Providing information

1.2.1.

The social worker should give the person information about their upcoming needs assessment in a format that is in line with their needs and preferences, and is accessible to them. Ensure they have enough notice and time to review documents, and prepare for the assessment.

1.2.2.

In line with regulation 10 of the Care Act 2014, the social worker must inform carers of people with complex needs about their right to a carer’s assessment (for more information, see the NICE guideline on supporting adult carers).

1.2.3.

The social worker should inform the person being assessed about where and how they can access information about their rights under relevant legislation, such as the Care Act 2014, the Human Rights Act 1998 or the Mental Capacity Act 2005 (for example, providing written or oral information or signposting to relevant online resources or agencies – see also the section on principles of social work for adults with complex needs for relevant links related to meeting communication needs).

Planning the assessment

1.2.4.

The social worker should be aware that a needs assessment can be stressful for the person being assessed, and their families and carers. Ensure that assessment practices are designed to minimise stress whenever possible, including:

• using a flexible approach to tailor the assessment to the person’s needs (for example, by amending the order of assessment questions)
• helping the person to understand assessment documentation when appropriate (for example, explaining complex concepts in a simple, clear way).

1.2.5.

Social workers should consider arranging a preparatory initial contact before the assessment itself if it will help the person with complex needs to participate fully in their assessment (in line with statutory guidance for a proportionate assessment in the Care Act 2014), taking into account:

• the urgency of the person’s support need
• whether the person wants a preparatory initial contact, and if so whether they would prefer this as a home visit, virtual contact or a phone call
• whether the person would have substantial difficulty in being involved in the assessment and if so, whether an independent advocate should be provided for the assessment.

1.2.6.

The social worker should ask the person about their preferences for the practical arrangements of the assessment, such as:

• the time and place of the assessment
• remote or in-person assessment
• whether they would like a supported self-assessment
• whether they would like anyone to be present to support them, for example a family member, carer or an independent advocate.

1.2.7.

The social worker should take into account that when there is a concern about potential safeguarding issues, an in-person assessment is likely to be needed.

1.2.8.

If the person chooses supported self-assessment, the social worker should discuss the advantages and disadvantages of this option with them, taking into account the complexities of their needs.

1.2.9.

The social worker should offer people with complex needs individualised support to complete a self-assessment, such as:

• ensuring that they have complete information about what it involves, including the list of areas and questions which it covers
• involving advocacy services
• providing details of who to contact if they want to clarify or discuss any areas of the assessment
• giving reassurance that they can ask for an in-person assessment if their preference changes.

Conducting the assessment

1.2.10.

The social workers must ensure that the information provided by supported self-assessment is an accurate reflection of the person’s circumstances (in accordance with section 6.44 of the Care and support statutory guidance, 2021). This can be done by cross referencing it with information from other sources (this should typically include involved family and carers or the multidisciplinary team).

1.2.11.

The social worker must conduct the needs assessment for adults with complex needs in compliance with statutory guidance (see regulation 2(1) of the Care Act 2014), and taking account of the following:

• whether the person’s needs arise from or are related to a physical or mental impairment or illness
• whether the person would have difficulties in achieving 2 or more of the 10 listed outcomes; see regulation 2(2) of the Care Act 2014
• whether there is a significant impact on wellbeing
• whether there are any unmet needs that may relate to a condition or difficulty that may need input from other specialist services, for example from speech and language services or mental health services.

Recording and reviewing the assessment

1.2.12.

The social worker should give the person a draft copy of their assessment and reviews, and the opportunity to identify any inaccuracies, omissions or differences of perspective, before the assessment is finalised.

1.2.13.

The social worker should acknowledge and record in formal case notes and the care and support plan any differences of opinion about the needs assessment.

1.2.14.

The social worker should give people with complex needs, their families and carers and other people important to them information about the complaints procedure, including how to access it and how to lodge a complaint if they wish to about the process or the outcome of the assessment.

1.2.15.

If the person chooses a self-assessment, the organisation must provide them with relevant information that they hold about them and their carer’s assessment if applicable, taking into account legal requirements related to consent (in line with sections 2[5] and 2[6] of the Care and Support [Assessment] Regulations 2014).

Planning the risk assessment

1.2.16.

Social workers should assess risks as part of a holistic process of assessing the person’s strengths, needs and wishes.

1.2.17.

The social worker should discuss and record the person’s views on involving family, carers, and other people important to them in the risk assessment in the formal case file. Let the person know that it has been recorded and share this information across relevant agencies and with other social workers when appropriate and necessary (in line with the UK GDPR and the Data Protection Act 2018).

1.2.18.

The social worker should consider conducting the risk assessment over several contacts, so that:

• there is an opportunity for rapport to develop between the social worker and person being assessed
• the person’s perspective on risks, their strengths, needs and wishes, and their health, environment and support networks are understood.

1.2.19.

When planning a risk assessment, take into account the urgency of any situation that may need a risk assessment within a short timeframe (for example, in a single visit; see also the section on responding to an escalation of need, including urgent support).

Conducting the risk assessment

1.2.20.

The social worker should support the person to engage in advance care planning, including:

• planning to cover their wishes in the event of any future loss of capacity (see the section on advance care planning in the NICE guideline on decision making and mental capacity)
• developing a risk management plan.

1.2.21.

Where a social worker has reasonable cause to suspect a person has experienced, is experiencing or is at risk of abuse or neglect, they must follow local safeguarding policies. If a need for action is established, the social worker must follow statutory safeguarding processes as set out in regulation 42 of the Care Act 2014.

1.2.22.

For people with complex needs, social workers should tailor risk assessments to the person’s strengths and needs and take into account beneficial and harmful outcomes, and their likelihood of occurring, including:

• risks to the person from their own behaviour (including accidents, self-neglect and suicide or self-harm)
• risks from others (including physical or sexual violence, psychological harm, neglect or exploitation)
• risks of harm to others
• risks of loss of independence or breakdown of caring arrangements.

1.2.23.

When assessing mental capacity, social workers must take account of section 1(4) of the Mental Capacity Act 2005, and not assume that the person lacks capacity because they have made a decision that the practitioner perceives as risky or unwise. See also the section on assessment of mental capacity in the NICE guideline on decision making and mental capacity, including recommendation 1.4.19 on the difficulty in assessing capacity in people with executive dysfunction.

1.2.24.

If a person lacks the mental capacity to make decisions related to risk, the social worker must seek and take into consideration their current wishes (and any relevant past wishes expressed at a time when they were believed to have capacity) about any decisions, in line with section 4(6) of the Mental Capacity Act 2005. For further details, see the NICE guideline on decision making and mental capacity.

1.2.25.

If a person makes a decision that is likely to put them at significant risk, the social worker should consider assessing their capacity to understand, retain and weigh up the relevant information about safety, taking into account:

• previous decisions and choices and
• the perspectives of involved family members, carers and multidisciplinary team members.

1.2.26.

Social workers should use plain language and terminology that is understandable and acceptable to the person. For example, talking about ‘safety’ or ‘being careful’, rather than ‘risk’ or ‘self-neglect’.

1.2.27.

In discussions between the person and the social worker about risk, consider the use of a structured risk checklist.

1.2.28.

The risk assessment should:

• include discussion of what has caused previous problems and unplanned escalation of needs
• identify what interventions have worked previously to manage and reduce risks.

1.2.29.

When assessing risk, in accordance with Social Work England’s professional standards, social workers should:

• think about how any assumptions or personal biases may have influenced their assessment (for example, assuming that frail people would not want to participate in physical activities)
• be reflective about their own values, and challenge the impact they have on their practice (for example, how they personally feel about tidiness when working with a person who is hoarding).

1.2.30.

Social workers should respect people’s rights to make decisions that they (the social worker) perceive as risky or unwise when the person has capacity to do so. Do not use such decisions as a reason to refuse care.

1.2.31.

If a person with capacity declines an intervention aimed at reducing risk (see recommendation 1.2.22 for the types of risk that may need to be reduced), social workers should continue to work with them to find ways to minimise risks.

1.2.32.

If a person has been assessed as lacking capacity, then in accordance with the Mental Capacity Act 2005, social workers must:

• ascertain the person’s best interests (using the best interests checklist in line with section 4 of the Mental Capacity Act 2005), including identifying whether there is a Lasting Power of Attorney or court-appointed deputy with appropriate decision-making powers to make best interests decisions
• ensure any restrictions or supervision in their care are proportionate to the risk of harm to the person
• take into account any less restrictive ways of meeting the person’s needs and managing risks and use these where appropriate.

1.2.33.

Social workers should avoid over-reliance on risk prediction (such as ‘high’ or ‘low’ risk) during assessments and when recording risks, and instead specify strategies on how to respond to factors contributing to increased risk and reduce potential harms.

1.2.34.

When deciding whether to share information in circumstances where the person does not give consent, the social worker:

• must balance the rights of the person with complex needs under the Human Rights Act 1998, Article 8 (right to respect for private and family life) against the effect on children or individuals at risk if they do not share the information and
• should record all information-sharing decisions, and the reasons for those decisions, in line with the organisation’s procedures and requirements.

Recording and reviewing the risk assessment

1.2.35.

In complex risk management situations involving potential risks of serious harm, the social worker should initiate and participate in a case conference involving all relevant agencies to:

• share information (in line with the UK GDPR and the Data Protection Act 2018) and
• develop a coordinated risk management plan.

1.2.36.

The social worker should include the person (and the person’s advocate, family and carers, if they wish them to be present) in case conferences for complex risk management situations involving potential risks of serious harm, unless doing so:

• would present a risk to (or cause an escalation of risk for) the person or
• would present a risk to any of the other parties involved (social workers, other care staff, or the person’s advocate, family or carers).

1.2.37.

The social worker should ensure that relevant information on significant concerns about risks is shared and discussed with all necessary agencies (taking into account the legal requirements under the UK GDPR and the Data Protection Act 2018).

1.2.38.

The social worker should:

• give the person a draft copy of their risk assessment, and the opportunity to identify any inaccuracies, omissions or differences of perspectives, before the risk assessment is finalised
• acknowledge and record any differences of opinion about the assessment of risk in the risk assessment document and formal case notes.

1.2.39.

Social workers should review risk assessments:

• at least annually and
• if needed, in response to an identified change in the person’s circumstances or change in risks.

Organisational support

1.2.40.

Organisations should:

• provide de-escalation training to staff to support their safety
• have systems for formally recording incidents of aggression, threats or abuse against staff.

1.2.41.

Organisations should support staff when they experience any safety-related incidents, for example by:

• debriefing them
• providing peer support
• providing counselling following serious incidents.

1.2.42.

Organisations should provide access to advice for social workers whenever they are working, including outside normal office hours, about immediate concerns related to the risk to the person with complex needs or others.

1.2.43.

Organisations should ensure the following are in place:

• training, including multi-agency training, to support staff in assessing risks thoroughly
• supervision structures to support staff and encourage reflective and inclusive practice (for example, a multidisciplinary team discussion about individual situations).

1.2.44.

Organisations should have a written strategy promoting a culture that supports staff in helping people with complex needs balance the benefits and harms relating to risk taking. This could include, for example, training and governance systems to support social workers with assessing complex and high-risk situations.

1.2.45.

For further principles of decision making in situations where people may lack capacity, see the NICE guideline on decision making and mental capacity.

Why the committee made the recommendations

The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took the Human Rights Act 1998, the Equality Act 2010, the Care Act 2014 and the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018 into account to address potential inequalities and data protection issues (for example, in access to services or in the services that people with complex needs receive). They also drew on the professional standards from Social Work England, the Professional Capabilities Framework from the British Association for Social Workers (BASW) and the Code of Ethics from BASW.

The committee discussed qualitative evidence related to supporting people to plan for the future that highlighted some of the barriers that could influence people’s access to and participation with services (for example, poverty, which is associated with inadequate housing and limited access to support). Such barriers could, in turn, result in people who use services feeling shame about their health conditions or living circumstances. This could further isolate them and make it more challenging for providers to support them. The committee therefore made a recommendation to emphasise that social workers need to treat people with respect and dignity to prevent barriers developing, and to understand and take into account the different circumstances of people with complex needs and any of their past experiences of services. This is also in line with the Human Rights Act 1998 and the Equality Act 2010.

There was some qualitative evidence related to approaches to needs assessments that showed people were not always aware of what to expect from an assessment, and that language could be a barrier to communicating with social workers during the assessment. The committee agreed that meeting these needs are important principles that would apply to all aspects of social work, so they decided to broaden the recommendation beyond just the assessment process. They recommended that the social worker find out whether an advocate is needed to support the person and help with communication, information and understanding the legal framework. The committee discussed that some people (for example, people with learning disabilities) may also have particular sensory needs or impairments (for example noise level or brightness of light) and therefore added that this should also be taken into account. Based on the same evidence, the committee also emphasised the importance of ensuring that all the person’s communication needs and preferences are addressed, to help them to actively participate in discussions. They noted that this was already covered in the section on overarching principles in the NICE guideline on people’s experience in adult social care services so they included a cross reference to this.

There was also some qualitative evidence showing that people did not always understand the purpose of the needs assessment and what it would entail. The committee used this evidence to recommend that sufficient information is provided for all activities and processes so that the person can understand what is going to happen and why. This will mean they can make informed choices and actively participate in the assessment.

The committee discussed the support that people may need to be actively involved in social work processes:

• qualitative evidence showed that cultural differences created challenges for practitioners
• qualitative evidence showed that not having family support can be detrimental to the person’s wellbeing
• quantitative evidence showed that differences in perspective because of culture lead to care needs not being raised or recognised by social workers
• in the committee’s own experience, people’s life experiences, expectations and emotional state can have an impact on their care experiences, and consequently lead to inequalities and poorer outcomes.

The committee made recommendations to address these problems. They also highlighted the positive impact of family support (if needed and wanted) which can help the person to be actively involved.

The committee drew on both quantitative and qualitative evidence from the review of individual and family casework. They discussed the qualitative evidence that suggested people’s cultural experiences and perspectives can differ from those of the practitioner, and that this may result in the practitioner making assumptions. Based on experience and expertise, the committee emphasised that the starting point would be relationship building to identify a person’s characteristics that might predispose them to inequality in healthcare provision, by actively listening to the person. They highlighted that forming trusting relationships is the cornerstone of social work and that looking at all aspects of the person’s life would ensure that the social work approach has the person with complex needs at its centre, and that any reasonable adjustments are being made in relation to those needs. They discussed that a record of reasonable adjustment decisions should be made to ensure that this was given due consideration. The committee noted that there was only a small amount of evidence, but acknowledged that this was a key area of social work that could lead to inequalities in access to care and care provision, if not addressed. In the absence of evidence for other experiences and circumstances that may lead to inequalities and discrimination, which may be multiple (see the definition of intersectionality), the committee applied the evidence about the challenges of cultural differences and assumption as well as their knowledge from the Equality Act to cover the protected characteristics as well as other life circumstances and experiences (see box 1).

The committee noted that a lot of qualitative evidence on the social worker’s role in multidisciplinary teams referred to information sharing as a potential facilitator to integrated working, as it provides continuity (and conversely, acts as a barrier if not present). They discussed, based on their experience, that information gets shared more about people with complex needs and between more agencies. There were concerns about the extent of information sharing, however. In the committee’s experience, people with complex needs value continuity and consistency and generally think that it is a positive idea to share information, but they want to be informed when and what information is shared and with whom (whenever this is possible and appropriate, in line with UK GDPR and the Data Protection Act 2018). The committee decided that this is a principle that should not be restricted to multidisciplinary team working but applies to all social work practice. The committee agreed that people need to be reassured that there are legal limits on information sharing and that their data is protected, but also that sharing where possible would mean that they would not have to repeatedly tell their life stories.

The committee discussed that there are a wide range of conditions, impairments or fluctuating health conditions that lead to complex needs. They discussed that the guideline should be viewed in the context of such needs and that social workers when meeting a person with a particular condition should be aware of the relevant condition-specific guidance associated with this. The committee decided to give some examples of the range of conditions that may be applicable.

How the recommendations might affect practice

The committee noted that most of these recommendations would standardise practice, as they are actions that are mandated by legislation (particularly the Equality Act 2010, the Care Act 2014), and supported by Social Work England’s professional standards or BASW’s Professional Capabilities Framework. This is particularly in relation to information sharing, and active listening and relationship building.

Return to recommendations

Why the committee made the recommendations

The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took into account the Human Rights Act 1998, the Equality Act 2010 (for example, to address inequalities in access to services or in the services that people with complex needs receive), the Care Act 2014, the UK GDPR and the Data Protection Act 2018 and the professional standards from Social Work England.

The committee used qualitative evidence from the reviews on individual and family casework, and helping people to connect with local communities and reduce isolation. This showed that the social work approach that people received was not sufficiently long or in-depth enough to address their complex needs. Based on this evidence, the committee recommended organisations provide sufficient time to social workers to build relationships in order to reduce inequalities.

The committee discussed that people’s life experiences may have an impact on their care experiences, and consequently lead to inequalities in access to care and care provision and poorer outcomes. They recommended organisations support and train social workers to discuss people’s personal and social identities, and life experiences. This is in line with professional standard 1.6 from Social Work England that outlines the role of the social worker to promote social justice, helping to confront and resolve issues of equality and inclusion. This would enable social workers to feel confident that they are providing an environment where people feel that they are free of discrimination, and emotional or physical harm, and feel safe in discussing the complex needs that they have. The committee highlighted that this would also improve wellbeing of people, but they discussed that the term wellbeing is sometimes interpreted only in physical health terms. They therefore decided to adopt the definition of wellbeing provided within regulation 1(2) of Care Act 2014.

There was qualitative evidence that social workers value support, supervision and training. The committee discussed that being up to date with relevant legal frameworks was particularly important to their work. They recommended that organisations should support this with continuous professional development so that social workers continue to develop legal knowledge and therefore act in accordance to the law when carrying out their duties.

Qualitative evidence showed that people felt existing services and interventions did not sufficiently address all their needs. This was also consistent with the committee’s experience of current practice, and they emphasised that planning of services (commissioning and configuring) should take this into account to address potential inequalities in access to care and care provision.

The committee discussed evidence related to responding to an escalation of need, and concluded as a general principle that organisations should ensure social workers be given appropriate training and support during and after response to an escalation of need. However, the committee also agreed this would benefit all areas of their work, so expanded the recommendation to be one for development of an overall framework for an open learning culture. The committee discussed that this was in line with Social Work England’s professional standards which also emphasise that families and communities should be taken into consideration. This will support social workers in learning from each other, and make them better able to appraise situations generally, but also specifically assess appropriate levels of risks that can be taken.

How the recommendations might affect practice

The committee noted that most of these recommendations would standardise practice. The recommendation that organisations should consider making time allowances to build relationships may lead to longer contact times than currently, but this would be balanced against better, individualised services and this was supported by the economic analysis. The recommendation on continuous professional development would address a current variation in practice in getting access and time for such training opportunities.

Return to recommendations

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England’s professional standards or BASW’s Professional Capabilities Framework).

There was some evidence showing that people did not always understand the purpose of the needs assessment and what it would involve, so the committee recommended giving people accessible information on why it is needed, the objectives, and how it will be done so that they have time to prepare. This also included raising awareness with carers about their right to have a carer’s assessment in line with regulation 10 of the Care Act 2014.

They also discussed that better understanding and knowledge (including of statutory rights) about social work assessments, both in terms of what is involved and the likely outcome, would reduce anxiety and stress for the person with complex needs. They noted that the social work can play an important part in addressing this by signposting to relevant resources.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by the Care Act (such as giving sufficient information).

Return to recommendations

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England’s professional standards or BASW’s Professional Capabilities Framework).

Based on their experience, the committee emphasised that social workers should conduct assessments in a way that would minimise stress for the person noting that this would lead to better relationships and engagement and would therefore impact positively on outcomes.

The committee discussed the review findings which suggested people were not always able to express their preferences during assessment. Based on this the committee recommended that there could, in some circumstances, be a preparatory initial contact before the assessment as a way of overcoming these issues. The committee agreed that this can be particularly important if the person may have difficulties being actively involved in the assessment. To address such difficulties, support may be needed from an independent advocate in the assessment. A preparatory meeting could provide the opportunity to assess whether there are any adjustments that can be made or family members who can get involved and could help and support the person with complex needs throughout the process. However, regardless of whether a preparatory meeting is held or not, the committee highlighted that the practical arrangements for the assessments always need to be established before the assessment takes place. They discussed the benefits and challenges of remote (for example virtual) compared to in-person assessments. While there are some advantages of remote assessment (such as when an urgent assessment is needed) there are also disadvantages (such as not being able to get cues from the person’s environment). While they could not categorically recommend 1 over the other, they highlighted that in cases of potential safeguarding concerns an in-person assessment would most likely be needed because missing any needs in these circumstances could have serious consequences.

The committee discussed qualitative evidence of possible challenges with self-assessment; for example, participants in a study reported that the self-assessment format was not always adequate or appropriate for people with multiple needs. Based on this, the committee emphasised that discussions should take place with the person about the advantages and disadvantages of this option so that they can make an informed choice, and that the person should be reassured that they will be supported and can change their mind and have an in-person assessment instead.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by legislation such as the Care Act or based on Social Work England’s professional standards or BASW’s Professional Capabilities Framework. The recommendation for a preparatory initial contact is a change to current practice since this is not uniformly done across the country. This may lead to an increase in the number of contacts, which may cause a potential resource impact and increase demands on social worker time. However, the committee noted that a preparatory visit is an option rather than a mandatory requirement and could be a virtual contact or a phone call. The additional resources needed to have some such preparatory visits may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.

Return to recommendations

Why the committee made the recommendations

The committee used the Care and support statutory guidance and regulation 2(1) of the Care Act 2014 to make these recommendations.

The committee noted that if self-assessment is chosen, the Care Act 2014 requires social workers to check that the information that is provided in the assessment is accurate, so they emphasised this in a recommendation. This could be achieved by gathering information from multidisciplinary team members or family and carers, where appropriate.

Based on the committee’s experience and expertise of the statutory guidance in relation to needs assessment, they discussed the content of the assessment and the related eligibility criteria. They agreed that it is important to highlight the questions that the social worker should take into account when deciding on the level of support that is needed in compliance with statutory guidance (eligibility outcomes of regulation 2(2) of the Care Act 2014). The committee discussed that some of the person’s needs may be outside of the expertise of the social worker, for example communication or mental health needs, and it is important that specialist input is sought to address these needs.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by either the Care and Support Statutory Guidance or the Care Act.

Return to recommendations

Why the committee made the recommendations

As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England’s professional standards or BASW’s Professional Capabilities Framework).

Evidence showed that people were not always given the opportunity to review their assessment details, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.

The evidence also suggested that needs can be interpreted differently by the person with complex needs and the social worker, which can lead to misunderstandings about the support that is expected. The committee acknowledged that differences of opinion could arise between a range of individuals, such as professionals and family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise. The committee noted that this could lead to tensions between the person with complex needs and the social worker, and could sometimes lead to complaints being made. They therefore emphasised that not only is good record keeping important when differences arise, but also that people should be given information about the complaints procedure, so they know what to do if they feel the correct processes have not been followed or they disagree with the outcome of the assessment.

In the context of self-assessment, the committee noted, based on their knowledge of legislation, that organisations have an obligation to provide the person who self-assesses with relevant information that they hold to help them in the process. The committee agreed that this was not always known by social workers and made a recommendation that this must be done to comply with legislation.

There is a lack of quantitative evidence addressing approaches to needs assessment and their potential impact on wellbeing. Because of this, the committee prioritised this topic for a research recommendation on needs assessment.

How the recommendations might affect practice

Most of the recommendations will standardise rather than change practice, as they are actions that are either mandated by the Care Act (such as giving sufficient information and support, or issues related to self-assessment) or extrapolated from it (such as preferences when arranging the assessment). The recommendation for a preparatory initial contact is a change to current practice, since this is not uniformly done across the country. This may lead to an increase in the number of contacts, with a potential resource impact and increasing demands on social worker time. However, the committee noted that it would not be routinely done and could be a virtual contact or a phone call. This may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.

Return to recommendations

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the low number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998 and the UK GDPR and the Data Protection Act 2018. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.

The evidence highlighted that when people with complex needs, and their families and other people important to them were actively involved in the risk assessment process, it facilitated discussions with social workers around risks and helped them make decisions about care and support needs. The committee agreed that this was an essential component of social work and consistent with the legal framework. The committee agreed that for people with complex needs, and their families and other people important to them to be actively involved the process, it needs to be relevant to the person and therefore holistic, looking at the person’s abilities and needs and taking their preferences into account.

The committee noted that the evidence suggested that people found it useful when family members supported them. However, they cautioned against being prescriptive about this because not every person would want their families involved in the process. Therefore, the committee recommended that social workers discuss the person’s views and preferences and that these be recorded and shared (in line with the UK GDPR and the Data Protection Act 2018) so that families are not inadvertently included in discussions if this would go against the wishes of the person with complex needs.

The committee discussed the evidence relating to contextual risk assessment that showed that people found the risk assessment approach worked better when their individual circumstances were fully understood. The recommendations emphasise the need for social workers to develop a rapport with, and engage with, the person at risk. When possible and practical, the committee recommended that ideally this should be done over several contacts so that the person’s circumstances and environment is fully understood. While the committee wanted to emphasise the need to build relationships and understand the person’s circumstances and environment, they also acknowledged that in some situations when a person is at urgent risk, immediate action needs to be taken which may not allow time for several contacts.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. While conducting risk assessments over several contacts (which could be a virtual contact or a phone call) is not consistently done across the country, and would add time to the assessment, this would improve outcomes through a better understanding of the person’s situation and environment. However, rather than this being implemented for everyone the committee thought that this could be one of the considerations around the assessment and would therefore not significantly change practice.

Return to recommendations

Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the small number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.

The committee noted the evidence related to assessing risk when a person lacks capacity, and so highlighted that risk assessments would also involve planning for the future so that the person’s wishes are known in advance and a plan is in place to manage risk. They agreed that this would lead to better outcomes, since any risky situation can be managed in line with the person’s preferences even if they later lack capacity to make decisions.

The committee discussed that safeguarding issues can be noticed in the risk assessment process and that it is therefore a legal duty in line with the Care Act 2014 that the social worker adheres to local policies to keep the person safe.

There was a lack of evidence about what works well and what could be improved in relation to the content of risk assessments, but despite this the committee agreed that it was important to provide guidance about what should be taken into account when conducting a risk assessment. They also discussed a guide about risk assessments from the Social Care Institute of Excellence and took this into account. In line with this, the committee recommended that to be effective the social worker should individualise the risk assessment and consider not only harmful outcomes but also where there are low risks and potential for good outcomes (for example, if the risks of harm from others and harm to others is low, it could mean that there is a good support network that the social worker could get involved to help with other potential risks that are high). The committee agreed to highlight categories of risks that would affect the person’s safety and the safety of other people, as well as risks to their independence and the independence of others who may depend on them so that plans can be made to minimise them.

The committee discussed their concerns that any risky decisions could lead the social worker to conclude that the person lacks capacity, and they therefore highlighted the legislation of the Mental Capacity Act 2005 which states that assessments of mental capacity should not be based on such assumptions. They discussed that such decisions can be challenging with some cognitive impairments, such as executive dysfunction, and therefore highlighted this in a cross reference to recommendation 1.4.19 of the NICE guideline on decision making and mental capacity.

The committee were aware that people who lack capacity to make decisions related to risk were particularly vulnerable, and that therefore the legislation in section 4(6) of the Mental Capacity Act 2005 needs to be followed so that their current wishes can be established if possible. Even though an assumption should not be made that someone is lacking capacity, the committee did not want to leave someone vulnerable to risk if they do lack capacity, so they recommended that a person who makes a decision that would put themselves at significant risk should be considered for an assessment of capacity. Getting the views of people close to the person and members of the multidisciplinary team may be helpful to determine whether an assessment may be necessary. This is to ensure their safety, and potentially the safety of their family members or carers.

The committee noted the qualitative evidence showing that people agreed that risk assessments work better when discussions take into account the words a person uses to describe risk and their understanding of risk. There was some evidence that checklists can help with this, but the committee was cautious to recommend these as a routine form of assessment as there are only a small number of validated checklists available, and so they would not address the range or complexities of risks for people with complex needs. They were also concerned that this could also be seen by the person as a tick box exercise, and so recommended that checklists be used as a starting point for a wider discussion including previous causes of an escalation of needs and what worked well before to minimise risk. Because of uncertainties with the evidence on the use of checklists and it being restricted to people with complex mental health needs, the committee also made a research recommendation on risk assessment.

When reviewing evidence indicating that risk assessments worked better if social workers fully understand the person’s perspectives of risk (when they have capacity to do so), the committee noted that this was consistent with their own experience. They therefore wanted to ensure that this was taken into account when assessing risk, but also that this should not stop social workers from providing necessary support if needed. The committee noted that this was in line with Social Work England’s professional standards which advise social workers not to prejudge the person’s state and also reflect on their own interpretations (which can be based on their own values), so as to avoid their own feelings around risk influencing their assessment.

The committee discussed evidence highlighting that a risk assessment works well for people who have capacity when it balances a person’s risk with their autonomy, and other evidence that showed understanding the person’s perception of risk facilitates the process. They therefore highlighted that people can make their own decisions about risks or decline interventions (for example, keeping many personal belongings if they are hoarding items even if it makes it difficult to move around their home). However, such choices should not be a reason to stop working with them or providing care even if the social worker perceives these decisions to be risky or unwise.

There was evidence related to detention under the Mental Capacity Act for people assessed as lacking capacity, and the committee used the principles of the Mental Capacity Act to highlight that the circumstances where potential risks for people who lack capacity could occur need to be carefully considered, including ascertaining the person’s best interests, so that any restrictions made are proportionate and justified.

There was evidence highlighting that it is difficult to define the seriousness of risk, which was consistent with the committee’s experience that risk would vary from person to person. The committee discussed that in the absence of such definitions, risk assessments can potentially place too much emphasis on the use of generic risk categories such as ‘high’ and ‘low’ risk – these do not distinguish the severity of potential harms from their likelihood, and do not take into account the different circumstances and choices of the person at risk. Based on these discussions, the committee made recommendations which emphasised that when recording risks social workers need to assess the severity and likelihood of identified potential harms to inform a risk management plan. This should weigh potential harms against potential benefits of risk taking, and a person’s needs and wishes.

The committee acknowledged that the person at risk may not always give consent for their information to be shared. The committee identified the Human Rights Act 1998 underpins such decisions, and this was stated in the recommendations.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. For advance decision making, while this is not a mandatory part of risk assessment it is commonly done, so the recommendation is likely to lead to standardised practice.

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Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account legislation, under the UK GDPR and the Data Protection Act 2018.

Based on their experience, the committee were keen to emphasise the need to balance any competing demands and perspectives of different organisations, and for different practitioners to be able to exercise their professional judgement. To achieve this, they recommended that, in complex situations involving potential risks of serious harm (for example these could be situations where there are many different opinions in the multidisciplinary team, potentially different complex harms or where 1 action to avoid 1 risk might bring about a further risk), social workers coordinate a case conference. Usually this would include the person and their family or carers but the committee decided that there are situations where a case conference could be a cause of distress for the person or may put a family member at risk. They therefore made a recommendation to highlight both that the person’s and their family’s involvement is important as well as situations when this may not be advisable.

Also based on their experience, the committee discussed that, when there are significant concerns about risks, information ought to be shared between agencies to ensure the safety of the person with complex needs. However, they emphasised that this can only be done within the constraints of the legal framework within the UK GDPR and the Data Protection Act 2018.

Evidence showed that people were not always given the opportunity to review their risk assessment, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.

The evidence also suggested that disagreements could arise across different organisations and among different practitioners because of the varying ways in which risk is conceptualised and decisions on managing risk are made. The committee also noted that differences of opinion could arise among professionals, the person with complex needs, family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise from disagreements.

The committee also noted that risk assessments need to be relevant, up to date and responsive to change and therefore, based on their experience, recommended that they are reviewed at least annually, or when circumstances change and a new review is needed.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice.

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Why the committee made the recommendations

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations.

The evidence showed that social workers valued support, particularly when they have experienced abuse, and ongoing training (including legal literacy). Based on the evidence and potential for high-risk situations, advice for social workers should be available whenever they are working, including outside normal office hours. The evidence showed that positive organisational cultures give social workers confidence in making risk assessments, and the committee drew on this to recommend a written strategy for training and support.

How the recommendations might affect practice

The recommendations reinforce current legislation and usual practice. The availability of training on risk assessment for social workers varies, so there may be a resource impact where it is currently not available. However, this would lead to better outcomes by improving the knowledge and awareness of processes and approaches to assess risks. Having out-of-hours access to advice in relation to risk for social workers who do not work during office hours is common practice (such as using an on-call system), so should not be an additional resource impact in most cases.

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