Positive Risk Taking – Trish O’Hara

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Most of the choices that people make in life naturally involve some element of risk. Avoiding risks altogether can limit life opportunities, and impact negatively on quality of life. People want choice and control for themselves and safety for those they care for. This is because risk is a concept that tends to have negative connotations, but people take considered risks all the time and gain many positive benefits.

People perceive risk differently, including people who use services, practitioners, and families. This can be difficult for social care practitioners and confusing for individuals and families. Therefore, adopting a balanced approach at a practice level can be a challenge. Balance and proportionality are vital considerations in encouraging responsible decision making.

In our work streams we have been considering:

What skills do staff need to properly develop positive risk taking in their practice?
How can learning programmes be developed that inspire and motivate practitioners to take a bold approach to positive risk taking?
What systems need to be in place to enable a responsive approach to positive risk taking?

Getting out of bed, and all that it entails – getting washed, dressed having breakfast, and taking the bus to work – carries risk. Though, staying in bed could still involve both psychological and physical risks.

Back in the mid 80’s the social care sector often ignored risk assessments. There were risk assessments in place for health and safety of the building and staff. However, what was lacking was person centred risk assessments to support the people using our services to positively live their lives.

I recall us supporting extremely complex individuals to go to Glastonbury music festival. We did this without a risk assessment, and this was back in the day when you could speak to Martin Eavis directly to get free tickets. They were the days of ‘try it and see’.

By the late 80’s risk assessments were firmly and quite rightly in place to ensure staff were confident to support people to try new things, and live as full as life as possible. Managers who would start a sentence ‘Yeah, let’s try that, let’s do a risk assessment’ with a smile. It was as if doing the risk assessment itself was the incentive to make it happen. Over time, I noticed that the sentiment of risk assessment changed. The managers started to say, ‘oh no, you had better risk assess that’. It seemed like the idea that risk assessment had become a way of limiting people. The intention changed. Risk assessment should be used as a tool to support empowerment, and innovation. It should also be used to listen to those that need care and support.

Finding time to embark on meaningful co-production, ensuring the person is an equal partner in the shaping of their services is likely to mean that people will be faced with more choice. Where people are faced with more choice this is likely to lead to options that introduce more risk.

So what is stopping our services effectively undertaking positive risk assessments, what are the barriers?

People perceive risk differently. For instance, it you ask nurses what is the main risk for older people in care homes, they are most likely to say, falls. If you ask social workers, they are likely to be concerned with risks to adequate housing or benefits. If you ask their family, it is likely to be that they are concerned that their loved one is treated badly. If you ask the person themselves, they may be more concerned with losing their identity and/or purpose. We come to the table with a bias based on role and relationship.

Getting the balance right requires professional competence, partnership working and understanding that safeguarding is about improving quality of life as much as safety, and can only really work if we keep it personal.

Because risk assessment is considered a skilled endeavour, we often see managers or team leaders completing the risk assessment from beginning to end from inside of an office, rather than inside the life of the person. Key-workers need to be trained to understand risk assessment and be part of the process, as they are often the people who know the person best.

There is also a real fear of being accused of neglect. Staff also struggle to understand that what may be important FOR the person may be in direct conflict with what is important TO them. A disproportionate response that infringes the rights of individuals to make their own, albeit at times, unwise decisions. Often there is a lack of a working knowledge of the Mental Capacity Act and what it means to deprive a person of their liberty. A general lack of knowledge when and where to apply the law.

Ultimately, risk is part of life and arguably the most successful people take many of them. It is impossible to self actualise without taking risks. It’s the only way to face the challenge of Everest. Many of us would make it to the top if we were given the chance to do it at our own pace (maybe years), using our own methods, with the right people and with the adaptations required to help us along the way. We would find our own peak and reflect on our own troughs knowing where we are, where we have been and where we are going.

We will continue to challenge practice in our work streams, and get practitioners to really believe that positive risk taking is a fundamental core of practice.

Trish O’Hara

Day Services Ignored Again

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Day services and DOLS

Day services have a history of being left out of all legislation. I am sure the talk of ‘registering’ them has come and gone for as long as I can remember. Surely now, with the new threshold ruling for DOLS, it must be time to take this more seriously.
Day services all over the country often operate as respite, although we know the funding is the persons and not their family. At times, the families needing the service more than the person. This is not a criticism of day service provision – I am one of the few left, who truly believes the need for building based services for some people who need the support of the ‘group’ to understand the world and build upon skills that underpin self-esteem.
With this in mind, I am more concerned than ever that day services are ‘containing’ clients, who may not have capacity, as much as every week day from 9am to 3pm – in constant supervision, the door locked and an expectation that the person is ‘held’ there until picked up by ‘the bus’ or their family at the end of the day. Surely those who use day services of any kind also are assumed has having the right to liberty and security – Article 5 of the HRA.
I know day services have provided personal care and administered medication without being registered and without the system considering this anomaly but surely the deprivation of liberty that arises now means we must support day services to work within the law.
My advice when training those services, is that they apply to the court of protection regarding DOLS. I am well aware that the courts may ignore these requests – although day services are imputable to the state. If the DOLS teams cannot take on these cases, then the courts must. Perhaps, the easiest thing to do is ‘register’ day services and bring them into the inspection of CQC – to ensure that all manner of care provided is in line with the standards expected.
I am not sure we can continue to ignore day services any longer – There needs to be more accountability across the sector for all people rely on it.

Trish O’Hara
Dec 2014

Assessors of capacity have a lot of responsibility to get it right

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With most assessments carried out by social workers or section 12 doctors – especially around the issue of deprivation of liberty – We must consider their knowledge of the persons communication. Seems to me, that a professional arriving and conducting an assessment about capacity with someone they are unlikely to have met before poses many problems. The four stage assessment is simplistic and rather wonderful but throws out the possibility of interpretation.
Does the person understand the information around the decision? A good assessor will need to ask a variety of questions around the decision to fully assess if the person understands. Do all assessors prepare the types of questions? Do they ask the questions in a variety of ways?
Can the person retain the information long enough to make the decision? Is the assessor looking for a consistent answer here? Is the assessor leaving the person for 30 minutes or so and returning. I suspect, if the person does not remember the conversation, then the assessor would record the person does not have capacity. But, I think it is necessary to reopen the discussion and find out if the person has a consistent answer regarding the decision.
Can the person broadly weigh up the benefits and risks? This one is so tricky – As a smoker, I am hard pushed to explain the benefits. I am well aware of the risks. It is important that the person is able to say ‘because I want to – or because I like it’. There are so many risks we all take that we do simply because we want to. It seems to me that we are asking people to jump through hoops that we would struggle to jump through ourselves.
Can the person communicate their decision in any way? So how much effort is gone to here? A person with dementia for instance, may be more lucid in the morning after a good night sleep and breakfast but by the afternoon, their capacity may fluctuate. Does the assessor make sure they assess at a time that is best for the person? Is the assessor listening to staff to ensure they know the answer to this? And once they arrive to assess, are there communication tools for those who may use non verbal communication? Does the assessor spend some time learning how the person communicates? The provider has a role to play here – It is pointless introducing a communication tool at the point of big decision and expecting the person to know how to use it. There needs to be access to a variety of communication tools for everyone in services who has communication difficulties. Speaking louder to them is really not enough. Using tools to make small day to day decisions over a long period of time – recorded as showing a consistent decision maker means that at the time of big decision, the person has a fighting chance of using the tool. The staff making sure the assessor sees the records of how the person decides and is expected to use said tool to best effect.
If we want assessors to be this thorough, we must ensure they are challenged. A visit from an assessor that lasts less than 30 minutes and makes a judgement about a persons capacity must be questioned. There needs to be an expectation that the assessor spends time with the person, their family and the support staff. The staff who may spend more time with the person than anyone must be listened to.
In summary, the assessors need to come at the ‘right’ time for the person, spend time with them, speak to family, advocates and importantly the front line staff. Look at records and learn how the person communicates to ensure the person has a fighting chance of staying in control of their decision making. The providers needs to build communication passports to ensure the person has the tools to make the decision, challenge assessors who do not fulfil this criteria.
To be honest, I am concerned that there is money to be made in independent assessment and seems to mean that assessors are packing out their day with assessments, spending so little time with the person who may be more complicated to assess. I am sure this is not the description of many of the Capacity and BI assessors out there, but I fear does describe how many assessments are conducted. One of the other concerns, particularly in hospitals, is that the front line staff have no time to spend with the assessor who are left to conduct the assessment to too little information or support.
If we are to get capacity assessments to reach the standard expected and hoped for, then everybody needs to work together to keep the person as in control of their decision making as possible.
Trish O’Hara November 2014