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Risk Management and Assessment Policy

1. Purpose

The purpose of this policy is to establish a proportionate and systematic approach to identifying, assessing, controlling, monitoring and learning from risks in the care home. It protects people receiving care, staff, visitors and others from avoidable harm while supporting dignity, choice, independence and positive risk-taking.

This policy supports compliance with Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Health and Safety at Work etc. Act 1974 and Regulation 3 of the Management of Health and Safety at Work Regulations 1999.

By embedding proactive risk management into our daily operations, we can:

• Prevent incidents and accidents, ensuring a safer environment.
• Promote the wellbeing of people receiving care by balancing safety with their rights, preferences, choice and independence.
• Meet legal and regulatory duties and provide reliable evidence of how risks are identified, controlled and reviewed.
• Support staff with clear guidance, ensuring they understand and manage risks effectively.

2. Scope

This policy applies to all employees, agency workers, volunteers, contractors, the registered manager, provider representatives and others whose work may create, identify, assess, manage or review risk within the service.

• All staff members, including care workers, nurses, senior management, and ancillary staff.
• People we support, ensuring they receive care that is safe and free from avoidable risks.
• Visitors, contractors, and external professionals, ensuring their safety while on the premises.
• Managers and governance leads, who must use risk information to oversee safety, quality, staffing, premises and business continuity.

It covers all aspects of risk assessment and management, including but not limited to:

• Clinical risks, such as falls, pressure ulcers, medication errors, and infections.
• Health and safety risks, including fire safety, environmental hazards, and equipment safety.
• Staffing risks, such as competency gaps, burnout, and absenteeism.
• Safeguarding risks, ensuring individuals are protected from abuse, neglect, or exploitation.
• Operational, information, financial and business-continuity risks, including risks arising from staffing, utilities, supplies, cyber security and disruption to essential services.

3. Related Policies

This policy is closely linked to several other key policies, including:

• CH11 – Safe Care and Treatment Policy, ensuring safety in care delivery.
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy, addressing safeguarding risks.
• CH16 – Health and Safety at Work Policy, covering environmental and workplace safety.
• CH17 – Infection Prevention and Control Policy, mitigating infection-related risks.
• CH19 – Emergency and Business Continuity Plan, ensuring preparedness for crises.
• CH25 – Notification of Other Incidents Policy, covering incident reporting and management.

4. Policy Statement

The care home is committed to reducing reasonably foreseeable harm while maximising individual choice and independence. Risk management will be person-centred, proportionate, evidence-based and continuous; it will not be used to impose blanket restrictions or prevent reasonable positive risk-taking.

We ensure that:

• Reasonably foreseeable risks are identified, documented, prioritised and reviewed at a frequency proportionate to the risk.
• Individual assessments are suitable and sufficient, linked to care plans, and reflect the person’s strengths, needs, health, mobility, communication, capacity, preferences, environment and desired outcomes.
• Workplace and premises risks are assessed by competent persons and controlled in accordance with health and safety and fire-safety duties.
• Incidents, accidents, near misses, safeguarding concerns, complaints and other intelligence are analysed for themes, and learning is used to improve controls.
• Staff receive regular training to identify, assess, and manage risks effectively.

5. Implementation – How We Manage Risk Efficiently

5.1 Identifying Risks

Risk identification is a proactive and continuous process. We use a variety of methods to identify risks, including:

• Pre-admission and admission assessments, followed by reassessment before new care, treatment, equipment or activities are introduced.
• Premises and environmental assessments covering, as applicable, fire, water safety, infection prevention, security, slips and trips, electrical safety, hazardous substances, equipment and emergency arrangements.
• Incident and accident reports, which are reviewed for trends and recurring issues.
• Staff observations and feedback, ensuring risks are identified in day-to-day operations.
• Regulatory guidance, safety alerts, professional advice, audits, inspections and changes in legislation or recognised practice.

Once identified, significant risks are recorded in the appropriate individual assessment, care plan or service risk register. Records will state the hazard, who may be harmed, existing controls, initial and residual risk ratings, further action, responsible person, completion date and review date.

5.2 Conducting Risk Assessments

We use the following risk-assessment process, proportionate to the activity and level of risk:

1. Identify the hazard and reasonably foreseeable harm, including who may be affected and how.
2. Consult the person receiving care and, where appropriate, their representative and relevant staff or professionals, recording the person’s desired outcomes and views.
3. Evaluate likelihood and severity, taking account of existing controls, and determine the initial risk level.
4. Select and implement controls using the hierarchy of control where appropriate, avoiding risk where reasonably practicable and otherwise reducing it so far as reasonably practicable without imposing disproportionate restrictions.
5. Record the residual risk, actions, ownership and review arrangements; communicate the controls to everyone who needs to follow them and monitor whether they work in practice.
6. Where a person has capacity and chooses to accept a risk, staff will provide accessible information, explore safer options and document the discussion and agreed plan. A capable person’s informed choice will not be overridden merely because others consider it unwise. Where capacity is lacking, decisions will be made and recorded in the person’s best interests using the least restrictive option.

Assessments will be completed and reviewed:

• Before or on admission and before staff undertake relevant care, treatment or support.
• Following an incident, near miss, safeguarding concern, change in health, behaviour, capacity, medication, mobility, equipment, environment or staffing, or when controls may no longer be effective.
• At the planned review date and whenever new information, professional guidance, safety alerts, audit findings or legal requirements indicate that reassessment is needed.
• Assessments will be completed by staff who are competent for the subject and level of complexity. Specialist advice will be obtained where necessary. Urgent risks will be controlled immediately and escalated; work or activities will be paused where they cannot proceed safely or lawfully.

5.3 Managing Specific Risks

Clinical Risks

• Falls Prevention: Individual assessments will consider mobility, medicines, vision, continence, cognition, footwear, environment and previous falls. Proportionate controls will be agreed with the person and relevant professionals, reviewed after any fall and reflected in the care plan.
• Medication Safety: Risks relating to prescribing, supply, storage, administration, covert administration, self-administration, monitoring and disposal will be assessed and managed in line with the medicines policy and professional advice.
• Skin Integrity: Individual risks of pressure damage will be assessed and managed through appropriate repositioning, equipment, nutrition and hydration, skin monitoring and timely clinical escalation.
• Infection Prevention and Control: Assessments will address transmission risks, outbreaks, isolation, staffing, ventilation, cleaning, personal protective equipment and access to vaccination, while taking account of individual needs and lawful consent.

Environmental and Workplace Risks

• Fire Safety: The responsible person will ensure that a suitable and sufficient fire risk assessment is maintained under the Regulatory Reform (Fire Safety) Order 2005. Personal emergency evacuation plans or equivalent arrangements will reflect each person’s needs, staffing levels and evacuation strategy, and will be tested through drills and review.
• Equipment and Moving and Handling: Equipment will be suitable, maintained, inspected and used by competent staff. Generic and individual moving-and-handling assessments will specify the task, equipment, technique and staffing required, with lifting equipment examined as required by law.

Safeguarding Risks

• Protection from Abuse: Staff will recognise and report abuse, neglect, exploitation and organisational safeguarding risks. Concerns will be referred promptly under local safeguarding procedures and reported to the police, CQC or other bodies where required; internal enquiries will not obstruct external investigations.
• Mental Capacity, Consent and Restrictions: Capacity will be presumed and assessed only where there is reason to doubt it, for the specific decision and time. Best-interests decisions, restraint and any deprivation of liberty will comply with the Mental Capacity Act 2005, be necessary and proportionate, use the least restrictive option and have the required authorisation.

Operational and Financial Risks

• Staffing Risks: Staffing levels, deployment, skill mix, competence, fatigue, lone working, agency use and foreseeable absences will be assessed against people’s needs and contingency arrangements.
• Business Continuity Risks: Our Emergency and Business Continuity Plan ensures that services remain operational during crises.
• Other material risks: Assessments will address, where relevant, nutrition, hydration, choking and dysphagia; behaviours that may challenge; self-harm or suicide; missing persons; hot water and scalding; bedrails and entrapment; legionella; hazardous substances; lone working; violence and aggression; transport; information security; and extreme weather.

5.4 Incident Reporting and Learning from Events

All incidents, accidents and near misses must be reported promptly through the internal system. Immediate care, medical assistance, safeguarding action, scene preservation and risk-control measures will take priority. The registered manager will ensure that:

• Events are recorded, reviewed or investigated proportionately, duty-of-candour requirements are considered, and corrective actions have named owners and completion dates.
• Learning and changes to assessments, care plans, training, staffing, equipment or procedures are communicated and checked for effectiveness.
• CQC notifications will be made only where an event meets a notification requirement in the Care Quality Commission (Registration) Regulations 2009, using the required form and timescale. Separate reports will be made under RIDDOR, safeguarding, fire, medicines or other legal arrangements where applicable.

5.5 Training and Staff Responsibilities

Risk management training and competency assessment will be proportionate to each role and will cover:

• Identifying and assessing risks in care delivery.
• Incident reporting and emergency response protocols.
• Health and safety legislation and infection control measures.
• Safeguarding and whistleblowing procedures.

Staff must follow agreed controls, remain alert to changing or dynamic risks, take immediate proportionate action where necessary, record and report concerns, and stop or escalate work they cannot carry out safely.

6. Compliance with CQC Standards

This policy ensures compliance with:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 9 (person-centred care), Regulation 11 (consent), Regulation 12 (safe care and treatment), Regulation 13 (safeguarding) and Regulation 17 (good governance).
• Health and Safety at Work etc. Act 1974 and Management of Health and Safety at Work Regulations 1999, including the requirement for suitable and sufficient assessments by competent persons.
• Mental Capacity Act 2005, Care Act 2014, Equality Act 2010, Regulatory Reform (Fire Safety) Order 2005 and other topic-specific health and safety legislation, as applicable.
• Care Quality Commission (Registration) Regulations 2009 and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, where notification or reporting thresholds are met.

7. Monitoring and Review

This policy will be reviewed at least annually and sooner where:

• Legislation, CQC requirements, safety guidance or recognised practice changes.
• An incident, near miss, safeguarding concern, complaint, audit, enforcement action or risk trend identifies a weakness.
• People receiving care, representatives, staff or professionals identify concerns, or service delivery, premises, equipment or staffing arrangements change.

The registered manager is responsible for ensuring that risk arrangements are implemented, audited and improved. The provider retains overall accountability and will receive assurance about significant and escalating risks.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
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