Professor Martin Green OBE, Chief Executive of Care England, explores the difficult balance between protecting people from harm and respecting their right to make choices — and why social care must move from being risk-averse to genuinely risk-aware.
Delivering choice and responding to service users’ needs is supposed to be at the heart of the care system, and this approach is essential for fostering independence and promoting well-being. However, this must be balanced with the need to maintain safety and regulatory compliance, and sadly, people are “hung out to dry” if they follow the service user’s preferences, and it goes wrong. What happens then is the system does not support providers and looks at the issue from the perspective of the Care Act responsibilities to deliver choice, autonomy and control. What the system does is criticise (and sometimes prosecute) the care provider for taking risks.
Co-producing care is the foundation of delivering choice, and understanding each person’s unique needs, preferences, and circumstances is central to good care. Employing a person-centred approach ensures that care is tailored to individual needs and requirements, rather than putting everyone into a one-size-fits-all model. Assessments should start with understanding what is important to the individual, gauging their appetite for risk, and discussing with them the consequences of things going wrong. Active listening involves creating an environment where people feel comfortable expressing their preferences and concerns. By listening to people’s views and responding to their desires, care providers can deliver care that gives people a good life, rather than just a service.
Flexible service delivery is really critical to good lives, yet people who use services often tell me one of their big frustrations is that, once a care plan has been written, the pressure is to follow it rather than respond flexibly to changing needs. Very few of us live lives that are prescribed and routine every single day; what most of us have is the flexibility to change things depending on how we feel. Providers of good care and support understand this and have built-in flexibility that responds to people’s changing preferences and needs. All too often, the current system of commissioning and regulation forces care providers to change care plans only when people’s needs change. We need to move to a flexible system that can accommodate people’s preferences and needs. Recognising and accommodating cultural and personal preferences is crucial to giving people good lives, and it is the essence of a rights-based approach enshrined in the Care Act.
Another important part of the Care Act is Safety and Regulatory Compliance, and the CQC standards set forth essential guidelines that ensure safety and quality in care provision. Care providers must remain compliant with these regulations while delivering choice. This includes conducting risk assessments, maintaining proper documentation, and ensuring staff are trained in safeguarding practices. These elements of the act are very important, but they can also be an impediment to responsive care and the management of risk. Risk Management and promoting choice are vital to compliance with both elements of the Care Act, though sometimes, they are very difficult to square. Successful providers undergo risk assessments in which potential hazards are evaluated, and appropriate measures are put in place. For instance, if a service user wishes to engage in a specific activity that might pose risks, care providers should assess these risks and provide alternatives or additional support to ensure safety. However, the essence of the Act is that if people have the capacity, they should be allowed to take those risks. The problem arises when something goes wrong, and the tendency is to shift accountability from the individual who decided to take the risk to the provider who may have facilitated the activity. This often leads to a risk-averse system, but in really good systems, we are risk-aware and do what we can to mitigate risk, though you will never eradicate it.
Continuous staff training is essential for maintaining safety and compliance. Staff should be well-versed in regulatory requirements, safeguarding policies, and the importance of supporting service users’ choices. Training programs that emphasise person-centred care alongside safety protocols can help staff balance these critical aspects effectively and also clearly define who holds the risk in any situation.
Involving families and advocates in the decision-making can enhance the support network surrounding service users. Family members often provide valuable insights into the individual’s needs and preferences, while advocates can help ensure the service user’s voice is heard, especially in complex situations. However, we must remember that sometimes the views of families conflict with those of the person we support, and the person must be at the centre of decisions about risk.
Implementing feedback mechanisms allows service users to express their satisfaction or concerns about the care they receive, and this can also be invaluable in helping care providers to develop and change services. Feedback can inform continuous improvement in services, ensure that safety and compliance measures are upheld, and clarify who bears the risk and when any service may be subject to scrutiny after a critical incident.
The ability to adapt to changing circumstances is crucial. Service users’ needs may evolve over time due to changes in health or personal circumstances. Care providers must remain flexible and responsive, ensuring that care plans are regularly reviewed and adjusted as necessary.
Delivering choice while responding to service users’ needs requires a delicate balance between empowerment and safety. By adopting a person-centred approach, promoting flexibility, adhering to regulations, and fostering collaboration, care providers can create an environment that supports individual choices without compromising safety. This holistic approach not only enhances lives, promotes dignity, respect, and independence, but also ensures safety and reduces risks.
