documenting the entirety of the risk assessment process and particularly evidence associated with risk.
• “Critical, reflexive and careful judgement … with the fully considered evidence of incomplete knowledge so that you can defend and justify your assessments, plans and interventions” (Cooper, 2011).

If the adult lacks capacity, some of the statements below will not apply, and decisions and agreements will be made with as much involvement as possible from the adult but not solely with them.

Risk assessment as a process

Risk assessment is an important process in adult social care as we work with individuals to enable them to achieve the outcomes that matter to them and promote their individual wellbeing.

The risk assessment process has four distinctive and sequential stages, and social care practitioners should go through each of them with the individual.

1. Understanding the person’s circumstances
2. Identifying risks
3. Assessing impact and likelihood of risks
4. Managing risks – risk enablement and planning

This framework is evident in a study undertaken by Clarke et al. (2011) which outlined a four-stage process for exploring risk with individuals and families living with dementia. However, this further guidance is equally as applicable for working with all individuals:

• Identify risks in the life-context of the individual and their circumstances (and therefore impact on quality of life and individual wellbeing).
• Identify risk perspectives from all the people involved.
• Identify weighting of risks (to establish high and low risk concerns, impact on emotional, social and psychological wellbeing).
• Identify current and past strategies for managing risks.

When we work with individuals during the risk assessment process it is important to remember that a person’s ability to engage can fluctuate either as a result of a cognitive impairment of the mind or brain or due to physical or emotional difficulties. In such circumstances it will be necessary to arrange conversations at times that are appropriate for them and/or provide additional support if required such as:

• Appropriate Person
• Independent Advocate, or
• Independent Mental Capacity Act Advocate.

What is risk?

Simply put, 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.
• A product of the likelihood that an event will occur and the impact that it will have if it does occur.

The four stages of risk assessment as a process

Understanding the person’s circumstances (Stage 1)

Risk is part of everyday life and “people with disabilities, both mental and physical, have the same human rights as the rest of the human race. It may be that those rights have sometimes to be limited or restricted because of their disabilities, but the starting point should be the same as that for everyone else” (Lady Hale, 2014).

When we work with individuals requiring support from Adult Social Care, we do so to promote choice and control for which there are likely to be elements of risk present. However, our practice is underpinned by strengths-based principles which recognises strengths, capabilities and potentials for self-directed support towards goals and outcomes that matters to the individual.

It may therefore be necessary and/or beneficial for some risk to be present but in such circumstances the decision should be made through,

Read “principles of practice” for some further guidance to help you understand the person’s circumstances.

Identifying risks and protective factors (Stage 2)

A social care practitioner’s role is to support an individual to identify, define and explore the beneficial or harmful outcomes of the identified activity/decision with the individual. This is to enable a thorough exploration which will allow consideration of the likelihood and impact and promote their ability to live the life they want and do the things that are important to them as independently as possible. Our role is not to stop people doing things but to trust people to make decisions and direct their own support, with help where they need and want it.

The first step of the risk assessment process is to jointly work with the individual, with or without the support of another person (for example an appropriate individual or independent advocate), to enable us to understand:

• what the activity means to them
• why is it important to them and for them
• what impact being able/unable to undertake the activity will have on their individual wellbeing.

It is important that when we engage in conversations, we begin from a position of strength, focusing on what is strong for the individual and not on what is wrong with the decisions they are wanting to make. We can learn from the principles of appreciative inquiry and rather than seeing the situation as a problem to be solved, consider it as a mystery to be embraced, utilising strengths, rather than seeking to overcome or minimise the weaknesses. We can, with an open mind, seek to explore and discover moments of strengths in the individual’s life, personal qualities and the networks around them. We can be open to seeing new potential and possibilities using the collective knowledge of the social care practitioner and the individual to whom the assessment belongs.

Once you have established a baseline understanding of the persons circumstances from their perspective, it is important to work with them to identify both the potential benefits and the potential harms of a given action, decision, behaviour, etc.

This enables us to support the individual to explore the risks that they are facing, or are likely to face, and the impact of the activity on them or others, now or in the future.

Working virtually with an individual will place a greater reliance upon the questions we ask in order to establish a baseline understanding of the person and find the answers to potential benefits or harms as we cannot use our other senses such as seeing for ourselves.

From the available information and initial contact with the individual, it should be possible to gauge a level of insight as to the potential harmful outcomes, likelihood of occurrence and potential impact. We should use this to determine which method of interaction is required, for example it is necessary to visit the individual in person or it is appropriate to, at least, start the risk assessment process virtually. It is important that we record our rationale for the chosen method(s) of interaction.

Pause for thought: Case study – about Amitesh

Amitesh is a 28-year-old male who lives with an acquired brain injury and limited use of his right side. He moved from residential care to supported living one year ago. He is unable to access the community without support which is authorised by a community Deprivation of Liberty Safeguard. (DOLiC)

You have arranged to review Amitesh’s care and support plan with his support worker and Mum, who is acting as his Appropriate Person. The appointment will be via video call. He has explained that he wants to discuss how he will be able go to the local supermarket without support.

Thinking about the first two steps of the risk process, what questions do you think you need to ask? SCIE will share its thoughts below to offer further guidance to shape your question creation.

SCIE’s thoughts

It is important that the conversations that we have enable us to evidence some key points, such as:

• What is it that is trying to be achieved and why?
• How will it be achieved and why will it be done this way?
• What are the potential benefits of the action being considered? To self, to others, from others, etc.
• What could go wrong? – what are the risks to self, to others, from others etc.

The answer to these questions:

• Must be seen from the individual’s point of view, though we will support the individual in exploring and understanding all the potential benefits and harms.
• Should include the individual wishes and aspirations.
• May include potential benefits for others but must include any potential harm to others.

Potential prompts to go through with the individual are:

• What is the good thing about doing this?
• What will I get out of it?
• What could go wrong if I don’t do it?
• What could go wrong if I do it?

Pause for thought: Case study – about Amitesh

With support, Amitesh was able to identify that it was important for him to go to the shops by himself to buy chocolate. He wants to do this as his friends who lived around him did so and not being able to do it made him feel sad and frustrated and it made him feel like a child.

Being able to go to the shop when he wanted and by himself would help him feel independent and he could use the communal mobility scooter to help him get there because he cannot walk very far.

Amitesh identified that it had been over 10 years since he had been out in the community without support, that he might get lost on the way to the shop and/or forget what he had gone to the shop for or not know if he has been given the right change.

To explore further the concern around not getting the right change and to ascertain if it is a risk, Amitesh was asked if he has any money close by and if he knows the value of the notes and coins that he had; simple questions were asked such as if he paid with a £5 note would he expect any change if the item cost 50 pence?

A balance sheet for supporting exploration of risk, protective factors and options

During the conversation we need to be able explore ways in which Amitesh could achieve the outcome he wishes to achieve, and a balance sheet tool may be a useful way of doing this.

The format of such a tool is not important but the detail which we add to it is key. A balance sheet:

• Provides an opportunity to work through and identify possible options for the person to achieve their desired outcome while minimising risk, where possible.
• Enables recording of the evidence gathered to demonstrate the advantages and disadvantages of the considered option which will be used to make decisions.
• Supports the analysis as to why it is or is not a realistic option, with reference to the facts that resulted in the decisions made.
• Enables the process to be open and transparent with the people we work with.

Activity: Getting to the shop

It may be necessary to have more than one interaction with Amitesh, to ascertain all the risks involved in relation to the decision to be made. These interactions can be using one or different methods.

The important thing is that we can evidence and define with clarity what the risks are from the perspective of the individual, the social care practitioner and any others as this will support the next stages or be affected by the decision. It is not possible to consider the impact and likelihood of a situation or take steps to manage it if we cannot define what the risk is first.

Assessing risks: impact and likelihood (stage 3)

Once the risk has been clearly defined and the potential beneficial and harmful effects identified, we will explore with the individual the impact and likelihood of each of the potential benefits and harms identified to assess the risk.

This stage is not:

• a method to prevent a person to achieve the outcomes that they would choose
• an opportunity to focus on the problem/s and things that are perceived to be a risk.

As a social care practitioner is not our responsibility to take the risk away. At this stage we should:

• Support the individual with their unique strengths, abilities and aspirations to make decisions that matter to them.
• Support the individual in understanding the likelihood and impact of all the identified potential benefits and harms, what is important for them alongside what is important to them and why.

It is essential that there is an evidenced based analysis of the severity and likelihood of harm which could arise.

When we assess risk, it is necessary to explore:

• How likely is this to occur? This should be proportionate to the potential consequences specified, and must be based on good information and evidence and consider the same factors – is the information up to date? Is it relevant? Can it be evidenced? What are the protective factors which could reduce the likelihood of the occurrence? Consider the strengths of the person’s current situation, the environment and what their family/friends/other support network are or can contribute. What additional actions would promote benefit and reduce the likelihood of the occurrence, for example the use of assistive technology, interventions to improve ability of the individual, maximising existing support networks?
• If something went wrong, what would the severity of the impact be? It is important to consider both a best-case and worst-case scenario, e.g. death, serious injury, admission to hospital, loss of accommodation. If it works, what is the level of benefit of the impact? It is important to consider equally the potential negative consequences and the potential benefits What are the protective factors which could reduce the severity of the impact? What additional actions would promote the benefit and reduce the severity of the impact, for example the use of assistive technology, interventions to improve ability of the individual, maximising existing support networks.

Pause for thought: Case study – about Amitesh

Thinking about the impact and likelihood that of the risk process, what questions do you think you need to ask based on the information you have?

SCIE’s thoughts

It is important to have conversations that will enable us to evidence some key points, such as:

• The likelihood of risk (degree of intent; immediacy/frequency of its occurrence or re-occurrence; timing: do different times of day or different days elevate or reduce the risk?).
• The severity of risk (i.e. the impact it could have if it occurs).
• Has something like this happened before, what are the similarities and the differences, how were they managed and to what end? Use your knowledge and experience to explore if previous solutions could help in this case.
• What’s the worst that could happen? For whom?
• What’s the best that could happen? For whom?
• What could happen if we don’t support the person to take the risk?

The answer to these questions:

• Must be seen from individual’s point of view, though we will support the individual in exploring and understanding the likelihood and severity of the decision.

Pause for thought: Case study – about Amitesh

An example of a risk assessment for Amitesh

Scale:

Low, medium, high

Unlikely, likely, very likely

What is the decision or choice to be made? Is it safe for Amitesh to go to the shops alone?

What are the potential benefits?

• Amitesh can be independent in going to the shops, his confidence will grow.
• Amitesh can feel like an adult and make his own decisions about when he goes to the shop.
• Amitesh will grow as an individual.
• It is something important for Amitesh and which he aspires to achieve.

1. How likely are the benefits to happen?
   • It is very likely that these benefits could be achieved.
2. What would be the impact if this happens?
   • Amitesh’s confidence could be increased, and he may even be able to take a next step within time.
   • Staff will be available to support other residents.

What are the potential harms?

• Amitesh could get lost. This could stress him out and/or make him vulnerable to other risks.
• Amitesh may forget what he went to the shop for and get stressed or lose his way.
• Amitesh may not get the right change and lose some money.

1. How likely is that these harms happen?
   • It is very likely that it will go wrong as Amitesh has not been out without support for 10 years and does not have the necessary skills to be able to do so at this time.
   • It is very likely that Amitesh may get lost.
   • It is very likely that Amitesh may not get the right change.
2. What would be the impact if this happens?
   • The severity could be high as Amitesh may get scared about being lost and when he is overwhelmed his ability to cope with a situation is reduced.
3. What are the existing factors which promote the benefit and reduce the chances of anything going wrong?
   • Amitesh lives in a supported living complex with staff on site 24 hours.
   • Amitesh has a telephone and has the phone number of the complex on speed dial which he is able to use.
   • Amitesh has been using the local community, with support, and so may have recollection of important landmarks which will help him to return home.
4. What additional actions would promote the benefit and reduce the chances of anything going wrong?
   • Supporting Amitesh to undertake a period of travel training to enable him to develop skills required to access the shop independently.
   • Not taking too much money to the shop.
   • Preparing a shopping list with staff in advance of going to the shop.
   • Using a phone to contact staff if he gets lost.
   • Using a phone to check in with staff when he has got his change.
5. What risks will remain after the action plan is in place?
   • If staff work with Amitesh in addressing the factors that increase the risk, the risk will be properly managed.
   • If staff conclude that they can’t provide Amitesh with the necessary skills and support to be able to address the factors that increase the risk, a decision should be made as to whether the remaining risk should be taken.

Stages one through three of the risk assessment process will enable the social care practitioner, regardless of method in which the intervention is undertaken, to recognise and work effectively with risk. It will enable the social care practitioner to arrive at a decision which should include the following narrative elements:

• A statement of the decision.
• The reasons for the decision.
• A description of the main alternatives.
• Reasons why the alternative may not be the best option or why the alternative may be the best option.

When we are working virtually with individuals to explore risk it is important that we are confident with the information we have been able to gather to enable us to make an informed and defendable decision:

Managing risks: risk enablement and positive risk-taking (stage 4)

Risk is part of everyday life and risk management is not about trying to eliminate risk but managing risks to maximise people’s choice and control over their lives. It is about weighing up the options and utilising the available resources to achieve the desired outcome. It is “not negligent ignorance of the potential risks … it is usually a very carefully thought-out strategy for managing a specific situation or set of circumstances” (Morgan, 2004).

Not all risk can be reduced or mitigated, but all can be managed if they have been properly identified and assessed. On some occasions the management of risks entail reduction or mitigation.

Individual choice* in risk enablement: It is the adult and/or carer’s right to make choices and take risks once they understand the information available and are aware of the risks.

Risk enablement: Risk enablement involves supporting adults and/or carers to identify and assess risks and then supporting them to take the risk they choose.

* unless assessed to lack capacity.

Key aims of positive risk-taking:

Some of the key aims of positive risk-taking are:

• Empowering people
• Working in partnership with adults and/or carers
• Developing trusting working relationships
• Supporting people to access opportunities and take worthwhile chances
• Learning from experiences
• Understanding consequences of different choices/actions
• Sometimes tolerating short-term risk for long-term gain
• Making decisions based on accurate/available choices.

Once the risks have been identified and assessed, the next step is to agree with the individual how the risks are going to be managed.

The goal of risk management

The goal of the management of risk is to develop contingency actions for any predicted pitfalls, in a way which improve the quality of life of the person, to promote their independence or to stop these deteriorating if possible. Please note that this may be just to make the individual aware of the potential consequences of the risk.

To manage risk effectively, it is important to:

• Develop and implement the action plan agreed with the adult/carer.
• Have clear monitoring and reviewing systems in place if appropriate.
• Ensure accurate documentation and sharing of risk assessment/action plan with relevant partners.
• Be ready to respond to the consequences.
• Agree risks owners – who takes responsibility.

Risk action plan

A risk action plan should include:

• What actions have been agreed?
• How the actions will be carried out and their significance to success?
• Who will be responsible for them?
• What is the time frame? Bear in mind that different aspects might have different time frames.
• How will good communication be ensured?
• What could go wrong – and how to overcome?
• What could go well – and how to build onto it?
• Review plan and agree timescale.

Pause for thought: Case study – about Amitesh

Amitesh wished to be able to go to the shop without a support worker or his mum so that he could:

• be like his friends
• be more spontaneous about his day
• have his favourite chocolate bar when he wanted and not just when he had a scheduled shopping session
• have greater independence.

The assessment of risk concluded:

• There was a probability of a harmful outcome for Amitesh if he was to go to the shop alone as he could get lost, forget what he was going to the shop for and not be given the right change.
• The likelihood of the harmful outcome was high due to him having had protective oversight while accessing the community for the past 10 years.
• The impact if something goes wrong could be high as he is not able to cope with his emotions when he is feeling overwhelmed.

There are additional actions which would promote his ability to achieve his goal.

Using the information available what might the risk action plan include?

SCIE’s thoughts

The Care Act 2014 is very clear that the starting point for care and support planning is the assumption that an individual can plan for themselves. This should be extended to the development of a risk action plan as should the notion that the plan is written in the first person to make it clear that it is the individual who owns it as it is there to support the individual to live a safer life.

Where possible, principles of co-production should be applied to support the individual to have as much control as possible over the choices that they can make.

How to work with risk virtually

During face-to-face interactions, we use our observation skills, amongst others, to understand any potential risks for the individual. Working virtually could reduce the opportunity to observe certain circumstances, behaviours, reactions, the non-verbal communication, the ability to see the unseen which could impact on evidence-based decision making.

Please note that whereas we have tried to include a wide range of risk factors there may be others not listed.

Working virtually places greater reliance on the use of effective strengths-based conversations, underpinned by open-ended questions and establishing meaningful relationships. This will enable a two-way exploration of the presence of risk, risk identification, risk assessment, and risk management to explore how best to support the individual to achieve the outcomes that are important to them.

From the available information and initial contact with the individual, it should be possible to gauge a level of insight as to the potential risks. We should use this to determine which method of interaction is more suitable for example it is necessary to visit with the individual in person? Or is it appropriate to at least start the risk assessment process virtually?

Important considerations

If we are working with people virtually, we will:

• Need to use this information as a starting point to consider the conversations and the information we need to gather from the individual.
• Need to review historical/available information so that we are aware of what gaps in evidence we have.
• Consider what existing information needs to be checked out so that we do not make assumptions that the current circumstances are the same.
• Need to ensure that any sharing of data, via email for example, is done so in accordance with sharing of information and joint working protocols to prevent data breaches in line with the Data Protection Act 2018.
• Where possible always seek permission from the individual before requesting and sharing information but if it is necessary to facilitate the provision to the individual of health or social care services, section 2(3) of the Health and Social Care (Safety and Quality) Act 2015 will limit repercussion.

If the adult lacks capacity, some statements will not apply, and decisions and agreements will be made with as much involvement as possible from the adult but not solely with them.

Please note that you can find information on Safeguarding risks with adults in further reading.

What information can help social care practitioners in the identification and/or assessment of different types of risks when working virtually?

The below information is intended to support social care practitioners to ascertain which questions could be asked and/or considered to supplement the lack of opportunity to gather intelligence through observation when undertaking virtual interactions.

Please note that although we have included a wide range of risk factors, the list is not exhaustive.

The below indicators of higher risk should not be used to make assumptions, but to prompt questions and source evidence. The risks considered in this resource are those of:

• Falls
• Personal/self-neglect
• Incontinence
• Environmental neglect
• Carer breakdown
• Social isolation.

Examples of types of risks and factors that could increase the level of risk

Falls:

Personal and self-neglect:

Read more: Self-neglect at a glance.

Malnutrition:

Environmental neglect and/or hoarding:

What factors increase the risk of carer breakdown?:

Credit: 10 symptoms of carer stress – and how to beat them (Live Better With).

What factors increase the risk of social isolation?

Other risks

There are other risks that social care practitioners should find out about, such as: cognitive deterioration, risk of hospital admission, risk of not taking prescribed medication, damage to equipment, lack of access to technology or the necessary skills need to use it effectively which should be addressed in line with the Equality Act (2010).

Do:

• Gather as much evidence as possible through questions, asking for descriptions, examples of behaviours, etc.
• Ensure you go through the risk process stage-by-stage jointly with the adult and/or carer, if they have capacity.
• Record appropriately the existing risks, their potential benefits and/or harms, their assessment and how they will be managed, including if the adult and/or carer is taking responsibility – if there is capacity – of the potential harms to themselves.
• Ensure you have a person-centred and risk enabler approach.

Don’t:

• Make assumptions – the existence of a risk factor or indicator does not mean there is a risk.
• Allow your threshold for risk to draw you to conclusions.
• Underestimate the potential benefits of taking a risk.

References

Clarke, C.L., Wilkinson, H., Keady, J. & Gibb, C.E. (2011) Risk assessment and management for living well with Dementia, Jessica Kingsley Publishers

Cooper, B. (2011) ‘Criticality and reflexivity: best practice in uncertain environments’, in Seden, J., Matthews, S., McCormick, M. and Morgan, A. (eds) Professional Development in Social Work: Complex Issues in Practice, London, Routledge, pp. 17-23

Kemshall, H. (2009), Working with sex offenders in a climate of public blame and anxiety: How to make defensible decisions for risk, Journal of Sexual Aggression, 15:3. 331-343

Morgan, S. (2004) ‘Positive risk-taking: an idea whose time has come’ Health Care Risk Report, 10(10), pp.18-19

Further reading