Nursing Risk Assessment and Intervention Management

9174 words (37 pages) Dissertation

13th Dec 2019 Dissertation Reference this

Tags: ManagementNursing

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Patchwork Text

Patch One- Discuss critically a particular intervention or incident which involved the assessment and management of risk

In this patch I will be focusing on a case that I am working on.  I will be exploring the situation, the perceived risks and what action was taken to manage the risks. This patch will conclude with a critical reflection on decision making process and management plan.

Situation and care/support plan

I am working within the Older Adults Operations Community Team as a Social Worker.  My team supports older adults over the age of 65 years in the community.  The case to be discussed and analysed for this patchwork text was an allocation through Duty following a safeguarding alert raised by the adult’s solicitor who is the formal advocate citing neglect and acts of omission by the care provider.

Background

Mrs Croft is aged 73, lives with her husband and their two dogs in a bungalow they own. The couple have no known family and have no children. A solicitor appointed by the couple holds Power of Attorney for Property/Finances and is their formal advocate. The solicitor holding a LPA was not perceived to be a risk as at present the Court of Protection would see her as the rightful decision maker regarding finances and property unless challenged.

Mrs Croft was diagnosed with dementia, which affects her short term memory. Has a history of atrial fibrillation, Hypotension, Osteo arthritis, pacemaker, anaemia. Osteo arthritis restricts her mobility at times due to pain. These conditions and dementia have an impact upon memory, mobility which affects her ability to manage day to day tasks independently. Mrs Croft requires support with preparation of meals and drinks, personal hygiene, washing and dressing, administration of medications as she forgets to take her medication, supervision after toilet use to ensure she completes the tasks hygienically, support accessing the community and attending to her health appointments and monitoring of physical and mental health as condition is likely to progress.

Mr and Mrs Croft are supported by a private care package commissioned by the local authority of 4 calls daily provided by X care agency over a period of 7 days.

Mrs Croft was initially referred to social services by her GP, who requested for social services intervention and support after her husband who is her main carer was incapacitated and hospitalised leaving Mrs Croft with no one to care and support her.  Mr Croft had an accident while out shopping, resulting in a fractured left hip.

Following the alert a home visit by myself and a colleague took place and evidence of neglect by the care provider were apparent. Evidence suggested that the adult had missed a substantial amount of medication, non-provision of adequate personal care, nutrition and hydration. The house was in a deplorable state with a strong smell of urine.  The adult was very dehydrated, malnourished and covered in a soiled night dress and lying in a soiled bed. The commode was full of faeces.  The adult was very pale and very weak.  I made an emergency call to her GP who responded within minutes and examined the adult.  The results were that Mrs Croft was severely dehydrated malnourished her physical health had deteriorated significantly.

A risk assessment was carried out as part of initial enquiries as the presenting risks indicated safeguarding concerns.  The risk assessment was used to inform any interim protection plan to safeguard Mrs Croft.  Consideration in the risk assessment were safety and protection of the adult at risk and the husband who is the main carer, the environment which was unhygienic and the chronology and pattern of pertinent events. The impact of the missed medication was also considered and whether the safeguarding process was the most appropriate response.

A check of the daily records indicated that a carer had called 15 minutes prior to our visit and had documented that there were no concerns. The time recorded in the daily notes indicated that a carer had just left and the call lasted only 15 minutes instead of 1 hour contracted time.  Clearly the care agency was not delivering according to expectations.

Once the safeguarding concern was raised the care provider handed 28 days’ notice, citing complexity in the care provision and unsafe conditions for the carers. This new development entailed reviewing the risk management plans taking into the consideration the notice period.

The presenting problems and the perceived risks in this case are malnutrition/hydration, risk of falls due to poor mobility and reluctance to use walking aids, muscle waste, further deterioration in cognition, physical health due to missed medication, risk of infections adult not supported with toilet needs and non-provision of adequate personal care and risk of self-neglect and social isolation, neglect and decline was apparent. Tyrer and Steinberg (1998, p.92) state that ‘in assessments views and concerns are represented in problem definition, in prioritisation of needs to be addressed and in decision making.’

Alongside the risk factors there are also protective factors. Mrs Croft has built up a good relationship with her neighbours and solicitor. The neighbours form an important network and increase her social capital. The neighbours have volunteered to walk the dogs on a daily basis.

Prior to the safeguarding alert I had raised concerns following a 4 weekly review were I noted that the level of care was not as expected. These were discussed with the care provider and the care/support plan adjusted and increased with the introduction of a cleaning and a shopping call and arrangement of a deep clean to ensure the premises were kept clean.  However, a few weeks after the review, the solicitor reported that on one occasion she had visited and found the adult’s hands covered in faeces sitting on a commode full of faeces. The bed linen and her night dress also covered in faeces.  .

A strategy meeting was convened to address the concerns and to review the support/care plan.  A representative from the care agency, Mr and Mrs Croft and the solicitor were present and participated in the meeting. The following risks were identified risk of malnutrition/dehydration, self-neglect, falls, risk of skin infections, further deterioration in in wellbeing.

The outcomes for the case, was for Mrs Croft to be in a place of safety and have her eligible outcomes met whilst investigations were in progress, Mrs Croft’s outcomes to be met and managed in the comfort of her home.  Source for a new provider

Critical Reflection on Practice

In making this decision 5 principles of the (MCA 2005) were taken into consideration.  Mrs Croft showed insight into her condition, abilities and awareness of her limitations.   Permission to complete the assessment and consent to share information was requested and obtained from the adult.  Mrs Croft fully participated in the assessment and consented to support being provided.  Mrs Croft was provided with options on the care provision and was able to make consistent choices and decisions. Mrs Croft clearly stated that she was struggling to manage and recognised a need for support. Throughout the assessment Mrs Croft’s views and wishes were taken into account.  The exchange model was employed. Milner and O’Bryne (2002, p.53 defined the exchange model as an empowering approach”.  In this model Milner and O’Byrne (2002 p.53) suggested that the service users are seen as experts on their own problems” In this approach Mrs Croft was put at the centre of the assessment.

Mrs Croft’s husband who is the main carer was present at the assesssment. Likewise including carers as part of the assessment process could be seen as essential as part of any holistic assessment.  This is particularly pertinent with the introduction of the Care Act 2014 which simplifies, consolidates and improves existing legislation “putting carers on an equal footing to those they care for and putting their needs at the centre of the legislation.

Did things go according to plan?

There was resistance from the Hospital Social Worker to place Mrs Croft in a circumstantial placement. The Social Worker suggested discharging Mrs Croft back to her home although the risk still remained in that the same care agency was still providing services till the end of the notice period.  After much deliberations and case conferences Mrs Croft was placed in circumstantial placement pending the outcome of the investigations.

Challenges were faced in relation to Mrs Croft’s desired outcomes, which differed from her husband’s preferred outcomes.  Mr Croft wanted to continue to care for his wife at home but this would have put Mrs Croft at significant risk as Mr Croft had no insight into Mrs Croft’s needs.  In this instance Mr Croft was able to express that he wanted to remain empowered and in control of his life and as a result he now feels happy that his wife has appropriate support and in a place of safety.

However it was possible to facilitate their wish to maintain as much contact as possible whilst continuing to consider any risks inherent in this to Mrs Croft.

Engagement and involvement of the vulnerable adult and her husband has shown to be possible and the adults felt empowered as from the onset they focussed on the outcomes they wanted.  As an individual is involved in decision making, paternalism is decreased.

Were desired outcomes Achieved if not give reasons, if yes what helped in achieving these

The desired outcomes were achieved.  There was a lot of collaborative, partnership working with the hospital team, case conferences held with GP, community team, solicitor (formal advocate) and the Mr Croft. Throughout I was working collaboratively with the GP, Mrs Willison and her family, building an effective relationship with the GP.

Multi-professional working is an interesting term as it suggests cohesion.  I realised that there was a gap in pathway knowledge in respect to mental health services. This was escalated in order for this to be addressed at a strategic level.  I feel I have made a contribution to practice improvement within both social care and our partners.

Weinstein et al. (2003, p.57) argue that: ‘General Practitioners and social workers have traditionally been viewed as mutually antipathetic.’  At the heart of inter-professional working lie the tensions of decision making respondent to the formal structure of the organisation in which they are employed.  Although there are inherent difficulties with inter-professional working, these can be overcome by individuals whose professional capacity exceeds the limitations of their organisations.

Referrals from the clinicians to a social worker have the expectation of assessment using the social model.  Watzlawick et al (1974) cited in Koprowska (2009, p.27) argued that ‘Successful therapeutic interventions frequently rely upon bringing second-order change, and that this holds good for social work as well.’

A desired outcome form has been developed from this process and our administration has uploaded the forms onto the system.  All outcome forms have been collated to achieve a better understanding of the desired outcome process and to inform professional practice individually and with safeguarding team.

Communication between the care agency and LA has improved with the introduction of joint monthly meetings to discuss complex care packages.

How effective were you in identifying risks and protective factors and managing the risks identified

 

Explain whether there were any differences in interpretation of what risk factors and protective factors were considered to be between the different parties involved

Service user

 

Carers

 

Other professionals

 

 

How were the differences managed.

 

 

The GP and the Care-Coordinator did not support the decision made for Mrs Croft to be supported in her home.  The option was perceived to be high risk, for Mrs Croft and that Mrs Croft should be placed in residential care. The decision was based on the fact that Mrs Croft has dementia and needed to be in a 24 hour establishment and that people with dementia cannot make decisions due to their impairment – decisions which are in conflict this and viewpoint is alien to those held within the social care profession. Clearly, interpretation of risk by different Professionals is different (each having different views about the balance between choice and protection.

Reflecting on the conversation with Mr and Mrs Croft, I realise that the predominate theory and information gathering was based on the exchange model. The exchange model was employed. Milner and O’Bryne (2002, p.53 defined the exchange model as an empowering approach”.  In this model Milner and O’Byrne (2002 p.53) suggested that the service users are seen as experts on their own problems” In this approach Mrs William was put at the centre of the assessment.

Policy and legislation indicate the importance of service user participation stating that they are experts in their own experiences and should be consulted in the delivery of care and support.  This ideology can often appear difficult when working with a person who has dementia and whom has limited communication skills.

Likewise including carers as part of the assessment process could be seen as essential as part of any holistic assessment.  This is particularly pertinent with the introduction of the Care Act 2014 which simplifies, consolidates and improves existing legislation “putting carers on an equal footing to those they care for and putting their needs at the centre of the legislation.

It was imperative to ensure steps were taken to provide communication methods that ensured Mrs Croft is given every opportunity to actively participate in the process and if the mental capacity assessment identifies a lack of capacity, a referral is made for an independent advocate to promote anti-discriminatory and anti-oppressive practice which promotes choice and independence.  I was able to make effective use of supervision opportunities to discuss, reflect upon and test multiple hypotheses, the role of intuition and logic in decision making, the difference between opinion and fact, the role of evidence, how to address common bias in situations of uncertainty and the reasoning of any conclusions reached and recommendations made, particularly in relation to mental capacity.

Reflecting on the Medical Model which reinforces a commonly held assumption or myth that older people would inevitably decline into ill health, disability and cognitive impairment (with associated costs to services that such a ‘burden’ would impose)  What should be an appropriate agenda for anti-oppressive social work practice with older people?  Social work practices and values should as an underpinning principle, aim to provide appropriate and sensitive services by responding to need regardless of the social status of the person.   I wonder.

When analysing my decisions regarding this case I think it is key to recognise my strong pull towards my social work values of justice and equality (Professional Capabilities Framework, 2012, PCF 2). I have had an urgency to ensure that Mrs Croft’s voice is heard and that she is not treated differently because of her age and mental impairment (PCF 4). I have adopted the principles of the disability movement and stand by the phrase “nothing about us without us” (Charlton, 1998) striving to include Mrs Croft in the decision-making process. Objective six within the Government document Valuing People (2001) stated that those with learning disabilities should have greater control and choice o;-=ver where and how they live, this objective was strongly felt in my work with Mrs Croft[, it is at the heart of community care and a principle that informs my decision making.

This case made me more aware of my values on respect for the equality, worthy and dignity of all people. My practice has focuses on meeting human needs and developing potential.  Human rights and social justice serve as the motivation and justification for social work action. The desired outcome for this case is for Mrs Croft’s views to be heard, to be given the support to express herself, and also to be given the support to enable her to live independently in her home with her husband and their two dogs.

Patch Two- A critical analysis/ evaluation of the knowledge/ evidence that was used in making decisions.

This patch will analyse the overlapping knowledge bases, used when making decisions relating to the risks set out within patch one, as defines by Scie (Pawson, 2003).  They are organisational knowledge, practitioner knowledge; policy, community and research knowledge and service user and carer knowledge.

The use of organisational knowledge on risk decision-making

It is important to acknowledge the Department of Health (DOH) (2007, p.5) policy on Independence, Choice and Risk which states that “the corporate approach to risk that an organisation takes overwhelmingly influences the practices of its workforce.”  The policy highlights that good outcomes in relation to choice and control are unlikely for adults if the organisation operates with a “fear of putting the organisation at risk, both financially, in terms of public relations, reputation or in breach of law.” As practitioners therefore it is important to recognise the attitude to risk in our own organisations as it is most likely affecting how we practice.

The approaches used during this case were person centred, task centred (in relation to outcomes), crisis intervention (minimising risk/protection plan) and a systems approach and ecological approach which has links with the strength based approach.  This allowed me to consider Mrs Croft’s protective factors as well as risk factors.  Mrs Croft has a secure base and has close links with neighbours and formal advocate.

Kolb’s Reflective Cycle (1974) allowed me to take consideration of Mrs Croft’s situation and promote protective factors and minimise risk.  Assessment of risk was based on sound evidence and analysis.

Within my own team I have recognised a shift in the attitude held by management regarding risk taking following a negative case experience within the team. New processes were introduced including the Complex Case Forum. This forum is chaired by senior managers and practitioners attend to present complex cases. These cases may be deemed high risk or high cost care packages. The forum allows open discussion and the opportunity to share thoughts on the cases and plan future steps. This process gives the practitioner the chance to share the risk with senior managers therefore not taking sole responsibility for decisions; this is often seen as a protective factor for the worker. I have presented Mrs Croft’s case at the complex case forum as a safeguarding was raised against the care provider and this case was complex as the case might end up as an organisational safeguarding in view of the fact that the care provider is involved in providing services to other vulnerable adults. There is a possibility this could bring the Local Authority into conflict with the care provider, perhaps putting the care provider’s reputation at risk. The complex case forum was also an opportunity to ensure on a legal footing I have covered all possibilities and have collected the necessary evidence if the case were to go to court. With regard to Mrs Croft’s case I found the complex case forum to be a positive experience it was good to share ideas with senior managers to ensure that as an organisation we all agreed on the direction that this case was taking.

Alongside the complex case forum I have also used a formalised risk assessment tool that my organisation has designed for case management. There are two types of risk assessment tools, actuarial and analytical/clinical based. Actuarial risk assessment tools are those which collect statistical evidence, practitioners score service users answers to set questions and then the scores are added resulting in a risk category being assigned (Silver and Miller, 2002). Analytical/ Clinical based risk assessment tools are more flexible and allow the professional to share their opinion; you are only ‘guided’ to consider the risk factors and therefore can also explore the strength factors (Milner and Myers, 2007). As an organisation the local authority focuses more on analytical based risk assessments which are embedded in our social care assessment process. Whilst working with Mrs Croft, I completed a social care assessment, this holistic tool allowed me to explore possible risks in Mrs Croft’s life but also protective factors in her support network and lifestyle. The organisation has recognised that actuarial risk assessments are not best suited to marginalised groups such as older adults in the community but most of all they negate to recognise the resources/ resilience people already possess. With the implementation of the Care Act 2015, the focus is on an asset based approach and with the use of analytic risk assessments I believe professionals are more capable of achieving this. The risks I see in Mrs Croft’s life could not be scored within an actuarial assessment as they are unique to her.

The use of practitioner knowledge on risk decision making

A practitioner’s knowledge can encompass many things and can be created through many different avenues. Pawson, et al. (2003, p.17) stated that a “practitioner knowledge is acquired directly through…distillation of collective wisdom at many points through media such as education and training, requesting and receiving advice, attending team meetings and case conferences, and comparing notes.” This generates a vast amount of knowledge that can be accessed at different points for different reasons.  When thinking about the knowledge that I hold as a practitioner in relation to my work with Mrs Croft and the risks highlighted within Patch one I do not feel that at the time I was always consciously aware of it, it is only now, as I reflect, that I can better understand what elements of my knowledge I have utilised.

Epstein (1994) and Kahneman (2011) have both identified ways of thinking in relation to decision making and in terms of how we gather our evidence. Epstein refers to the Experiential and Analytical whereas Kahneman calls it System 1 (Thinking Fast) and System 2 (Thinking Slow). Thinking Fast/ Experiential refers to automatic responses where we use our intuition and it is effort free whereas Thinking Slow/Analytical is conscious thought with deductive reasoning, it is rational. Kahneman believes that there is too much going on in our lives to analyse everything therefore System 1 makes up most of our decisions. As a practitioner I have noticed that management would like for there to be clear use of system 2/ Analytical but when working in crisis, as we often are, Thinking Fast is a necessity.

Thinking Fast/ Experientially is part of heuristics. Heuristics is defined as the mental shortcut that allows you to make quick judgements particularly when faced with complex decisions (Gigerenzer and Todd, 1999). Heuristics involves using intuition and emotional responses and therefore can lead to biases. As a practitioner it is vital to make use of reflective practice or supervision to explore your thought processes so as to avoid bias decision making.

Reflecting on my work with Mrs Croft it is clear that the Thinking Fast/ Experiential label is present. From the very start of my work with Mrs Croft and her husband I have been aware of an emotional pull towards her case and situation. When I first met with the Care-Coordinator  she was also particularly emotional about her case. Mrs Croft in many ways resembles why we both came into the social care field, she is a vulnerable adult. When I witnessed the state Mrs Croft was left in, it is very difficult not to feel an emotional pull. Luhmann (1989; 1995) emphasised that emotions are often viewed as too personal and unstable to form part of our stable social institutions whereas Zinn (2008) states that emotions are a modesty advisor in decision making. I have found with my work with Mrs Croft that I often have a feeling that can be explained as intuition. Parker and Stanworth (2005, p.321) say that “intuition can be expressed in emotional terms, e.g. when individuals use the sense that ‘it feels right to me’ as a basis for action.” However through reflective practice and conversations with colleagues I have been able to explore these feelings further, to give direction to my search for evidence. I recognise through experience in practice that hard evidence is more valuable when presenting an action plan/request to my manager.

O’Sullivan (2011, pp.119-20) spoke of framing situations in a certain manner and how this can cause biases. He identified the difficulties that can arise from mixing your personal belief system with your professional role for there is a potential that you could “distort the decision situation” and frame it in a particular way. When I first started working with Mrs Croft I was conscious of the fact that both Mrs Croft and her husband have no known family.  My expectation was that there must be some family member somewhere.  I therefore embarked on a family hunt.  This is a personal belief of mine that there must be family somewhere who can be consulted and involved in the lives of the adults. I was aware of my personal beliefs and worked to ensure that this personal expectation did not frame my professional work with Mrs Croft, that I did not “make assumptions and [have] rigid views,”

The use of policy community and research knowledge on risk decision making

Remaining up-to-date with policy and research knowledge is fundamental to practicing as a social worker, the College of Social Work highlighted this need within the Professional Capabilities Framework (2012) domain 5, “Knowledge: apply knowledge of social sciences, law and social work practice theory.” Whilst working with Mrs Croft and her husband legislation and policy have guided me with regard to my decision making. However when undertaking this course I have subsequently read articles which have further informed my knowledge and have brought me to reflect on this case.

My practice of social work and critical reflection on my practice led me to improve my professional skills and conclude that social work requires vast knowledge and application of theory and research. It is also my role to integrate social work theoretical frameworks with the realities of the practice. The task proves challenging because application of principles depends on the context and organisation culture as much as it depends on the desired outcome. There are also grey contexts for which social ethics and values do not provide guidelines for decision making, and these instances require more than theoretical knowledge. It is in such instances that supervision becomes invaluable.

Legislation

When working with Mrs Croft it quickly became apparent that there was a need to complete a Mental Capacity Act (MCA) assessment. As part of the risk management plan, it was identified that there was a need for change of accommodation to a circumstantial placement pending the outcome of the safeguarding investigation and in view of the notice served by the care provider. Through Liaison with the Hospital Social Worker a case conference to plan Mrs Croft’s safe discharge was convened. Mrs Croft’s was visited when she was at her most responsive and gave her the best opportunity to answer questions put to her – this is in line with the Mental Capacity Act principles which exemplify anti-discriminatory and anti-oppressive practice. It became apparent that Mrs Croft was at this point entitled to consideration for Continuing Health Funding which, if successful would enhance Mrs Croft and her husband’s economic well-being as there would be no means tested contribution.

The MCA Code of Practice (2005, p.19) clearly states, in the first of five principles, that “a person must be assumed to have capacity unless it is established that they lack capacity.”

A formal capacity assessment took place regarding change of accommodation. This is because Principle 2 of the Act states “a person is not to be treated as unable to make a decision unless all practicable steps to Mrs Croft to do so have been taken.” With Mrs Croft in mind this principle particularly relates to her mental impairment. The solicitor has been advocating on behalf of the adult by supporting the adults throughout the investigation, acting as a protective factor monitoring and supervising.

Whilst working with Mrs Croft and reflecting on the build up to the Mental Capacity Act assessment it has emphasised to me why this law needs to be in place. Far too often I hear health professionals stating that people with dementia cannot make decisions citing their impairment as the reason. The MCA was designed as a protective factor for those with disabilities/cognitive impairments to allow them to make unwise decisions and if they lack capacity following assessment for decisions to be made in their best interest with due processes followed.

The following legislation informed decision making Legislation (No Secrets (Department of Health 2000) Statutory guidance Section 7, Dignity in Care and Human Rights article 5 /8, Right to private and family life. Care Act 2014 Section 42 Duty to make inquiries.

I recently undertook Virtual Dementia Training which has given me understanding and insight into the condition from a very practical viewpoint.  I was able to utilise this training to good effect in the way I approached Mrs Croft during interactions. – an example being to approach her from the front so that she could see me approach.

I was able to demonstrate clear evidenced based practice and requested that the care provider put in place charts for nutrition and bowel movement; these were kept updated in order to inform the forthcoming review – thus promoting Mrs Croft’s best interests.

This form of intervention was in response to the identified risks and to gather evidence to ensure the correct interventions and risk management plans were in place to address them.

I was able to acknowledge the centrality of relationships for people and the key concepts of attachment, separation, loss, change and resilience.  This was particularly prevalent as the husband was suffering from extreme anxiety from the situation of his wife’s deteriorating condition.  I used this knowledge when I drew my best interest conclusion regarding the most suitable placement and accommodation for Mrs Croft. Psychological and emotional impact for both adults was taken into account.

Research

As part of this course I have read a number of articles to broaden my understanding of risk on reflection I have been able to identify where they could potentially informed my decision making whilst working with Mrs Croft. Jon Glasby (2011, p.8) for example wrote about “risk and regulation in an era of personalisation”. Glasby was looking at personal budgets and the potential for increased choice and control verse the risk that service users could experience exploitation from family members amongst many other things. Glasby argued that although some may fear personalisation resulting in increased risk to service user he felt that it could decrease risk as it put service users more in control of their lives. As a professional I am inclined to agree with Glasby that personal budgets give the control to the service user, allowing them to plan their own care and employ those they want. However with regard to Mrs Croft I feel that at present she falls within the category of those who could potential be exploited.

The use of service user and carer knowledge

As a practitioner I recognise the need to utilise the knowledge and information that the service user and carer can bring to the table, they are the experts in their own situation. However this case has highlighted the conflict that can exist between service user and carer and because of this it is vital to remember that there are potential biases with regard to the knowledge that each may bring to the discussion.

The outcomes that

Mr Croft has capacity in relation to deciding about provision of care and support.  He understands that his wife needs to be in a safe environment where her care needs could be adequately met.

Challenges were faced in relation to Mr Croft’s desired outcomes, which differed from his wife’s preferred outcomes.  Mr Croft wanted to continue caring for his wife at home but this would put Mrs Croft at significant risk as Mr Croft has no insight into Mrs Croft’s needs.  Mr Croft is in denial that he can no longer adequately care for his wife.  However it was possible to facilitate their wish to maintain as much contact as possible whilst continuing to consider any risks inherent to Mr Croft.

When meeting with the GP to discuss the prospect of Mrs Croft’s returning home after examination and treatment he was very negative about the idea. The GP focussed on the fact that Mrs Crofts due to deterioration in cognition is better off in a residential home. The GP did not consider Mrs Croft’s wishes and the psychological and emotional effect/impact of separation on both Mr and Mrs Croft.   The GP only looked at the negatives and he has reinforced this thought process by collecting other negative experiences of older adults living independently with support in their own homes. Baron (1998, p.281) talks about a tendency to seek out evidence that supports one idea, a bias which enables irrational belief persistence, the solicitor appears to have done this with regard to continued support for Mrs Croft in her home. Baron identifies “two types of biases: 1. Overweighing and under weighing of evidence 2. Failure to search impartially for evidence.”

When I had meetings with the GP he would list-off other accounts of how older adults with dementia are at risk of falls and have been lost etc. Equally I could recount other cases where older adults have experienced success being supported in their homes to live independently, having choice and control of their lives.- it was clear that my evidence was not going to be weighed as highly as the evidence the GP  had already collected. The formal advocate (Solicitor) tended to concur with the GP.  It was difficult to put value to the knowledge she brought to the discussion as she was unable or unwilling to look at the evidence presented by the professionals in an open way. It also came to light that she had limited knowledge of the Mental Capacity Assessment. The accounts of the risks were definitely shared with other professionals to ensure we were making a balanced decision.

Whilst working with the Crofts it was very difficult to understand and gather their account of the risks and protective factors as they saw them. Mrs Croft’s cognitive impairment was a  barrier with regard to this.  Gaining the couple’s trust was vital for the professionals working with them, especially as we were all trying to gather their account of the risks they perceived in their lives. The adults were sharing information with me perhaps they perceived the social worker as a protective factor. Faulkner (2012, p.12) speaks of the “risk of losing independence [as a] greater concern than many of the potential dangers perceived in their lives.” Independence is seen as “having control over your life, having choices.” As professionals we were telling the Crofts this was what we wanted for them, choice and control, they clearly responded to this.

This patch has demonstrated that there was an array of factors involved with the decision making process, some were conscious and some as a practitioner you only become aware of on reflection. As I continue to develop into an experienced practitioner I hope to be able to confidently draw on various knowledge bases to ensure clear and positive decision making in relation to risk management and the planning process.

Patch Three- Reflection, ‘stitching’ the patches together and identification of future developmental needs

Whilst reading literature about risk assessment and management I have been able to identify my strengths and weaknesses with regard to these processes. I have reflected that I am open minded in my assessment of what constitutes a risk, for example with Mrs Croft’s case my viewpoint was that the adult was at risk of infections, malnutrition/dehydration, falls social isolation, further deterioration in physical/mental health and loss of independency. The GP and other professionals wanted both adults to be permanently placed in residential care. I strongly feel that Mr Croft continuing to live in his home with support is a risk worth taking and see my role as supporting him as he continues an independent lifestyle.

In respect of my weaknesses when it comes to risk management I want to comment on Parton (2001) who states that Local Authorities are trying to juggle the conflicting elements of an increasingly dependent society alongside decreasing finances. Therefore a weakness would be that with limited resources I am not always able to source the correct support to ensure a risk management plan is executed correctly. At present there is a greater reliance on voluntary services and these are not always able to dedicate time to a set management plan. Difficulties with limited resources forces practitioners to be creative and innovative when managing risk.

As a practitioner I need to be aware of my viewpoint on risk both in my personal and professional life for this could impact on how I support service users. I recognise in myself that although I am not a risk taker I am most definitely not risk adverse. I believe that I take calculated risks and do not shy away from what some may deem as risky behaviour if I am confident and comfortable with the decision. As a Practitioner I feel that my attitude to risk hopefully empowers others to take calculated risks and does not result in them feeling wrapped in cotton wool.

As a social worker I feel empowered by the Mental Capacity Act (2005), it is there to support people and endorses the right to make unwise decisions. This piece of legislation is key to my work with Mr and Mrs Croft. This Act allows for the assessment of both adult’s decision making capabilities without the prejudice of what that decision may be. The Mental Capacity Act can in many cases simplifies the element of risk, if the person is found to have capacity then for the professional the risk is now an unwise decision owned by the vulnerable adult.

When discussing cases with other professionals different opinions and conflicting opinions and perspectives of risk are very evident. Situations that are said to be risky by some are not always deemed that way by others. Perhaps more experienced workers can call on past experience as their evidence base, decreasing their concern in certain situations. As I move into the category of experienced worker I would hope that I can call on past experience without becoming desensitised to potential risks. Regardless of professional experience I feel it is important to remember that each case is an individual and therefore they may respond to the same situation differently.

I now understand that heuristics are at play with regard to my ability to make quick decisions when confronted with a complex or risky situation. I believe that it is very important to listen to your inner voice, your intuition, alongside the slower processed, rational factors that you can evidence. Heuristics decreases the risk to workers when on the frontline for it allows them to respond at a quicker rate, thus protecting themselves in risky situations.

I recognise that my future practice with risk assessment and management needs further development with setting management plans. At present I feel that I have clear assessments of risk but the follow up plan to manage and decrease the risk is not as comprehensive. Titterton (2005) noted that practitioners need to move on from risk assessing and talk more about management. Management is the area that brings the accountability and this is also the point at which the risk is reviewed. People are not constant and therefore management plans must allow for review and reassessment. Due to the complexity of this case I feel I have learnt a lot about processes and procedures, liaising with other professionals and teams and will now have a much better idea of what to do and where to start with any cases like this in future.

In order to further develop my skills with risk management I will take advantage of any training opportunities that arise, these are normally part of the adult safeguarding boards training programme and Learning Sets. I have also identified the need to continue utilising supervision and reflective practice as they both offer the chance to speak with other professionals about case work enhancing my knowledge and reflecting on my decisions.

The reflection adds great value to the practice of social work. Taylor says that practical reflection offers value in the form of insights that arise from increased awareness (Taylor, 2010, p. 124). I learnt that the application of skills can sometimes be subtle, and it takes critical reflection to identify such skills (Taylor, 2010, p. 95).  I exercised the skills of working directly with individuals and their families when reconciling the roles of the care provider with the expectations of the solicitor). The skills also require effective communication and observation of overt behaviour to evaluate whether all parties involved were in agreement.

Reflecting on the situation, I felt that the seemingly lack of regard for Mrs Croft’s dignity was not concurrent with my professional social work values nor my personal values as I try to always treat people as I would wish to be treated

On reflecting back on the events, I acted with caution.  Caution helps us to act correctly under all circumstances, through reflection and reasoning of the effects produced by our words and actions. I felt that I had acted professionally, that I had been very thorough, had gathered the necessary information, spoken to all appropriate parties and I had remained in charge of the investigation.  I would conclude that it was a substantiated safeguarding incident and for the Care provider to make some major adjustments to the details of the daily reports. Act upon and implement recommendations agreed in strategy meetings, improve communication within the organisation and other professionals. Consider extra risk management for the higher risk adults, report back any concerns timeously and not wait for reviews.

Through debriefing and critical reflection, I was able to reflect that a safeguarding case can often be emotionally challenging for the carers and Social Workers as the process can evoke powerful feelings.   The idea is not to work against the care providers but to build a good relationship based on trust and a genuine desire to have the best outcomes for the adults.  Also to take these safeguarding cases as a learning curve and improve on the shortcomings.

Although I am passionate about injustice/abuse I do have the ability to weigh up what will work or not and when to ‘let go’ and try a different approach, or just accept reconciliation. Quote to have the strength….. to recognise ….to  accept those we can’t’

Right now I feel overwhelmed, anxious and fearful of making mistakes.

The insights in this work are in the form of lessons learnt and thoughts on what can be done differently to improve the practice. Implementation of the insights from reflection is what leads to improvement in the practice and health care of individuals. Critical reflection is, therefore, an integral part of social work practice. It offers an inside look that analyses the ability of a social worker to identify and compensate for gaps in knowledge and the realities of practice.

Despite all the advantages captured in the conclusion, critical reflection fails to offer the means to observe and analyze work procedures (Taylor, 2010, p. 125). It means that social workers must learn from their practical work experiences and make adjustments as they continue the practice. The measures of success remain tools like Knowledge and Skills Statement and Professional Capabilities Framework. Social workers must take active participation in their learning and development to avoid career stagnation. As a social worker, the best experience on application of theories and research is in actual use. Individuals will make mistakes, but the advantage is that they get to learn from them and make better decisions in future.

The reflection added great value to the practice of social work. Taylor says that practical reflection offers value in the form of insights that arise from increased awareness (Taylor, 2010, p. 124). I learnt that the application of skills can sometimes be subtle, and it takes critical reflection to identify such skills (Taylor, 2010, p. 95).  I exercised the skills of working directly with individuals and their families when reconciling the roles of the care provider with the expectations of the organisation. The skills also require effective communication and observation of overt behaviour to evaluate whether all parties involved were in agreement The insights in this work are in the form of lessons learnt and thoughts on what can be done differently to improve the practice. Implementation of the insights from reflection is what leads to improvement in the practice and health care of individuals. Critical reflection is, therefore, an integral part of social work practice. It offers an inside look that analyses the ability of a social worker to identify and compensate for gaps in knowledge and the realities of practice.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference List

  1. Baron, J., 1998. Thinking and Deciding. Cambridge: Cambridge University Press.
  2. The Care Act 2015.(c.23). London: HMSO
  3. Charlton, J., 1998. Nothing About Us Without Us: Disability, Oppression and Empowerment. Berkeley: University of California Press.
  4. Crowther, N., 2007. Nothing without us or nothing about us? [pdf] Available at: <http://disability-studies.leeds.ac.uk/files/library/crowther-Nothing-without-us-bt.pdf> [Accessed 27 April 2015].
  5. Department of Health, 2007. Independence, choice and risk: a guide to best practice in supported decision making. [pdf] London: Department of Health. Available at: <http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Direct_Payments/Risk_Management/DH_074775.pdf> Accessed 29 April 2015].
  6. Department of Health, 2001. Valuing People: A New Strategy for Learning Disability for the 21st century. London: The Stationery Office.
  7. Epstein, S., 1994. Integration of the cognitive and psychodynamic unconscious, American Psychologist, 49, p.709-724.
  8. Faulkner, A., 2012. The right to take risks: Service users’ views of risk in Adult social care.[pdf] London: JRT. Available at: <http://www.jrf.org.uk/sites/files/jrf/right-to-take-risks-faulkner.pdf>[Accessed 27 April 15].
  9. Gigerenzer, G. and Todd, P., 1999. Simple Heuristics that make us smart. Oxford: Oxford University Group.
  10. Glasby, J., 2011. Whose risk is it anyway? Risk and regulation in an era of personalisation.  JRF scoping paper: Rights, responsibilities, risk and regulation, September.
  11. Kahneman, D., 2011. Thinking Fast and Slow, Allen Lane.
  12. Luhmann, N., 1979. Trust and power. Chichester: John Wiley and Sons.

Luhmann, N., 1988. Familiarity, co

Notes

Conflict in practice

Hospital social worker undermining community social worker.

Making decision regarding adult’s husband in the community.

Requesting information from the care provider instead of colleague.

Wanting dictating course of action.

Dignity

As a matter of principle, the council must ensure that it does no further harm through its intervention. Any

involvement must be proportionate and reasonable, however the first priority must always be to ensure

the safety and wellbeing of the adult at risk. Other less restrictive options should be explored as soon as it is safe and appropriate to do so.

Lack of respect for adult.  Everyone deserves respect, to be treated with dignity and not to be discriminated against people receiving services are treated with dignity and respect.

Proportionality The least intrusive response appropriate the risk presented.

The aim of Making

Safeguarding Personal is to ensure that safeguarding is person-led focused on the outcomes that they

want to achieve. It engages the person in a conversation about how best to respond to their safeguarding

situation in a way that enhances involvement, choice and control as well as improving quality of life,

wellbeing and safety.

Serious concerns relating to an adult who has care and support needs, is unable

to protect themselves because of those needs and who has been placed at risk of

harm because of the actions (deliberate or unintentional) of others.

The focus should be on improving their safety and wellbeing and supporting them to reach the

resolution that is right for them. there is evidence that the service is failing to

meet fundamental standards,

Meet required service quality standards and ensure service users are treated with dignity and

respect.

Risk enablement

8. Managing risk is a key aspect of keeping people safe. However, it is recognised that risk is an inevitable consequence of people making decisions about their lives. If a person has the mental capacity to make a decision and understands the possible consequences of their choice, they are entitled to accept an

element of risk. Essex has a robust policy on risk enablement that aims to support people to achieve

their aspirations while balancing risks to themselves and others. The key elements are set out in the

Support Planning Policy (section 4).

Services should prioritise both safety and

independence.

People should be informed of their rights to be free from abuse and supported to

exercise those rights. Options to support individuals to be free from abuse should be

tailored to people’s individual needs and target the outcome or resolution they want to

achieve.

This includes

understanding and using powers under social care legislation, the Mental Capacity Act,

Mental Health Act and other legislation to safeguard people’s rights.

Essex works in partnership with Southend and Thurrock to provide a common approach

to safeguarding across the county. The SET Safeguarding Adults Guidelines set out the

system and process all organisations should use to raise safeguarding concerns.

This includes a framework for confidentiality and information sharing across agencies.

Early sharing of information is key to providing effective help where there are emerging

concerns. The wellbeing of adults at risk of abuse or neglect is more important than

concerns about sharing information.

In considering how to respond the following factors need to be considered:

 the adult’s needs for care and support

 the adult’s risk of abuse or neglect

 the adult’s ability to protect themselves or the ability of their networks to increase the support they

offer

 the impact on the adult and their wishes

 the possible impact on important relationships

 the potential of action increasing risk to the adult

 the risk of repeated or increasingly serious acts involving children or another adult at risk of abuse or

neglect.

 the responsibility of the person or organisation that has caused the abuse or neglect and

 research evidence to support any intervention.

Once enquiries are completed, the council should decide with the adult who has been the subject of

concern, what, if any, further action is necessary and acceptable. One outcome might be the

development of an agreed plan of action for the adult which should be recorded on their care plan. This

should set out:

 what steps are to be taken to assure their safety in future

 the provision of any support, treatment or therapy including advocacy

 any modifications needed in the way services are provided

 how best to support the adult through any action they take to seek justice or redress

 any on-going risk management strategy

 any action to be taken in relation to the person or organisation that has caused the concern.

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