Chapter 8: Assessing and managing the risk of harm
1. The Act provides the legislative framework within which partnerships should establish and implement their own multi-agency procedures and processes. This chapter addresses some of the matters that partnerships should bear in mind in developing these procedures, particularly in relation to multi-agency risk assessment and decision making processes, and also with regard to large scale investigations and initial and significant case reviews.
2. The provisions of the Act are concerned with adults at risk of harm. Local procedures should therefore concentrate on the following:
- an assessment of whether the adult is at risk of harm;
- an assessment of the nature and severity of any risks identified, including when and where the adult may be paced at risk and an identification of the factors that will impact on the likelihood of risk;
- the identification of reasonable and proportionate timescales for undertaking inquiries and assessments;
- the development of a protection plan (that can be single or multi-agency), that identifies actions and supports that will eliminate or reduce the risks identified;
- reviewing and amending protection plans as risks and circumstances change;
- reviewing whether the adult continues to meet the criteria for an adult at risk of harm, and if not whether there are other supports that will still be required out with the provisions of the Act.
3. Many referrals that are made concerning people who are believed to be at risk of harm will result in a determination that they are not at risk of harm and therefore require no further action under the provisions of the Act, though this does not preclude other support or involvement through other relevant legislation, local procedures or alternative services to respond to the individual's needs.
4. For other adults the inquiry and investigation process will determine that they are at risk of harm and will need continuing assistance with their support and protection. Such a determination will follow from an assessment process that should involve all relevant agencies. Some cases will involve few or single agency involvement. Others will require the involvement of a wide range of agencies.
5. In all cases the assessment process should be based on information supplied by all relevant agencies. This will be coordinated through the Council, with the council officer having a key role in the process. The multi-agency assessment should be considered by an interagency Adult Support and Protection Case Conference. This will be assisted by the collation of up to date and well balanced inter agency chronologies.
6. Multi-agency adult protection procedures should give guidance on the convening of meetings of agencies as the best approach to managing risk by agreeing a protection plan.
7. Such meetings should be as inclusive as possible, with the presumption that the adult themselves will be in attendance (unless it is considered not to be in their best interests) or that arrangements have been made to ensure that the adult's views and wishes can be conveyed to the meeting. Consideration of timing, venue and accessibility of meetings can assist in making it easier for the adult to attend. The adult does have the right to decide not to attend and this should be respected unless there is reason to believe that this decision has come about as a result of undue pressure.
8. The purpose of such meetings will be defined by local procedures, but should include the sharing of information relating to possible harm, the joint assessment of current and ongoing risk and the need to agree a specific and detailed protection plan with timescales for addressing risks and providing services to support and protect the adult.
9. The needs of many people may mean that a case conference convened as part of adult support and protection concerns may also need to consider other options for protecting people including under the provisions of the Mental Health (Care and Treatment) (Scotland) Act 2003, and the Adults with Incapacity (Scotland) Act 2000 may also be helpful. However such considerations should not compromise any actions that may need to be taken under the Adult protection legislation.
10. During the Covid pandemic in 2020 greater use has been made of virtual meetings and case conferences. This such meetings will require special consideration in the context of enabling the adult to participate as fully as possible, not only in relation to how readily they can use new technology but also in preparation in advance for what can feel very different to a face to face meeting.
11. If the meetings of the agencies with the adult are to be effective it is essential that:
- the chairperson is trained in the skills necessary for that role including training on communication support and the ability to take account of the wishes and feelings of the adult at risk and the outcomes which matter to them. Arrangements vary across Scotland but the chairperson is usually either a manager at team leader level or, in some areas an officer whose specific role is to chair such meetings and who has no direct involvement in service provision
- where the adult at risk has not attended, the reasons for this are recorded;
- consideration should be given to the size of the meeting when the adult is present in order not to make the meeting overwhelming;
- the meeting is correctly minuted and sets out who has been invited and who is present (for audit purposes those who have not responded should also be noted) and who has contributed information either in person at the meeting or through previous submissions;
- a protection plan is agreed across all relevant agencies, including identification of who is responsible for which aspects of the protection plan, the anticipated timetable, and reporting arrangements;
- the adult has been able to contribute to the fullest possible extent and they understand the actions in the protection plan. Where the adult has not attended, arrangements must be agreed for how the outcome of the meeting is explained to them, and who will be responsible for doing this;
- a date for a review meeting has been agreed, unless it has been agreed that no further actions are required under the terms of the Act.
12. There will be occasions where the alleged perpetrator of harm may be a carer or relative of the adult at risk of harm. In such circumstances there may also be a need to consider the provision of support to the alleged harmer as well as to the adult themselves.
Large scale investigations
The Act makes no reference to large scale investigations (LSIs), but these have become increasingly prevalent across Scotland since the implementation of the Act. Many partnerships have their own procedures, sometimes across a number of partnerships (e.g. within one Health Board area). LSIs frequently involve other agencies including the Care Inspectorate, the NHS and the police, but there are no nationally agreed definitions of what warrants an LSI, or guidance for conducting LSIs or for governance arrangements locally. This section of the Code provides some broad guidance for consideration by partnerships in developing their LSI procedures.
13. An LSI may be required where there is reason to believe that adults who are resident of a care home, supported accommodation, an NHS hospital or other facility, or who receives services in their own home may be at risk of harm due to another resident, a member of staff, some failing or deficit in the management regime, or in the environment of the establishment or service. In such circumstances this means that there is a belief that a particular service may be placing all its residents or service users at risk of harm.
14. An LSI should be considered if one or more of the following applies:
- an adult protection referral is received that involves 2 or more adults living within or cared for by the same service;
- a referral is received regarding one adult, but the nature of the referral raises queries regarding the standard of care provided by a service;
- where more than one perpetrator is suspected;
- institutional harm is suspected;
- a whistle-blower has made serious allegations regarding a service;
- there are significant concerns regarding the quality of care provided and a service's ability to improve. These concerns could come from a regulatory body such as the Care Inspectorate;
- an adult or adults are living independently within the community but are subject to harm from a perpetrator or group of perpetrators, or it is strongly suspected that more than one adult is subject to such harm;
- concerns regarding an adult are raised following their admission to hospital or discharge. This may include concerns about a care service that are evidenced by an admission to hospital, or concerns regarding an NHS service area;
- concerns are raised via a complaint to the Care Inspectorate, NHS Board, or the local Council or Health and Social Care Partnership;
- concerns are raised by GPs, District Nurses, Dentists, Allied Health Professionals etc. who attend a service.
15. Harm in a care setting can include:
- Financial, physical or sexual abuse
- Neglect or omission of care
- Exploitation, coercion or undue influence to the detriment of the adult
- Psychological abuse, however subtle.
- Undignified or degrading treatment
16. Initial consideration should take place regarding the need for an LSI, including discussion with all other relevant agencies. A decision whether to proceed to an LSI would be expected to take place in a multi-agency meeting, and such meetings would be expected to be chaired by a senior officer of the council at Head of Service level or above.
17. The range of agencies involved in an LSI will vary but will always involve:
- the Council and HSCP, including contracts and commission staff
- the Care Inspectorate
- the service provider responsible for the care of the adults
According to circumstances the following, amongst others, may also be involved:
- Police Scotland;
- the wider NHS;
- the Office of the Public Guardian;
- the Mental Welfare Commission;
- Health Care Improvement Scotland;
- other councils and partnerships may become involved if they have people placed in the service subject to the LSI.
18. If an LSI is instituted a lead officer should be appointed and an oversight group established. All regulatory agencies and staff will have a role to play. Operational staff will have a high level of involvement as all residents or service users will need to minimally have an initial inquiry undertaken, and some of this may move through to the investigation stage.
19. It is likely that a number of residents or service users will have protection plans put in place, and that there will also be an improvement plan put in place for the service provider regarding staffing, practice, procedural and other issues.
20. The investigation, and subsequent protection planning and action must remain proportionate and reflect the individual needs of all the residents for continuity of care. The families of residents should be kept informed, and the residents themselves kept informed in keeping with their best interests.
21. The individual protection plans and service wide improvement plan will all stay in place until agreed that they are no longer necessary. Individual protection plans will be overseen through normal case conference processes. The improvement plan will be monitored by the oversight group.
22. The oversight group will be responsible, on the basis of the progress against the protection plans and improvement plan, for determining when the LSI can be concluded.
23. LSIs often take place in parallel with other investigations, for example NHS led Adverse Event Reviews or Care Inspectorate activity. Every effort should be made to coordinate such overlapping investigations to minimise duplication and maximise the opportunity for interagency learning.
24. Senior managers in partnerships are responsible for initiating and overseeing LSIs. They should keep Adult Protection Committees regularly appraised of the progress of any LSIs that may be underway, and provide the Committee with a final report once the LSI is concluded. This will ensure that any necessary actions arising out of the LSI relating to the duties of Adult Protection Committees can be noted and necessary responses actioned. Adult Protection Committees should advise Officer Groups accordingly.
Initial and significant case reviews
25. A significant case review is a means for public bodies with responsibilities relating to the support and protection of adults at risk of harm to learn lessons from considering the circumstances where an adult at risk has died or been significantly harmed. An initial case review is an opportunity to consider information relating to the case, and recommend whether significant case review or other response is required.
26. The Scottish Government published an Adult protection significant case reviews: interim framework in November 2019. This places the responsibility for commissioning and overseeing such reviews with Adult Protection Committees and for submitting final reports to the Chief Officer Group for approval. This is therefore referenced in greater detail in the revised Guidance for Adult Protection Committees, publication of which will coincide with publication of this revised Code of Practice.
27. This guidance identifies the Care Inspectorate as the central repository for all ICRs and SCRs as a way of supporting learning from these reviews to be shared more widely. As such, it is important that all learning reviews that are similar in purpose though not labelled as an ICR or SCR are also submitted to the Care Inspectorate.