Chapter 47 – Orla Dowling (D3SOP7)
Domain 3 Standard of Proficiency 7
Be able to prioritise and maintain the safety of both service users and those involved in their care.
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KEY TERMS Safety versus risk Maintaining and prioritising safety Proportionality Positive risk management Safety culture |
Social care is … providing a safe and caring environment for service users, which includes the identification and control of risks to achieve effective, efficient and positive outcomes for service users and staff. |
Introduction
The social care sector offers services to a broad client base who can experience challenges at different times in their lives (Lalor & Share 2013). Social care workers aim to enhance the well-being of and empower those we work with. It is a fulfilling profession that is ever evolving, and continuous professional development and openness to change is required. Social care workers provide services to those who might otherwise be at risk, and this can pose some challenges. We have a duty of care to those we work with to provide a safe and efficient service in all settings.
The examples in this chapter are based on my experience of working with children, young people and families who are at risk in their home or community.
TASK 1
Become familiar with the health and safety policy in your service.
Safety Versus Risk
A risk is the possibility of an event occurring that will have a harmful outcome. Social care workers complete risk assessments to ensure the safety of service users, themselves and the general public (Seden 2016). In social care, the risks for social care workers vary depending on the type of service and the service user’s background. As social care workers we have a duty of care to the service users we work with and are expected to complete risk assessments daily. It is important that we are familiar with health and safety policies and reporting mechanisms.
Safety involves a risk being controlled or reduced to an acceptable level (Roeser et al. 2012). When we discuss safety, we consider both the physical and psychological safety of service users, staff members and members of the public. Physical safety can include the work environment, hazards and equipment. Psychological safety is when a person feels respected, that they can apply themselves to a task without fear of consequences and is comfortable voicing opinions. The presence of psychological safety in a challenging work environment can help social care workers overcome barriers to change and learning (Edmondson et al. 2016).
What an acceptable risk level is will be established by each organisation; this can be found in the risk assessment policy. In social care we determine the level of risk by using a risk assessment.
TASK 2
Please read Chapter 50 on how to complete a risk assessment.
Please read Chapter 54 for a greater understanding of risk and safe environments.
Maintaining and Prioritising Safety
When discussions of safety arise, we consider the guiding legislation and policies, including the Health Act 2007; the Health and Social Care Professionals (Amendment) Act 2019; the Health, Safety and Welfare at Work Act (2005); the Equal Status Acts 2000-2008; the Safeguarding Vulnerable Adults at Risk of Abuse Policy and Procedure (2014); and the National Guidance for the Protection and Welfare of Children (2017).
Maintaining safety first involves the formal process of following guiding legislation and policies within organisations. These can include behaviour guidance, medications management, health and safety, and risk assessment. In these formal processes, best practice guidelines are provided to ensure safe environments are created in the social care setting. As social care workers we have a responsibility and duty to keep our knowledge of these policies up to date. Continuous training and development, supervision and discussions with colleagues are key to keeping up to date with relevant legislation.
Another aspect of maintaining safety involves knowledge of the service user we are working with. Access to care plans, behaviour support plans, daily logs and incident reports can equip us with the relevant knowledge to keep the service users and ourselves safe. These will provide us with details about the service users’ likes, dislikes, triggers, emotional needs, coping mechanisms and overall support needs. This knowledge is invaluable; however, it will not on its own provide us with the expertise to maintain safety. Equally important is relationship-building with a service user. When key relationships are established, social care workers can be attuned to changes in a service user’s demeanour. We rely on our communication skills, in particular non-verbal communication. Being aware of subtle changes in a service user’s non-verbal cues can equip us to adjust our communication styles or plans to ensure safety for that service user and others. In practice these changes may be so subtle that others involved in a young person’s care do not notice them.
Case Study 1
While engaging with a young male, Noah (pseudonym), aged 15 years, I noticed a subtle change in his non-verbal communication. I had been working with Noah for two years and we had developed a strong professional relationship. The goals for engagement that day included assisting Noah in meeting with his social worker. Noah had compiled a list of questions and had been working on remaining calm during the meeting. At the beginning of the meeting Noah expressed himself well and put forward his questions. After a few minutes, I noticed the right side of his jaw twitching, a very subtle change. I suggested that we take a break and went outside with Noah. Once outside Noah began to speak about his frustrations with the conversation and noted that he had felt himself becoming extremely angry, stating, ‘I was about to pick my chair up and throw it at him.’ An open discussion was had with Noah and he was soon able to return to baseline and recommence the meeting. Reflecting back on this experience, it was evident that the safety of Noah, the social worker and myself may have been in jeopardy. My ability to pick up on the subtle change in Noah’s non-verbal communication was attributable to the relationship I had built with Noah and my ability to notice his triggers and provide a safe space for him to explore his emotions and return to baseline.
Effective teams can improve the overall efficiency of a service and promote psychological safety. Team meetings are opportunities for staff members to share their expertise, generate creative ideas and improve safe practices. They also provide a space for improving communication channels and developing staff relationships. In the social care sector, we rely on teams of people in all services. At times social care workers are faced with complex cases that are physically and psychologically demanding. Having a team who foster open communication, shared goals and practices will help reduce of stress or burnout. Team discussions should be open, with all members sharing ideas or highlighting concerns. Fostering a team-based approach allows social care workers a safe environment to discuss incidents or concerns, build self-awareness, develop creativity, reflect on incidents or events, and develop professional relationships.
Case Study 2
Georgina is a 20-year-old female who lives independently with support from social care workers for 55 hours per week. Georgina has been supported by the organisation for four years and has a staff team of five social care workers. Georgina has a diagnosis of mild learning disability, PTSD, and borderline personality disorder. At times Georgina struggles with emotional regulation and low mood. The staff team, along with a manager, have weekly team meetings, at which there are open discussions, and all members have the opportunity to share ideas, discuss concerns, develop procedures and provide input into actions. During the most recent team meeting two staff members noted the following changes in Georgia’s demeanour; sitting in the dark (closing windows and doors), watching a movie on loop, sitting in a curled- up positions, needing prompting to engage in conversation. Other team members had not noted any change in Georgina’s demeanour.
An open discussion was had by the team, and some noted that these changes are concerning. It was discussed that Georgina did not normally close the door as it made her feel trapped and caused flashbacks of previous traumatic experiences; and that Georgina usually greeted staff in an upbeat and friendly manner. But as prompting was needed it seemed as if she had withdrawn into herself, that fixating on one thing, the movie, signified that Georgina was stuckin her emotions and also that sitting in a curled-up position and hugging her knees implied that Georgina was in need of comforting. These behaviours had been noted previously and had resulted in Georgina engaging in risk-taking and self-harm behaviour.
The team agreed that these were early warning signs that Georgina’s mood was low. The team agreed on a safety plan and put this in place immediately. The safety plan included contacting Georgina’s psychologist, developing a safety procedure with Georgina in the event that she feels like harming herself, supporting Georgina in using her self-soothing toolkit, and procedures in the event of Georgina self-harming or exhibiting suicidal ideation.
The case study above outlines both the importance of buildings a trusting relationship with the service user and the value of effective team meetings. As some of the members were new to the team and were not aware of these early warning signs, the open team discussion was essential – without the knowledge provided by the rest of the team they might have approached the situation in a different manner. This could have led to Georgina’s and the team’s physical and psychological safety being compromised. For students on placement, observing other staff members’ interactions and approaches to different service users will give you an insight into appropriate interactions or responses to situations. Attendance at team meetings and care plan reviews affords new staff members and students a comprehensive understanding of a service user. These opportunities should be afforded to all students.
The question of prioritising the safety needs of a service user and those involved in their care can seem a difficult and daunting task. Not all risks are equal; some can lead to more severe consequences than others. Risk prioritisation is a part of overall risk management and involves identifying the physical and psychological factors of safety. Once the risks are identified, control measures are put in place. The risks may still exist, but they are less likely to lead to serious illness or injury.
Task 3
Review the case study below and explore the following questions
- What are the safety concerns for the service user, social care worker and the public?
- How would you safely engage with George in a person-centred manner?
- What, if any, safety measure would you put in place?
The safety of service users and those involved in their care is deemed of equal importance. In the social care sector, we may assume that we are challenged to manage the risk of maintaining the safety of both service users and those involved in their care while also working in a person-centred manner. However, these should be done in conjunction; they are not contradictory.
Case Study 3
George, aged 17, has been referred to the organisation you work in. He is completing the last two weeks of an eight-month placement in a children’s special care centre. The staff from the special centre report that he has engaged well in all the programmes and the level of incidents has decreased over the last month. George’s referral notes his history, which includes drug and alcohol misuse, violent attacks on members of the public, and robbery. George’s care plan involves sourcing independent accommodation and providing support in all areas of education and training, daily living skills and social networks.
In the above case example, we can easily note the safety concerns for all involved. In social care, we may fall into the trap of prioritising the safety of staff members and the public over the best interests of the service user. Therefore, in the above scenario it may seem justified to limit George’s involvement in the community. However, putting in place safety measures can reduce the risk to an acceptable level while also promoting George’s best interests. Some safety measures that could be put in place include increasing staffing levels to two staff to support George, a detailed risk assessment, a safety plan, regular team meetings, regular individual meetings with George, and implementing a behavioural guidance document with input from George. This would set the expectations for both George and staff members. An example of some expectations set out may include:
- Staff members to knock on George’s bedroom door and wait to be invited in.
- George and staff members will show mutual respect.
- Staff members will not transport George if he presents under the influence of drugs or alcohol.
- George to inform staff members if he is feeling overwhelmed.
Proportionality
HIQA (2019) notes that social care services are moving towards a person-centred approach that involves empowering service users to participate in their own care. There are challenges to this, and when a person is deemed not to have the capacity to make some decision an intervention is required. This intervention involves social care workers weighing up the safety of the service user and the risks involved, for both the person in question and the public. This decision involves a balance between the service user’s rights, choice, quality of life and personal growth and health and safety concerns.
Proportionality involves taking measures that restrict a service user’s liberty in order to protect the public from harm (DoH 2020). Social care workers are responsible for meeting the needs of service users and preventing them harming themselves or others. At times this may lead to a dilemma about whether the service user’s choices can be supported or if there are risks to themselves and others that require an intervention (Seden 2016). Kemshall (2013, cited in Seden 2016: 10) has identified some of the key components in assessing risk:
- Identification of the risk
- The likelihood or probability of the risk occurring
- The situation in which the risk may occur
- The impact of the risk
- The consequence of the risk and who it may affect.
Social care workers aim to manage safety by reducing risks. While working in the field we make ‘defensible decisions’ – decisions that are ethical and made with the information available (Seden 2016). The measures taken to reduce risks should be the least restrictive. It must be decided whether the interference with a person’s rights is justified. When considering such a decision, consider: if the goal will be achieved; if there is no other less restrictive measure; if the measure is proportionate to the benefit; if not implementing the measure would result in significant harm. These measures should be assessed and reviewed regularly.
Positive Risk Management
Positive risk management relates to building a culture within a service where risk management and safety is openly discussed and proactively managed (HIQA 2019). In society, risk-taking is an accepted part of life; however, for some of the service users we work with it is often discouraged. In the case of people with a disability, taking positive risks may be avoided because of perceived fears in relation to ability or capacity. But safety considerations must be balanced with some risk-taking, as there are positive outcomes that benefit a person’s quality of life. Positive risk management involves identifying the risks, looking at potential benefits and developing actions to minimise the risk while helping a service user achieve the desired outcomes. It is also acknowledged that contingency planning should be put in place if the risk becomes unacceptable.
Case Study 4
Peter is an 8-year-old boy living in foster placement. Peter has been in care for two years and has had one previous placement. During his interactions Peter likes to take charge and becomes frustrated if he is not winning games or another individual is not following his lead. Peter’s frustration is exhibited by shouting or hitting other children. Peter has expressed that he would like to join a local football team; however, his foster carers highlight that there are too many risks.
TASK 4
Look at the above case study and determine the following.
- The potential risks involved to Peter and the public
- Whose safety should be prioritised
- The potential benefits for Peter
- How the risks could be minimised.
When developing risk assessments in social care it is important to apply a human rights-based approach. This considers the risks and rights that could affect the person’s or other people’s safety or wellbeing. As social care workers we encounter complex situations where we need to consider a service user’s preference and the risk of harm versus their right to autonomy. HIQA (2019) developed the FREDA principles as a guiding framework for ensuring human rights-based approaches to care. These five principles are fairness, respect, equality, dignity and autonomy.
TASK 5
Please read Chapter 5 to help you apply the FREDA principles to your practice.
Safety Culture
The culture of an organisation affects the beliefs and attitudes of the team, including health and safety performance. ‘The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management’ (HSL 2002: 6). The main components for safety culture are situational (policies, management systems), psychological (values, norms and attitudes) and behavioural (observations, reporting measures).
The level of management influences health and safety in various ways. A manager’s attitudes and behaviour towards safety influences workers; this can include encouragement of safety ideas, reporting procedures and how safety is prioritised in policies and procedures. Staff who perceive their managers as being involved in safety and open to discussion around this are more likely to use coping strategies then those with less involved managers (HSL 2002). In the social care sector, having a manager who is open to discussion around safety, supports reflective practice and is open to change helps promote psychological safety.
Pidgeon and O’Leary (1994, cited in HSL 2002: 3) outline four factors which reflect a positive safety culture:
- Organisations learning through practice. An organisation is transforming continuously as it learns from past experiences and best practice. This knowledge should be transferred throughout the organisation.
- Management’s commitment to safety. Managers who are perceived to have safety considerations at the forefront of their work influence the safety conditions on the ground. If a manager does not encourage safety practices or dismisses concerns, staff members will have greater exposure to risks.
- Shared concern and care for hazards. Safety concerns are shared among the staff team, discussed openly at team meetings and agreed actions are followed by all. All staff members report concerns of hazards to managers.
- Realistic practices for controlling hazards. As an organisation, putting in place control measure that are realistic or SMART contributes to the success of avoiding the hazard. Control measures should be more easily accessed by all staff members.
TASK 6
Review the case study below and explore the following questions.
- How would the different responses from management influence the safety culture in an organisation?
- How can you effectively maintain the safety of Gemma, Sonya and the public?
- What, if any, safety measures would you put in place?
Case Study 5
Sonya, an employee, has started on a new case with Gemma, an 8-year-old girl who has recently moved into a foster family. Gemma has experienced two previous placement breakdowns. Sonya is asked to work one-on-one with Gemma in the community assisting her with emotional regulation using therapeutic interventions. After her first session, Sonya outlines to her manager (Bill) that she feels the case should be two-on-one, for the following reasons.
- Gemma is sporadic in her movements in the community and not aware of her physical safety, e.g., running out in front of cars.
- Sonya noted that Gemma has previously made disclosures about a worker’s misconduct.
The manager’s (Bill’s) possible responses:
- Bill completed a risk assessment on the case, held a team meeting where an open discussion was had and safety measures agreed. He also sourced a second worker for the case. Bill then offered an opportunity for Sonya to attended supervision to reflect on the process.
- Bill listened to Sonya’s request and explained that the case was one-to-one and that this would not change. Bill also noted that the disclosures Gemma made related to misconduct, not to any form of abuse, and therefore were not of a concern to the organisation. Bill also sent Sonya some suggested activities that she could use to engage with Gemma.
Tips for Practice Educators
- Provide the students with induction training and allow them time to review the service’s policies and procedures, in particular those related to health and safety in the workplace, employees’ and employers’ rights and responsibilities.
- Allow students the opportunity to review the organisation’s risk assessment folders, health and safety policies, staff handbooks, behaviour guidance policies and behaviour intervention pans. If possible the student should also have the opportunity to view individual service users’ care plans. This will assist the students to put this proficiency into practice.
- Taking part in team meetings will give the student the opportunity to see some of the processes of developing and implementing safety procedures. This will equip them with an understanding of how informed decisions regarding a service user’s capacity to maintain their own safety are reached.
- Provide the student with a task of carrying out a risk assessment and safety plan. The student should be provided with all the relevant documentation needed. The student should be able to look at the risks and benefits and put in place any safety measures needed.
- Students should be afforded the space to critically reflect. The time afforded may be used to unpack incidents and reflect on current safety procedures. This can be prompted through supervision. Give students the opportunity to articulate their concerns and reflect on their experiences in a supportive environment.
References
Curtice, M., Bashir, F., Khurmi, S., Crocombe, J., Hawkins, T. and Exworthy, T. (2011) ‘The proportionality principle and what it means in practice’, The Psychiatrist 35(3): 111-16.
DoH (Department of Health) (2020) ‘Ethical framework of decision-making in a pandemic’. Available at <https://www.gov.ie/en/publication/dbf3fb-ethical-framework-for-decision-making-in-a- pandemic/#> [accessed 13 July 2021].
Edmondson, A.C., Higgins, M., Singer, S. and Weiner, J. (2016) ‘Understanding psychological safety in health care and education organisations: A comparative perspective’, Research in Human Development 13(1): 65-83.
HIQA (Health Information and Quality Authority) (2018) National Standards for Children’s Residential Centres. Dublin: HIQA.
HIQA (Health Information and Quality Authority) (2019) Background Document to Inform the Development of Guidance on a Human Rights-based Approach to Care and Support in Health and Social Care Settings. Available at <https://www.hiqa.ie/sites/default/files/2019-06/Draft_Guidance_Human_ Rights-Based_Approach_to_Care_Background_Document.pdf> [accessed 12 July 2021].
HSA (Health and Safety Authority) (2012) Health and Safety at Work in Residential Care Facilities. Available at <https://www.hsa.ie/eng/Publications_and_Forms/Publications/Healthcare_Sector/ Residential_Care_Facilities.pdf> [accessed 13 July 2021].
HSL (Health and Safety Laboratory) (2002) Safety Culture: A Review of the Literature. Available at <https://www.hse.gov.uk/research/hsl_pdf/2002/hsl02-25.pdf> [accessed 13 July 2021].
Lalor, K. and Share, P. (2013) ‘Understanding Social Care’, in K. Lalor and P. Share (eds), Applied Social Care: An Introduction for Students in Ireland (pp. 3-18). Dublin: Gill and Macmillian.
Roeser, S., Hillerbrand, R., Sandin, P. and Peterson, M. (2012) Handbook of Risk Theory: Epistemology, Decision Theory, Ethics and Social Implications of Risks. New York: Springer.
Seden, J. (2106) ‘Social work: Risks, needs and balanced assessments’, K216 Readings. Milton Keynes: Open University.
Social Care Workers Registration Board (2017) Standards of proficiency for social care work. Dublin: CORU Health and Social Care Regulator.
Tusla (Child and Family Agency) (2016) Proficiencies: Reflection Guide for Social Workers and Social Care Workers. Dublin: Tusla.
