Chapter 8: Assessing and managing the risk of harm
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 learning reviews (prior to May 2022, referred to as Initial and Significant Case Reviews).
Risk assessment and management
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 placed 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 collation and analysis of a multi-agency chronology, and its contribution to risk assessment;
- the development of a support and 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 support and 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 outside of the provisions of the Act.
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. This does not preclude other support or involvement through other relevant legislation, local procedures or alternative services to respond to the individual's needs.
For other adults the inquiries 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.
To ensure robust risk assessment, any reports generated as part of, or at the conclusion of, inquiries, including use of investigative powers, should include all relevant information and a chronology, to be completed by the council officer. Analysis of risk and the adult's ability to safeguard themselves are key. Reports should also include information pertaining to significant others in the adult's life, and provide a clear overview of the risks, vulnerabilities and protective factors, as well as the adult's views.
Good practice suggests that any risk assessment is accompanied by a risk management plan. This can be developed at any point of the adult support and protection activity and should be updated to reflect emergent and relevant information. Partnerships may wish to embed risk management plans into their inquiry and investigation processes. Risk management/protection planning work should evolve over time and be adjusted as needed during activity.
A good risk management plan will clearly outline the risks, outline the protective factors, invite some analysis reflects multi-agency views including concerns, and say clearly what action was being taken to mitigate the risks identified. A good risk management plan will clearly demonstrate what support and protection measures are being put in place where, when and why.
Chronologies are an essential feature of risk assessment in adult support and protection activity.
A chronology is:
- a summary of events key to the understanding of need and risk, extracted from comprehensive case records and organised in date order
- a summary which reflects both strengths and concerns evidenced over time
- a summary which highlights patterns and incidents critical to understanding of need, risk and harm
- a tool which should be used to inform understanding of need and risk. In this context, this means risk of harm to an adult
A chronology may be:
A multi-agency chronology must comply with information sharing guidance and protocols in the way that it is developed, held, shared and reviewed; reflecting information sharing guidance in this document, including duties to cooperate under Section 5 of the Act. It must be accurate, relevant and proportionate to purpose.
A multi-agency chronology:
- is a synthesis which draws on single-agency chronologies
- reflects relevant experiences and impact of events for the adult
- will include turning points, indications of progress and/or relapse
- will inform analysis, but is not in itself an assessment
- may evolve in a flexible way to integrate further necessary detail
- may highlight further assessment, exploration or support that may be needed
- is a tool which should be used in supervision
A chronology, whether single- or multi-agency:
- is not a comprehensive case record and cannot substitute for such records
- is not a list of exclusively adverse circumstances
A multi-agency chronology is most likely to be developed by the council officer as part of inquiries, to contribute to the risk assessment and subsequent decisions. Contribution to the chronology is a collective responsibility. Forming a chronology should assist a shared understanding with and between those involved in the risk assessment, as well as to contribute to any subsequent support and protection plan, if appropriate. The perspective of the adult at the centre of the adult protection process should be explored to gain understanding of the impact of events and to check their perception of accuracy.
The format of a chronology should record purpose, authorship and date of completion. It should include the nature and sequence of events; outcomes or impact on the adult; sources of information; and responses to events as necessary for the purpose of this adult support and protection assessment. Guidance is provided in the Care Inspectorate's Practice guide to chronologies 2017.
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.
Subsequent to inquiries and investigative activity, the multi-agency assessment may be considered by an interagency Adult Support and Protection Case Conference. A case conference could be convened when there are concerns that an adult is at risk of harm and the engagement of the adult and all relevant agencies in the assessment of risks and strengths, and in planning for next steps, is required. This will be assisted by the collation, in advance of the case conference, of up to date and well balanced inter-agency chronologies. The collated chronology may be updated to reflect information arising from the case conference.
Multi-agency adult support and protection procedures should give guidance on the convening of meetings of agencies as the best approach to managing risk by agreeing a support and protection plan. The guidance should include reference to who chairs case conferences, noting that the chairperson role requires someone who is well-versed in the Act. The chairperson should have significant experience in adult protection practice; have sufficient authority, skill and experience to carry out the functions of the chair; and be able to challenge all contributing services on progress in supporting and/or protecting the adult at risk of harm. Local areas may wish to include in their ASP learning and development plans training for those responsible for chairing multi-disciplinary case conferences, supervision and support of practitioners, and decision-making.
The chair's role includes:
- agreeing who to invite and ensuring that all persons invited to the case conference (or review case conference) understand its purpose, functions and the relevance of their particular contribution
- sharing with the adult the nature of the meeting, and possible outcomes
- ensuring that the adult's views are taken into account
- facilitating information-sharing, analysis and consensus about the risks and protective factors
- facilitating decisions and determining the way forward, as necessary
- if progressing with a support and protection plan, facilitating the identification of a core group of staff responsible for implementing and monitoring the support and protection plan
- agreeing review dates
- following up on actions and responsibilities when these have not been met.
Such meetings should be as inclusive as possible with the presumption that, barring serious risks to attendance, the adult themselves will be in attendance 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.
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, the continued implementation of any existent management plan, and the need to consider and, if appropriate, agree a specific and detailed support and protection plan. Any plan should include timescales for addressing risks and providing services to support and protect the adult. The plan should include reference to the adult's views, strengths, needs and concerns over time, for the purpose of reducing risk of harm.
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. However, such considerations should not compromise any actions that may need to be taken under Adult Support and Protection legislation. It may be helpful to have a Mental Health Officer present at a case conference.
During the Covid pandemic in 2020 greater use has been made of virtual meetings and case conferences. 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 for what can feel very different to a face-to-face meeting.
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 has accurate minutes 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 support and protection plan may be agreed across all relevant agencies, including identification of who is responsible for each aspect of the support and 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 support and 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.
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.
If a review meeting has been agreed, the decision may also be taken to convene a core group between case conferences. A lead professional – likely to be the council officer - should be identified to be kept informed of relevant updates relating to the adult and implementation of the support and protection plan; and lead professionals to comprise the core group who will work with the plan should be identified.
The core group would be those who have direct and ongoing involvement with the adult, and may also include the adult. They are responsible for implementing, monitoring and reviewing the support and protection plan, in partnership with the adult. The core group should:
- be co-ordinated by the lead professional;
- meet on a regular basis to carry out their functions;
- keep effective communication between all services and agencies involved with the adult;
- activate contingency plans promptly when progress is not made or circumstances deteriorate;
- recommend the need for any significant changes in the plan to the case conference chair and provide updates to the review case conference, including any update to risk assessment and chronology;
- be alert, individually and collectively, to escalating concerns that may require immediate response and/or additional support.
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. LSIs may be viewed as an example of public bodies and other agencies / office-holders performing their functions under Section 5 and co-operating with each other to protect adults at risk of harm. 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. At this time, there are no nationally agreed definitions of what warrants an LSI, nor 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.
An LSI may be required where there is reason to believe that adults who are service users of a care home, supported accommodation, an NHS hospital or other facility, or who receive services in their own home, may be at risk of harm due to another service user, a member of staff, some failing or deficit in the management regime, or in the environment of the establishment or service. An LSI may also be indicated by the need to address structures or systems that lead to possible harm for all those under such structures. In such circumstances, this means that there is a belief that a particular service may be placing some or all of its residents or service users at risk of harm.
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 General Practices, District Nurses, Dentists, Allied Health Professionals etc. who attend a service.
Harm in a care setting may 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.
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 with sufficient seniority to affect strategic and operational changes (e.g., Head of Service level or above).
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;
- General Practices;
- 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.
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 individual inquiries and any subsequent investigation activity is undertaken.
It is possible that a number of residents or service users will have support and protection plans put in place. There may also be a service-level action plan developed regarding areas identified for improvement. These may include themes such as quality of care; processes and procedures; leadership and management; or systemic issues arising across the service and/or service provider. Action to address structural and systemic harm will likely include the care provider and regulatory partners, such as the Care Inspectorate, to support service improvement while ensuring improved outcomes for residents and service users.
The large scale investigation, and subsequent protection planning and associated actions, must remain proportionate and reflect the individual needs of all the residents, including considerations related to continuity of care. The residents and families of residents should be kept informed of the progress of the investigation. Local procedures should also give consideration to how service providers will be engaged in LSI processes, including attendance at meetings, to promote collaboration in the reduction of harm and improved outcomes for service users.
The individual support and protection plans and service-wide improvement plan will remain in place until agreed that they are no longer necessary. Individual support and protection plans will be overseen through normal case conference processes. The improvement plan may be monitored by the oversight group.
Local procedures should make clear the process and governance arrangements by which an LSI can be concluded, based on progress against the protection plans, any improvement plan and activity, and any ongoing risk to service users.
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.
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. Such reporting could include the identification of patterns or themes arising in regulated care settings. This will ensure that any necessary actions arising out of the LSI relating to the duties of Adult Protection Committee can be noted and necessary responses actioned, noting that regulatory bodies may have ongoing responsibilities in keeping with their remit.
Adult Protection Committees should advise Chief Officer Groups accordingly.
The approach to Significant Case Reviews has been revised, with key objectives to ensure that essential recommendations translate into effective learning to prevent recurrence of the most serious events regarding adults at risk of harm. To this end these reports are now called Learning Reviews.
An Adult Support and Protection Learning Review is a means for public bodies and office holders with responsibilities relating to the 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. It is carried out by the Adult Protection Committee under its functions of keeping procedures and practices under review, giving information and advice to public bodies and helping or encouraging the improvement of skills and knowledge of officers or employees of public bodies as set out in Section 42(1) of the Act.
The Scottish Government published Guidance for Adult Protection Committees in Conducting a Learning Review in May 2022. 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 guidance identifies the Care Inspectorate as the central repository for all adult protection learning reviews, enabling learning from these reviews to be shared more widely. As such, it is important that all case reviews or reflective learning reviews that are similar in purpose though not labelled as a learning review, are also submitted to the Care Inspectorate.
It is important to note that all reviews or reflective learning exercises serving the same purposes of a learning review – and meeting the criteria for a learning review – should use the learning review guidance, including the protocol for submission to the Care Inspectorate.
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