Last reviewed 17 July 2020
The Health and Safety Executive (HSE) stress the need for risk assessments to be “proportionate” and “balanced” and to reflect a common-sense approach where health and safety are an integral part of running an organisation.
The approach is reflected in guidance, such as HSG65 Managing for Health and Safety, INDG449 Health and Safety Made Simple — The Basics for Your Business and INDG275 Plan, Do, Check, Act — An Introduction to Managing Health and Safety.
The guidance is applicable to both residential and domiciliary social care. It encourages employers to treat health and safety as an integral part of good management generally, rather than as a stand-alone system. It advises them to develop a risk profile which focuses on practical measures to protect people from significant and real risks rather than being preoccupied with the trivial.
The HSE states that the law does not expect an employer to remove all risks, but to protect people by putting in place measures to control realistic risks, so far as reasonably practicable.
Adult social care guidance
In the context of residential adult social care, risk management and assessment are supported by specific HSE guidance, HSG220 Health and Safety in Care Homes .
HSG220 concentrates on specific risks such as:
moving and handling
slips and trips
falls from height
hazardous substances, infections and diseases
violence, aggression or challenging behaviour
falls from windows and balconies
scalding and burning
The guidance requires that all these areas should be subject to appropriate risk assessment and policy. It provides practical advice for care homes, although much of its contents will also be applicable in domiciliary care.
Further guidance on assessments for infection prevention risks can be found in Prevention and control of infection in care homes — an information resource, published by the Department of Health and Social Care. Such guidance should be considered with reference to the latest public health information on the coronavirus (Covid-19) pandemic.
Service providers are also asked to consider different elements of risk which are common to all service users and staff or relate to individuals only. These include:
common risks to everyone using a care home premises, for example, legionella, fire, asbestos, electrical equipment, infection control risks, etc
common risks to service users, for example, from falls from height or scalding
individual risks to particular staff, for example, expectant mothers and young workers
individual risks to particular service users, for example, the risk of an individual falling out of bed.
In a setting, such as a care home, some residents will be more capable than others. This means that care home managers must balance measures to prevent harm to the most vulnerable with the need to respect the freedoms and autonomy of all.
In a similar way, when making risk assessments of a group activity, a manager must plan measures which will protect the most vulnerable without unnecessarily restricting the freedoms of others.
Failure to address risks adequately
Examples of what can go wrong when risks are not addressed adequately are easy to find in records of incidents involving injuries, deaths and prosecutions.
For instance, in March 2020 a South Wales care home operator pleaded guilty to breaches of fire safety regulations at a residential care home in Porthcawl. The offences related to fire safety arrangements including inadequate training for staff and a failure to conduct appropriate evacuation drills. The home was ordered to pay £24,000 in fines plus over £9000 in costs.
Scalding cases, falls from height and manual handling cases are also tragically common in the care sector.
In 2018 the Care Quality Commission prosecuted a provider and registered manager of a nursing home where a resident died after falling from a second-floor bedroom window. At the time of the fall, in July 2016, the window did not have restrictors fitted. The provider was fined £16,500 for failing to take measures to prevent falls from windows and the manager £1000 for failing to complete an up-to-date risk assessment.
In October 2017 a provider was issued with a £45,000 fine and ordered to pay nearly £15,000 costs when a 72-year-old woman with dementia was severely burned after sitting on a portable heater at a nursing home in Croydon. The court found that the provider had failed to ensure that the risk of burns and scalding from portable electric heaters was safely managed.
And in August 2017, a Suffolk care home was fined £60,000 and ordered to pay costs of £50,000 following the death of an 89-year-old resident. The service user was being moved with a hoist from her bed to a chair when she slipped through a poorly fitted sling. The HSE found that the home did not have adequate arrangements in place to ensure users could be hoisted safely.
“Sensible” risk assessment and autonomy
HSG220 is supported by an HSE web page, Sensible Risk Assessment in Care Settings.
The guidance acknowledges that those who work in health and social care constitute a large and diverse workforce looking after a predominantly vulnerable population. It also acknowledges the importance of enabling residents to live in a safe environment.
However, the web page reinforces the “sensible risk assessment” message and looks at the need for balance in adult social care, particularly a balance between the needs, freedom and dignity of individual service users and their safety. Thus, the guidance states that the freedom and dignity of service users must be taken into account, and this includes their right to take the risks they consider reasonable.
In both residential and domiciliary adult social care settings, the freedom and autonomy of service users, which is a vital part of living with dignity and independence, must often be weighed against the duty of service providers to care for people and protect them from danger. The results of getting the balance wrong may not only result in an overprotective environment where a person’s independence and autonomy is affected, but can also result in tragic accidents.
Making balanced decisions
In order to protect and care for their service users, the HSE warns that some care providers may find it hard to maintain a reasonable balance and find themselves adopting a “risk adverse” and over-protective approach. Care assessments, the HSE points out, should enable people to live fulfilled lives safely, rather than be a means of restricting their reasonable freedoms.
The HSE guidance is fully compatible with actions required by social care regulators such as, in England, the Care Quality Commission. However, the HSE reminds providers that regulators will usually expect the health and safety risks identified for the individual to be recorded as part of their care assessment or support plan.
In this respect, the guidance says that the provision of care and support should be tailored to meet the needs of the individual and should encourage them to do what they can for themselves. Where an activity is seen to put a service user at some level of risk, then a balanced decision must be made weighing up the needs, freedom and dignity of the individual and their safety.
Provided a “suitable and sufficient” risk assessment has been carried out, the HSE states that they will generally support decisions by care managers to, wherever possible, allow everyday activities to be undertaken. All risk assessments should be documented and reviewed as necessary and should identify and implement any sensible precautions to reduce the risk of significant harm to the individual concerned.
The guidance is clear that “huge amounts of paperwork” is not a requirement, although adequate records should be kept. The guidance also reminds providers that in the health and social care sector many health and safety risks identified for individuals are already assessed and recorded as part of their personalised care plan.
Good practice examples from the HSE
The HSE guidance provides a number of useful examples to illustrate what it means by a sensible and proportionate or balanced approach.
These include the following.
The provision of a single cup hot water dispenser for a young person with learning disabilities so they can make their own cups of tea and other hot drinks whenever they wish without the risks of scalding that arise from handling a standard kettle.
Measures to enable a care home resident who develops dementia to continue going independently to the local shops for their newspaper. Such measures, designed to address the risk of getting confused and lost, could include the shopkeeper helping to point the service user in the right direction each time, and additional checks by the home.
Similar measures for a resident with dementia whose risk assessment identifies a risk of walking long distances and getting lost. Proportionate control measures could include a modern telecare tracking system which can be worn by the person and provides a GPS positioning signal so that their whereabouts can be monitored.
Adaptations to the kitchen in a home to allow a resident to continue to “help-out” despite a risk assessment identifying that certain kitchen features or items may pose a risk. The adaptations may enable the resident to help-out safely or additional supervision could be put in place.
Measures to enable a person with learning difficulties to ride a horse despite the danger of falls and injury. Such measures could include the selection of a reputable leisure provider, use of protective clothing, safe supportive seating, the selection of a suitable horse and close supervision.
Covid-19 coronavirus risk assessment
Additional guidance on the assessment of infection control risks related to the coronavirus pandemic can be found in official documents from public health authorities, such as COVID-19: adult social care risk reduction framework, published by the Department of Health and Social Care.
The guidance states that providers must undertake risk assessments to identify those workers who may be more vulnerable to Covid-19 infection or may experience significant health challenges as a result of infection. Risk assessments should include all workers in both direct and non-direct care and support roles, including permanent employees, agency, locum and bank staff and unpaid volunteers.
Key points for care managers identified in the HSE guidance are as follows.
Concentrate on real risks where there is a realistic risk of harm.
Liaise closely with the individual, carer and family when carrying out risk assessments in order to achieve outcomes that matter to them.
Look at how the risks flowing from an individual’s choice can best be reduced, so far as is reasonably practicable, by putting in place sensible controls.
When organising group activities, think how the most vulnerable can be protected without unnecessarily restricting the freedoms of the most capable.
The HSE Sensible Risk Assessment in Care Settings web page can be found at www.hse.gov.uk.
HSG220 and further guidance about how to conduct a risk assessment can be found elsewhere on the HSE website.
Further material on risk profiling can be found in the HSE document, HSG65 Managing for Health and Safety.