Fair access to care services (FACS): prioritising eligibility for care and support
Initial contact - Managing risks and safeguarding
Giving people more choice and control inevitably raises questions about risk, both for individuals exercising choice over their care and support, and for public sector organisations who may have concerns about financial, legal or reputational risk ... Councils should take steps to ensure that an effective risk management strategy is embedded at every level of their organisation ... [and] build support for a cultural shift away from risk-aversion towards genuine user control and supported decision-making. This will require agreement from all relevant parties about what proportionate safeguarding measures should be put in place for each individual requiring support(‘Personalisation and support planning ...’, DH, 2010, paras 133/134)
James’ story – risks and concerns arising from family changes
James, aged 34, has a long-term mental health condition and lives with his parents. Without one of them accompanying him he gets into trouble in the community, and this is now happening regularly. Both parents are in their mid-seventies. His father had a mild stroke 15 months ago which seriously undermined his confidence, is now mainly housebound and does not like to be left alone. Three times in the past 15 months James has been arrested because of his behaviour, and detained under the Mental Health Act.
The Department of Health’s 2010 policy guidance ‘Prioritising need in the context of “Putting people first”’recognised that some people coming forward, or referred, for needs and risk assessment could be at risk of, or subject to, abuse, neglect or exploitation. It is important to raise awareness of this issue, and how to respond to it, among staff involved in assessment.
The Department went on to publish in 2011,  and refresh in 2013,  a statement of policy on adult safeguarding. Its aim is to give people at a local level – councillors and communities as well as professionals and agencies – the national context for their own responsibilities and activities. It also acts as a bridge between the current No Secrets guidance  and the duties and powers contained in the Care Bill. the government believes that safeguarding is everybody’s business, with communities playing a part in preventing, identifying and reporting neglect and abuse. Measures need to be in place locally to protect those least able to protect themselves.
The statement sets out six cross-agency Safeguarding Adults principles:
- Empowerment – Presumption of person-led decisions and informed consent.
- Prevention – It is better to take action before harm occurs.
- Proportionality – Proportionate and least intrusive response appropriate to the risk presented.
- Protection – Support and representation for those in greatest need.
- Partnership – Local solutions, services working with their communities, which have parts to play in preventing, detecting and reporting neglect and abuse.
- Accountability – Accountability and transparency in delivering safeguarding.
It also provides examples from an individual’s point of view of how the outcomes of effective safeguarding could be experienced:
- Empowerment – I am asked what I want as the outcomes from the safeguarding process and these directly inform what happens.
- Prevention – I receive clear and simple information about what abuse is, how to recognise the signs and what I can do to seek help.
- Proportionality – I am sure that the professionals will work for my best interests, as I see them, and will only get involved as much as needed.
- Protection – I get help and support to report abuse. I get help to take part in the safeguarding process to the extent to which I want and to which I am able.
- Partnership – I know that staff treat any personal and sensitive information in confidence, only sharing what is helpful and necessary. I am confident that professionals will work together to get the best result for me.
- Accountability – I understand the role of everyone involved in my life.
The section of the 2010 DH Guidance on ‘Personalisation and support planning’ linked together two aspects of risk in practice: safeguarding; and risk assessment and management. The 2013 policy statement argues for a clearer distinction:
In order to support those people most vulnerable to abuse and neglect, it is vital that agencies agree collectively those issues that require a safeguarding response, as opposed to issues, which relate to standards and quality of care more widely.
Staff involved in assessment will need to:
- be familiar with local inter-agency agreements on the issues requiring a safeguarding response
- work with other professionals and agencies, particularly GPs, community nurses and hospital Accident & Emergency staff, to reduce risk of abuse or neglect, and safeguard adults and carers in vulnerable situations
- note, and know how to respond to, signs and symptoms of possible harm, abuse and neglect, working to empower individuals and communities to protect themselves and one another
- take appropriate action when there are serious safeguarding concerns, seeking advice from line managers and accessing specialist expertise
- work with children’s services when there is any indication of child safeguarding concerns
- assess whether Mental Capacity Act procedures should be initiated.
The White Paper ‘Caring for our future’  sets out the government’s proposals to strengthen local safeguarding arrangements and processes. It underlines the need, when abuse does occur, or there is the possibility of abuse occurring, to identify it quickly and take appropriate action. Local authorities will have a responsibility for convening a statutory multi-agency safeguarding adults board, parallel to the safeguarding children board, and responsible among other things for developing inter-agency safeguarding strategies and conducting safeguarding adults reviews. The core members of the board are nominated by the local authority, clinical commissioning groups in its area and the chief police officer. The Care Bill contains the legislative provisions for reforming adult safeguarding.
Risk assessment and management
Risk assessment and management are core features of the local authority’s assessment responsibilities. Staff will need to:
- work with individuals and carers, and where appropriate with partner agencies, to support the assessment and management of risk to the person, carers, family and the public
- involve individuals, carers and other professionals in the assessment and management of risks arising in situations of uncertainty, unpredictability and conflict
- consider whether aspects of the individual’s or carer’s physical or mental health require the involvement of health professionals in the risk assessment process
- seek support when risks to be managed are outside the practitioner’s own expertise
- work, when necessary, within the organisation’s procedures for managing media interest in risk and safeguarding situations.
Limitations on an individual’s right to have control over their lives
The Mental Capacity Act seeks to define and limit the circumstances in which an individual is judged to lack capacity. It sets out five principles which must be met, and the procedure which must be followed. The principles are:
- A person must be assumed to have capacity unless it is established that she/he lacks capacity.
- A person is not to be treated as unable to make a decision unless all the practicable steps to help her/him to do so have been taken without success.
- A person is not to be treated as unable to make a decision merely because she/he makes an unwise decision.
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests.
- Before an act is done, or a decision is made, careful consideration has to be given to ensuring that it is the least restrictive option, and will minimise as far as possible limitations on the individual’s rights and freedom of action.
The Care Bill sets out a number of matters to which the local authority must attend in carrying out its functions under the Bill. These include the importance of beginning with the assumption that the individual is best placed to judge his or her own wellbeing; attending to the individual’s views, wishes and feelings; and ensuring that any restriction on the individual’s rights or freedom of action is kept to the minimum necessary for achieving the purpose for which the function is being exercised.