Risk identification and virtual interventions for social workers

Published: November 2020

This quick guide will help social workers and social care practitioners understand how to gather evidence and information, so they are able to identify and assess risks normally gathered through observation.

Social workers and social care practitioners should try to gather as much information as possible about the adult and/or carer circumstances before and during an intervention to ensure any risks are looked at properly. When we talk to or visit somebody, we use our observation skills, amongst others, to understand any potential risks for the individual. When our interactions are over the phone or online, we need to ask relevant questions to find this out.

If we don’t have the opportunity to observe certain circumstances, behaviours, reactions, etc. we may miss information and we may lack some evidence. We should document clearly when we have evidence to make a statement or professional decision, and when we don’t have the necessary evidence and we are using our professional judgement to either assume or trust what we are being told by others.

We have to differentiate between risk identification, risk assessment, minimising risk and risk management.

If the adult lacks capacity, some of the statements below won’t 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 within the most common risks addressed in this resource we have not added Safeguarding. See safeguarding adults’ resources in Further reading.

Risk assessment as a process

The detail and outcome of the risk management process are captured in a risk assessment form.

The risk assessment process has three distinctive and sequential stages, and the social worker or social care practitioner should go through each of them with the adult and/or carer.

What is risk?

  • 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.
  • Risk is a product of the likelihood that an event will happen and the impact that the thing happening will have if it does happen.

To deal with risk properly, it is crucial to distinguish between the following stages in the process:

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

Clarke et al (2011) suggest a four-stage process to discuss risks with people with dementia and their families (though the stages are perfectly adaptable for other groups of people coming into contact with social care):

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

Identifying risks

The social worker or social care practitioner jointly with the adult and/or carer will identify – name, define – the risks that the adult and/or carer is facing, or is likely to face, or is causing, or is likely to cause others.

Within the risk-identification stage, it is important to identify both the potential benefits and the potential harms of a given action, decision, behaviour, etc.

What are the potential benefits? The answer to this question:

  • must be seen from individual’s point of view, though the professional will support the individual in exploring and understanding all the potential benefits. 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?
  • should include the individual wishes and aspirations

What could go wrong? Is there a possibility that anyone may be harmed? The answer to these questions:

  • must be seen from individual’s point of view, a potential prompt could be for the individual to think: What could go wrong if I do this? And must specify any potential harm to others

The professional will support the individual in exploring and understanding everything that could go wrong for them and for others.

Assessing risks: impact and likelihood

Once there is clarity and agreement on potential beneficial and harmful effect of the decision, action, behaviour, the social worker or social care practitioner will assess with the individual the impact and likelihood of each of the potential benefits and harms identified, to assess the risk.

The social worker or social care practitioner will support the individual in understanding the likelihood and impact of all the identified potential benefits and harms.

How likely is this to occur? The response to the question should be appropriate to the potential consequence specified and must be based on good information and evidence:

  • If something went wrong, what would severity of outcome be? In responding to this question it is essential that there is an assessment of the severity of harm which could arise and to consider a worst-case scenario
  • If something went right, what would be the benefit of it? In responding to this question, it is essential to assess how beneficial the outcome can be and to consider a best-case scenario

Managing risks: risk enablement and positive risk-taking

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

Risk enablement and positive risk-taking are ways of managing risks positively.

Managing risk positively is: weighing up the potential benefits and harms of exercising one choice of action over another, identifying the potential risks involved, and developing plans and actions that reflect the positive potential and stated priorities of the service user. It involves using available resources and support to achieve the desired outcomes, and minimising the potential harmful outcomes. 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, S. (2004) ‘Positive risk-taking: an idea whose time has come’

    Individual choice

    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.

Key aims of positive risk-taking:

  • 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

What information can help in the identification and/or assessment of different types of risks?

Find below useful information or indicators to identify and/or assess different types of risks, that can be used to ascertain which questions could be asked and/or considered to supplement the lack of opportunity to gather intelligence through observation.

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

It is always important to check the adult and/or carer notes and find out any previous history and circumstances without making assumptions that the current circumstances are the same.

The below indicators of higher risk should not be used to make assumptions, but to prompt questions and source evidence.

What factors increase the risk of falls? What would be useful to know to ascertain if there is risk of falls?

Find below a list of factors that increase the risk of falls or information that will be useful to know to ascertain if the adult and/or carer is at risk of falls.

  • Historical information – any falls in the last 12 months?
  • Medication – are they taking any medication? There is evidence that some medicines increase the risk of falls (i.e. sedatives, hypnotics, anxiolytics)

Factors that may increase the risk of falls

  • Medical conditions Open

    • Circulatory disease
    • Chronic obstructive pulmonary disease
    • Arthritis
    • Thyroid dysfunction
    • Diabetes
    • Incontinence
    • Parkinson’s disease
    • Stroke
    • Dementia
    • Depression
  • Mobility, balance and gait Open

    • Feeling unsteady or having problem with balance
    • Reduced grip strength
    • Lower extremity sensory impairment
    • Reduced lower extremity strength
    • Reduced walking speed
    • Difficulty arising from chair - the ‘Timed Up and Go’ test:
      • Stand up from the chair
      • Walk 3 metres (10 feet) at your normal pace
      • Turn
      • Walk back to the chair at your normal pace
      • Sit down again
    • Reduced knee, hip or ankle strength
  • Ethnicity Open

    • There are some studies in the UK and the US that suggest that Caucasian ethnic groups fall more frequently than Afro-Caribbean, Hispanics or South Asians
  • Nutritional deficiencies Open

    • Nutritional deficiencies can sometimes lead to low body mass index and this has been associated with increased risk of falls
    • Vitamin D deficiency may lead to abnormal gait, muscle weakness, and other circumstances that may increase the risk of falls
  • Impaired cognition Open

    • Even at a relatively moderate level, cognitive deficit is associated with increased risk of falls. An indicator could be a reduced mental status test score
  • Visual impairments Open

    • Visual impairments such as impaired visual acuity, contrast sensitivity, visual field, cataract, glaucoma and macular degeneration can increase the risk of falls
    • Wearing multifocal glasses can impair depth perception and edge-contrast sensitivity and therefore difficulty in detecting obstacles
  • Foot problems Open

    • Problems with feet can affect balance and therefore increase the risk of falls. Some known feet problems are bunions, toe deformities, ulcers, deformed nails and general pain in walking
    • Wearing non-appropriate footwear is also a contributor to increase the risk of falls
  • Other Open

    • Environmental hazards such as poor lighting, slippery floors, uneven surfaces, old carpets, clutter, etc can increase the risk of falls
    • Clothing that is not elastic or allows comfortable movement can cause problems
    • Inappropriate walking aids or assistive devices can also impair mobility

What factors increase the risk of personal neglect? What would be useful to know to ascertain if there is risk of personal neglect?

Find below a list of factors that increase the risk of personal neglect or information that will be useful to know to ascertain if the adult and/or carer is at risk of personal neglect.

It is important to understand that ‘good personal hygiene’ is not a standard that social workers and social care practitioners should impose, other than when it affects the individual’s health or poses a risk to others. The definition of ‘good personal hygiene’ should be defined with the individual, and the importance of personal hygiene for maintaining dignity should be considered.

  • Signs of self-neglect Open

    • Fuzzy or rotting teeth, bad breath – mouth hygiene
    • Greasy hair
    • Dirty nails
    • Sweating and body odour (esp. sweat patches)
    • Skin - spots
    • Unkempt general appearance
    • Clothes and other items left on the floor
    • Showers/Baths not taken regularly
    • Becoming ill often
    • Not cleaning the toilet
    • Not getting rid of rubbish
    • Not washing clothes and bedding frequently
    • Not storing food properly
    • Not washing hands

    Read more: Self-neglect at a glance

The five Rs of poor personal hygiene:

  • Respect Open

    How is the person spoken about? Are you hopeful about the potential for them to grow, develop and contribute to the lives of others?

  • Risk Open

    What are the hazards to wellbeing, mental and physical health, and community relationships for everyone who might be affected?

  • Reason Open

    What is the person’s own perspective on their self-care and what expectation do you have for their situation? For example, many drugs used in psychiatry increase sweat production and a variety of conditions weaken the sense of smell.

  • Resource Open

    Does the person own a toothbrush and the other things they need for maintaining personal hygiene, including access to a safe, warm and private place?

  • Refer Open

    Who else should be involved right now? If the situation is deteriorating, what would trigger further action from you, the landlord, environmental health, mental health services or others?

What factors increase the risk of malnutrition? What would be useful to know to ascertain if there is risk of malnutrition?

Find below a list of factors that increase the risk of malnutrition or information that will be useful to know to ascertain if there adult and/or carer is at risk malnutrition.

There isn’t one definition of malnutrition, but the below are generally accepted:

Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome.

BAPEN, 2018

Malnourishment = A state of nutrition in which an imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue / body form and function and clinical outcome.

BAPEN, 2016

Malnutrition is a term that can be applied to people who are undernourished and also over nourished.

Factors that increase the risk of malnutrition

  • Mental health conditions Open

    • Chronic eating disorders
    • Depression
    • Dementia
    • Schizophrenia
    • Grief
  • Social circumstances Open

    • Social isolation – mainly if it is due to mobility or health problems
    • Low income - not having enough money to spend on food
    • Being unable to leave the house or reach a shop to buy food
    • Finding it physically difficult to prepare meals
    • Living alone, which can affect a person’s motivation to cook and eat
    • Having limited cooking skills
  • Medical conditions Open

    • Having long-term health conditions that affect appetite, weight and/or how well nutrients are absorbed by the gut, such as Crohn's disease
    • Having problems swallowing (dysphagia)
    • Dentures too big or teeth problems – unable to chew effectively
    • Sore mouth, oral blisters, etc.
    • Loss of smell or taste due to drugs or disease
  • Multiple symptoms that can indicate that the adult and/or carer suffers malnutrition Open

    • Little or no appetite, a lack of interest in eating and drinking
    • Weight loss – clothes too large, dentures too big, rings/ jewellery too big
    • Low energy and feeling tired and/or weak
    • Poor concentration
    • Unable to perform normal tasks
    • Altered mood
    • Reduced physical ability
    • In children, not growing or putting on weight at the expected rate
    • Getting ill often and taking a long time to recover
    • Wounds taking a long time to heal
    • Feeling cold most of the time

What factors increase the risk of incontinence or double incontinence? What would be useful to know to ascertain if there is risk of incontinence or double incontinence?

Find below a list of factors that increase the risk of incontinence or information that will be useful to know to ascertain if the adult and/or carer is at risk of incontinence.

The NHS defines urinary incontinence as ‘the unintentional passing of urine. It's a common problem thought to affect millions of people’ and lists the below types:

  • Stress incontinence – when urine leaks out at times when your bladder is under pressure; for example, when you cough or laugh
  • Urge incontinence – when urine leaks as you feel a sudden, intense urge to pee, or soon afterwards
  • Overflow incontinence (chronic urinary retention) – when you're unable to fully empty your bladder, which causes frequent leaking
  • Total incontinence – when your bladder cannot store any urine at all, which causes you to pass urine constantly or have frequent leaking
  • Mixture of both stress and urge urinary incontinence

Main risk factors or causes for urinary incontinence

  • Medical conditions Open

    • Constipation, having lower urinary tract symptoms (LUTS) or a urinary tract infection, obesity, weak pelvic floor muscles, changes in the nerves controlling the bladder or pelvic floor, overactive bladder, enlarged prostate (for men)
  • Medications Open

    • Diuretics, opioids, antidepressants, sedatives, hormone replacement therapy
  • Food and drinks Open

    • Alcohol and caffeine
  • Other Open

    • Pregnancy and vaginal birth
    • Family history of incontinence
    • Increasing age – although incontinence is not an inevitable part of ageing

Main risk factors or causes for bowel incontinence

  • Weak bowel muscles
  • Changes in the nerves controlling the bowel
  • Diarrhoea
  • Irritable bowel syndrome (IBS)
  • Severe piles (haemorrhoids)
  • Childbirth or surgery damaging the muscles or nerves you use to control your bowels
  • Conditions that can affect the nerves in your bottom – such as diabetes, a stroke or spina bifida

What factors increase the risk environmental neglect and/or hoarding? What would be useful to know to ascertain if there is risk of environmental neglect and/or hoarding?

Find below a list of factors that increase the risk of environmental neglect or information that will be useful to know to ascertain if the adult and/or carer is at risk of environmental neglect.

The below does not necessarily refer to hoarding, but to any type of environmental neglect.

Factors that increase the risk of environmental neglect

  • Social circumstances Open

    • People who live alone, are unmarried, have had a deprived childhood (i.e. with lack of material objects)
    • Many people with hoarding disorder also experience other mental disorders, including depression, anxiety disorders, attention deficit/hyperactivity disorder or alcohol use disorder
  • Signs that may mean the adult and/or carer may be neglecting their environment Open

    • Unusually large number of items on furniture and/or on the floor
    • Keep or collect items that may have little or no monetary value, such as junk mail and carrier bags
    • Find it hard to categorise or organise items
    • Have difficulties making decisions
    • Struggle to manage everyday tasks, such as cooking, cleaning and paying bills
    • Have poor relationships with family and/or friends
    • Suspicion of other people touching items
    • Obsessive thoughts and actions: fear of running out of an item or of needing it in the future; checking bins for accidentally discarded objects

Animal hoarding involves an individual acquiring large numbers (dozens or even hundreds) of animals. The animals may be kept in an inappropriate space, potentially creating unhealthy, unsafe conditions for the animals.

What factors increase the risk of carer breakdown? What would be useful to know to ascertain if there is risk of carer breakdown?

Find below a list of factors that increase the risk of carer breakdown or information that will be useful to know to ascertain if the carer is at risk of breakdown.

Signs that may mean the carer may be at risk of breakdown

  • Anxiety, depression, irritability
  • Feeling tired and run down
  • Difficulty sleeping
  • Overreacting to minor nuisances
  • New or worsening health problems
  • Trouble concentrating and relaxing
  • Feeling increasingly resentful and impatient
  • Drinking, smoking, or eating more
  • Neglecting own needs and responsibilities
  • Cutting back on leisure activities
  • Withdrawal from friends and family
  • Carer’s life revolves around caregiving, but it gives them little satisfaction
  • Feeling helpless and hopeless
  • Changes in appetite, weight or both

Useful statements to put to the carer to check

Could this be you?

  1. You can’t sleep properly (even when your loved one does).
  2. You’re permanently exhausted and can’t be bothered to do things you used to enjoy.
  3. You suffer stomach complaints, headaches or have other aches and pains you can’t seem to shift.
  4. You find yourself getting very irritated, angry or snappy with your loved one when they repeat themselves or behave in a way that you know they can’t help.
  5. You worry constantly about money, future finances and how you’ll be able to manage.
  6. You’ve lost your appetite and aren’t eating properly – or are eating too much and have gained weight.
  7. You’re having anxiety or panic attacks.
  8. You’re drinking or smoking too much.
  9. You pretend everything’s fine and rarely ask for help.
  10. You often feel tearful and emotional when you think about ‘what might have been’ if your loved one hadn’t been diagnosed with dementia.

Now be honest with yourself. How many of these statements sound familiar? Do you recognise yourself in one or two, more than five or most of them? Remember, stress doesn’t only affect you mentally, it can lead to physical ill health which, in turn, can impact on your ability to be a good carer.

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

Factors that increase the risk of carer breakdown

  • Role confusion
  • Unrealistic expectations
  • Lack of control
  • Unreasonable demands

What factors increase the risk of social isolation? What would be useful to know to ascertain if there is risk of social isolation?

Find below a list of factors that increase the risk of social isolation or information that will be useful to know to ascertain if the adult and/or carer is at risk of social isolation.

Signs that may mean the adult and/or carer may be at risk of social isolation

  • Deep boredom, general lack of interest and withdrawal
  • Losing interest in personal hygiene
  • Poor eating and nutrition
  • Significant disrepair, clutter and hoarding in the house
  • Strong difficulty in connecting with others in a non-superficial way
  • Not having close friends, just mainly acquaintances or casual friends
  • Low self-esteem and negative feelings of self-doubt
  • When you try to connect or reach out, it’s not reciprocated, and you’re not seen or heard
  • Leaving the house feels like stepping into the scary unknown
  • Lack of motivation to arrange any calls or meetings

Factors that increase the risk of social isolation

Obviously at this moment, social distancing and restrictions to meeting people to counter COVID-19 are increasing the risk of social isolation.

  • Other causes of elderly social isolation Open

    • Disability
    • Living alone
    • Limited finances
    • Impaired mobility
    • No family close by
    • Never having married
    • Transportation challenges
    • Divorced, separated, or widowed
    • Inability to remain physically and mentally active
    • Lack of access and inequality due to rural living or being part of a marginalised group
    • Poor health and wellbeing including untreated hearing loss, frailty, substance abuse and poor mental health, including depression
    • Societal barriers such as ageism and lack of opportunities for older adults to engage and contribute
    • Unemployment
    • Lack of an adequate social support network
    • Bereavement
    • Domestic violence
    • Some mild forms of autism, such as Asperger's Syndrome
    • Dementia and Alzheimer's
    • Sexual orientation issues

UCLA Loneliness Scale

Ask the person to respond to a series of questions developed for the UCLA Loneliness Scale, which might help both of you assess how much isolation is impacting them.

The person should respond by using these numbers:
1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Always

  1. How often do you feel unhappy doing so many things alone?
  2. How often do you feel you have no one to talk to?
  3. How often do you feel you can’t tolerate being so alone?
  4. How often do you feel as if no one understands you?
  5. How often do you find yourself waiting for people to call or write?
  6. How often do you feel completely alone?
  7. How often do you feel unable to reach out and communicate with those around you?
  8. How often do you feel starved for company?
  9. How often do you feel it’s difficult for you to make friends?
  10. How often do you feel shut out and excluded by others?

Take the full 20-question survey

Other risks

There are other risks that social workers and social care practitioners should find out about, such as: cognitive deterioration, risk of hospital admission, risk of not taking the medication, damage to equipment, wandering.

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, 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.

Further reading