At a glance 31: Enabling risk, ensuring safety: Self-directed support and personal budgets

Published: November 2010

Key messages

Introduction

This ‘At a glance’ briefing highlights some of the emerging findings from research and practice regarding risk taking and safety in the implementation of self-directed support and personal budgets.

The briefing summarises research findings from UK and international studies and emerging practice. The aim is to highlight evidence of what may help or hinder risk enablement and adult safeguarding in the context of promoting independence, choice and control. It also provides some examples of how practice is developing.

The briefing does not constitute guidance or advice on safeguarding and self-directed support. Its main purpose is to signpost current and growing knowledge and to give an indication of potentially effective ways of working for all those interested in risk enablement, safeguarding and frontline practice in personalisation.

Individual adults who use social care and support services and/or their carers should be able to make their own decisions and take risks which they deem to be acceptable to lead their lives their way.

Close 2009

Background

The personalisation agenda for the transformation of adult social care in England promotes independence and aims to give people who use services more choice and control over the way their support is provided. The move to self-directed support and personal budgets includes the option for people to have a direct payment to purchase their own support.

Some commentators have been concerned about potential challenges for practitioners in balancing risk enablement with their professional duty of care for self-directed support and personal budgets. Personal budgets have sometimes been misunderstood, leading to the idea that people will be left unsupported in organising their own services and will have to take full responsibility for managing their budgets and risks alone.

Other concerns are:

• the possibility of increased risk to those already shown to be at risk of abuse or neglect
• the possibility that people using services, and their carers, may be reluctant to take advantage of new opportunities for choice and control because of fear of potential risks
• organisational and professional risk aversion which can hinder choice, control and independent living.

Policy on safeguarding

The key statutory guidance in England is No secrets: Guidance on developing multi-agency policies and procedures to protect vulnerable adults from abuse (DH 2000). No secrets is currently under review (DH 2009).

In addition Safeguarding adults (ADASS 2005) provides a safeguarding good practice framework used by many local authorities.

Among other things, multi-agency arrangements have been influenced by the Dignity in Care campaign, equalities and human rights legislation, Fair Access to Care Services guidance, mental health legislation and wider debates about child protection systems. All support for decision making in relation to self-directed support should be in line with the principles of the Mental Capacity Act 2005 (for further details see SCIE’s At a glance 5: Mental Capacity Act 2005).

The key policy guidance in Northern Ireland is Safeguarding vulnerable adults: regional adult protection policy and procedural guidance (DHSSPS 2006). However a wider programme of reform is being taken forward by government to improve vulnerable adult safeguarding outcomes, and this will include a review of policy (2011). In addition 'Safeguarding vulnerable adults: a shared responsibility' (2010) sets out eight key safeguarding standards, criteria to achieve those standards and guidance for good practice in safeguarding vulnerable adults. It is targeted at organisations in the community, voluntary and independent sector, although providers of regulated services can also use these standards to enable their compliance with the requirements for the protection of vulnerable adults set out in the Minimum Standards published by the DHSSPS and in the Quality Assessment Framework under Supporting People.

Practice issues

Traditionally, continuing risk assessment and risk management has been seen as an essential part of adult social care.

The assessment of risk has often raised difficult questions for practitioners balancing empowerment with duty of care. The rights of adults to live independent lives and to take the risks they choose need to be weighed carefully against the likelihood of significant harm arising from the situation in question.

Relevant issues in assessing the seriousness of risk of abuse include:

• factors which could increase exposure to risk, e.g. environmental, social, financial, communication and recognition of abuse
• existence of networks and support to minimise risk
• nature, extent and length of time of abuse
• impact on the individual and on others.

Practitioner attitudes to risk

A UK research review on risk perceptions and risk management strategies in adult social care (Mitchell & Glendinning, 2007) found that studies tended to concentrate on risk in relation to mental capacity and competence of people with mental health problems, physical risks for older people, and competence and some positive risk taking for people with learning disabilities.

The views of people who use services were largely absent, and there were few evaluations of risk management systems and interventions.

Professional assumptions about the competence and capacity of people with mental health problems were found to be linked to perceptions of these people as dangerous individuals. This was particularly true for black people.

The review also showed that both people who use services and practitioners may withhold, or be reluctant to share, risk-related information. This can leave people without support when taking the risks that are important to them, or conversely leave them ill-informed about options and choices.

Studies examining the experience of direct payment users emphasised the positive benefits of the risk involved with someone purchasing their own care.

Messages at corporate, practitioner and service user level

Because it is a new approach for the UK, little investigation into risk enablement practice for personal budgets has been undertaken. Also, there is a lack of specific research focusing on how people using support services perceive and manage risk. However, some lessons can be learned from the IBSEN evaluation, international studies and the implementation of direct payments.

Themes emerging from research are centred on the three different levels where risk management may be focused: corporate, practitioner and service user level. Most of the evidence available concerns organisations and practitioners.

Corporate level

The corporate level relates to how the whole organisation is responding and how risks are being managed by local authorities/Northern Ireland health and social care trusts . Key messages from the research are that:

• The promotion of choice and control for people who use services implies the need for organisational change to respond to new person-centred ways of working.
• Risk enablement should become a core part of the transformation of adult social care. It cannot be a ‘bolt-on’ solution to existing systems which do not have the person at the centre.
• Practitioners may not be confident about sharing responsibility for risk if their organisation does not have a positive risk enablement culture and policies.
• A supportive system is one which clearly incorporates self-directed support with safeguarding policy and practice, abuse detection and prevention. Risk enablement and safeguarding training for staff, people using services, carers and families is important.

Practitioner level

The practitioner level relates to how frontline staff and first-line managers are enabling choice and control alongside ensuring the safety of people using services. Key messages from the research are that:

• Corporate risk approaches can result in frontline practitioners becoming overly concerned with protecting organisations from fraud when administering direct payments. This reduces their capacity to identify safeguarding issues and enable positive risk taking with people who use services.
• Practitioners need to be supported by local authorities/Northern Ireland health and social care trusts to incorporate safeguarding and risk enablement into relationship-based, person-centred working.
• Social work skills and relationship-based working with the person using the service are required, both to promote risk enablement as part of self-directed support and to detect and prevent abuse as part of safeguarding.
• Rebalancing social work resources towards frontline activity with people using services, their carers and families could enhance overall organisational risk management and safeguarding.

People who use services, their carers and families

This level relates to how people using adult social care services are staying safe, including how they identify their own risk and safeguarding issues and are supported to take positive risks as part of person-centred assessment and support planning. Key messages from the research are that:

• Certain studies show that some people who use services may withhold information on ‘risk taking’ from the practitioner or their families in order to remain independent and in control of their own decisions.
• Being risk averse has resulted in some frontline practitioners making decisions about direct payments for people based on generalised views about the capacity or ‘riskiness’ of certain groups (particularly people with mental health problems), rather than making decisions with the individual with an understanding of their circumstances.
• With the support of frontline staff, people using services should be enabled to define their own risks and empowered to recognise, identify and report abuse, neglect and safeguarding issues.
• Communication which supports risk enablement and safeguarding should be led by the language and understanding of the person using the service. This approach should be a core part of self-directed support, including assessment and regular review of outcomes.
• Informed choice is vital for risk enablement. Personal budget holders need access to information and advice about safeguarding, employment, legal aspects, reporting, peer support and accredited people and organisations.

What is happening in practice?

The research has shown that risk enablement needs to be a core part of the self-directed support process and that personalisation and adult safeguarding practice and policy need to be more closely aligned and inform each other. They should be underpinned by the principle of personcentred practice and the promotion of choice, control, independent living, autonomy and staying safe. A shared adult personalisation and safeguarding framework can support this.

ADASS and the South West Regional Improvement and Efficiency Partnership in England have developed a safeguarding and personalisation framework with safeguarding leads, people using services and other key partners (Richards 2010).

The framework is structured to support processes at corporate, practitioner and individual service user level. It can be used to check and improve local practice in terms of high level business processes, risk assessment and risk management.

Some local authorities/Northern Ireland health and social care trusts and social care providers are already implementing a culture of positive risk taking, as the examples in this summary show.

Risk enablement panels are also beginning to emerge as a way of helping with challenging or complex decisions which may arise as part of signing off a person’s support plan. They show how local authorities/Northern Ireland health and social care trusts can implement self-directed support and personal budgets in ways which empower individuals while ensuring risks are managed and responsibility is clear. The emphasis is on shared decision making which supports person-centred frontline practice and improves practitioner confidence. Duty of care decisions can be made in a shared and informed way, with transparent, shared responsibility.

Further information

• SCIE Report 36: Enabling risk, ensuring safety: Self-directed support and personal budgets
• SCIE At a glance 5: Mental Capacity Act 2005
• Putting People First
• In Control

References

• ADASS (2005) Safeguarding Adults: A national framework of good practice and outcomes in adult protection work London: ADASS
• Close, L. (2009) Safeguarding and personalisation: Two sides of the same coin
• Department of Health (2000) No secrets: Guidance on developing multi-agency policies and procedures to protect vulnerable adults from abuse London: Department of Health
• Department of Health (2009) Safeguarding adults: Response to consultation on the review of the No secrets guidance London: Department of Health
• DHSSPS (2006) Safeguarding vulnerable adults: regional adult protection policy and procedural guidance
• DHSSPS and NIO (2010) Adult safeguarding in Northern Ireland: regional and local partnership arrangements
• Mitchell W & Glendinning C (2007) A review of the research evidence surrounding risk perceptions, risk management strategies and their consequences in adult social care for different groups of service users: Working paper no. DHR 2180 01.07 York: University of York Social Policy Research Unit
• Richards P & Ogilvie K (2010) South West Region: A safeguarding and personalisation framework February 2010 ADASS/South West Regional Improvement and Efficiency Agency
• Volunteer now (2010) Safeguarding vulnerable adults: a shared responsibility: Standards and guidance for good practice in safeguarding vulnerable adults