Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
50 items
1 source
11 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
85match
R101 - Whole-system commissioning with cross-agency risk assessment
Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a risk assessment that assesses how the impact of change in one part of the system impacts on another...
Matched on
terms: assessment, care, failure
Inquiry recommendation
78match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: assessment, care
Inquiry recommendation
78match
WATE-(31) - Require comprehensive child needs assessment before admission to care
Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Matched on
terms: assessment, care
Inquiry recommendation
78match
53 - Timing of first review of assessment
The first review of the initial assessment should take place within one week of the initial assessment, and should take place in every case. It should be a multi-disciplinary review, with representatives from the prisoner’s wing, healthcare and the team responsible for implementing the establishment’s violence reduction strategy all contributing to it. The documents set out in paragraph...
Matched on
terms: assessment, care
Inquiry recommendation
77match
6 - Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and...
Matched on
terms: assessment, care
Inquiry recommendation
73match
SP22 - LCC online harms risk assessment review
Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff have a consistent and up-to-date understanding of online risks, and that they have access to effective tools and...
Matched on
terms: assessment, care
Inquiry recommendation
68match
R28 - Nutritional screening
Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate and timely referrals should be made to dieticians for patients identified as being in need of specialist nutritional...
Matched on
terms: assessment, care
Inquiry recommendation
66match
74 - Mental health assessments to address risk
When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Matched on
terms: assessment
Inquiry recommendation
66match
R68 - Cumulative risk assessment across protection plans
Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also be evaluated.
Matched on
terms: assessment
Inquiry recommendation
66match
R25 - Pressure damage risk assessment
Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score in accordance with best practice guidance. Where patients are identified as at risk they must be reassessed at the frequency identified by the risk scoring system employed. Compliance should be monitored...
Matched on
terms: assessment
Inquiry recommendation
62match
11 - Objective assessment before referral or removal
In cases of child sexual abuse neither a referral nor a removal of a child should be undertaken unless both an objective assessment of the situation has been made and in addition meticulous planning, so as to balance the risk inherent in intervention against the success of the legal process (15.28).
Matched on
terms: assessment
Inquiry recommendation
62match
52 - Guidance for duty governors on risk assessment
The instructions for completing the form should give duty governors guidance on how to exercise the options available to them when dealing with prisoners who are both at risk of self-harm and a risk to their cellmate.
Matched on
terms: assessment
Inquiry recommendation
62match
39 - Missing cell-sharing risk assessment form on arrival
If prisoners arrive on a wing without a copy of the cell-sharing risk assessment form, they should be placed in a single cell until the form is found or a new one completed.
Matched on
terms: assessment
Inquiry recommendation
57match
WATE-(32) - Follow emergency child admissions with comprehensive assessment within prescribed period
All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Matched on
terms: assessment
Inquiry recommendation
57match
77 - Measures for mentally disordered prisoners on wings
The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner is to share a cell, carefully selecting their cellmate • ensuring that, whatever difficulties there may be in...
Matched on
terms: care
Inquiry recommendation
57match
73 - Reception health screen referral to mental health
The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where the prisoner’s behaviour is such that the healthcare officer completing the questionnaire considers it desirable.
Matched on
terms: care
Inquiry recommendation
56match
7 - Audit maternity and paediatric services
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be in place by September 2015.
Matched on
terms: assessment, care
Inquiry recommendation
53match
61 - Risk management model for highest-risk prisoners
The risk management model for the management of prisoners to whom MAPPA applies and who have been identified as posing the greatest risk to the public should be adopted by all establishments. Prisoners who have been identified as being a high risk to their cellmate on any review of the cell-sharing risk assessment, or posing a very high...
Matched on
terms: assessment
Inquiry recommendation
53match
60 - OASys for short-sentence prisoners at induction
All adult prisoners serving sentences of less than 12 months’ imprisonment who had an OASys assessment before being sentenced should have that assessment reviewed during the induction process. The review need only address the risk of harm which the prisoner poses to staff and other inmates. If resources permit, adult prisoners serving sentences of less than 12 months’...
Matched on
terms: assessment
Inquiry recommendation
53match
55 - Wing officers calling for reviews
Wing officers should be reminded of the need to call for a review of an assessment when the necessity for one is triggered by some occurrence which might affect the prisoner’s emotional well-being.
Matched on
terms: assessment
Inquiry recommendation
53match
SP2 - Shared multi-agency risk-assessment tool
Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public sector services.
Matched on
terms: assessment
Inquiry recommendation
53match
JB-15.4 - Amend firearms authorisation forms for risk assessment and tipping points
There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to evidential and, where appropriate, geographical tipping points; c. include a dedicated box on the FA2 form to be...
Matched on
terms: assessment
Inquiry recommendation
52match
WATE-(45) - Require social worker assessment and inter-departmental consultation before residential school placement
Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of the child's needs and family situation is needed as well as an educational assessment; and (b) in the...
Matched on
terms: assessment
Inquiry recommendation
48match
115 - Consistent background information for interviewers
Each interviewer should wherever possible have consistent and relevant background information about the child and in particular about his or her emotional, physical and mental development (17.54), and an assessment of the child’s wider family (17.55).
Matched on
terms: assessment
Inquiry recommendation
48match
57 - Distinguish CSE risk from actual exploitation
The Department for Education and the Welsh Government must ensure that their updated national guidance makes clear that signs that a child is being sexually exploited must never be treated as indications that a child is only 'at risk' of experiencing this harm. In line with this, local authorities in England and Wales should ensure that their assessment...
Matched on
terms: assessment
Inquiry recommendation
48match
JB-15.2 - Require multidimensional risk assessments throughout operations
Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Matched on
terms: assessment
Inquiry recommendation
45match
56 - Monitoring implementation of risk minimisation plans
The officer responsible for monitoring the processes for implementing measures outlined in risk minimisation plans should also be responsible for monitoring their actual implementation.
Matched on
classifier match
Inquiry recommendation
45match
R35 - Inpatient facilities on risk register
Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs should automatically place any inpatient facility or facility for people with challenging behaviour on its risk register.
Matched on
classifier match
Inquiry recommendation
44match
45 - Evidence sufficient to secure retention
Where there is a likelihood of harm continuing to the child if he or she is not retained in care the evidence for a Child Protection Order should be sufficient to give a reasonable expectation of securing such retention after a referral to the Children’s Hearing (16.17).
Matched on
terms: care
Inquiry recommendation
41match
101 - Medical examinations before placement
Medical examinations of children removed under Child Protection Orders should be carried out before they enter their placements (17.38).
Matched on
classifier match
Inquiry recommendation
41match
44 - Clear and cogent evidence for Orders
A Child Protection Order should only be sought where there is clear and cogent evidence to support the Order (16.16).
Matched on
classifier match
Inquiry recommendation
41match
62 - No separate risk classification
It is neither necessary nor desirable to introduce a risk classification, similar to the security classification, which identifies the degree of risk which a prisoner poses to staff and other inmates.
Matched on
classifier match
Inquiry recommendation
41match
59 - OASys assessor access to prior behaviour
OASys assessors should have access to information relating to prisoners’ behaviour while serving previous sentences and to information held in security files.
Matched on
classifier match
Inquiry recommendation
41match
58 - OASys use in all establishments
OASys should be used by all establishments to identify the risks posed by prisoners to staff and other inmates, and the risks which are identified should be fed back to the wings.
Matched on
classifier match
Inquiry recommendation
41match
57 - Register showing proportion of high-risk prisoners
The register of prisoners assessed as high or medium risk should identify what proportion of the establishment’s population those prisoners represent.
Matched on
classifier match
Inquiry recommendation
41match
51 - Instruction on completing form XF001
Staff who are tasked with completing form XF001 should be instructed on how to complete it by a senior officer. In particular, they should be reminded that they are only assessing the risk prisoners pose to other inmates. They should not automatically assess prisoners as a high risk simply because they claim, for example, to be prone to...
Matched on
classifier match
Inquiry recommendation
41match
9 - Guidelines on allocating shared cells
The Prison Service should publish guidelines to assist officers in allocating cells to those prisoners who have to share a cell.
Matched on
classifier match
Inquiry recommendation
41match
8 - System to apply change of prisoner status
All establishments should have a system for ensuring that immediate effect is given to a prisoner’s change of status, by making certain that they do not share a cell with a prisoner of a different status.
Matched on
classifier match
Inquiry recommendation
41match
R95 - Blue light protocol for at-risk registers
HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent the person having to leave their home in the community.
Matched on
classifier match
Inquiry recommendation
41match
R82 - Risk-based inspection prediction
RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service users with behaviour that challenges; services with poorly trained staff, insufficient staff, poor staff management, high sickness levels...
Matched on
classifier match
Inquiry recommendation
41match
POH-14 - Post Office to engage in negotiations during HSSA appeal period
During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated or mediated settlement of their claim.
Matched on
classifier match
Inquiry recommendation
41match
POH-12 - Amend GLOS to allow claimants oral submissions at panel hearings
The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by an independent panel prior to that panel making a binding determination in respect of a claimant's claim or...
Matched on
classifier match
Inquiry recommendation
40match
2 - Objectives the Safety Case must demonstrate
The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the operation of the installation and its equipment are safe (paras 17.36 and 21.56-57); (ii) that the potential major...
Matched on
classifier match
Inquiry recommendation
39match
R7 - Reorganisation due diligence
In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment should be undertaken by the Board or Boards responsible for all patient services before the reorganisation takes place. Subsequent to that reorganisation regular reviews of the process should be conducted to assess its impact upon patient services, up to the point...
Matched on
terms: assessment
Inquiry recommendation
36match
10 - Guideline content: common background and interviews
The guidelines should proceed on the assumption that the lack of privacy which cell-sharing entails is more likely to be ameliorated if prisoners with a common ethnic and religious background share cells. But that should only be the starting point for the process. All prisoners should be interviewed on their arrival, either in the first night centre or...
Matched on
classifier match
Inquiry recommendation
36match
3 - Safety management system content
The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of design should be directed to its review and upgrading so far as that is reasonably practicable (para 21.56)....
Matched on
classifier match
Inquiry recommendation
32match
56 - Reporter's power to return the child
The Reporter’s existing power to have the child returned should continue but should be qualified in its exercise by the proviso that the return of the child would not expose the child to the risk of significant harm (16.29).
Matched on
classifier match
Inquiry recommendation
32match
53 - Written statement of grounds
At the time of making the application or within forty-eight hours thereafter a written statement of facts setting out the grounds for the perceived risk to the child should be prepared and presented to the Sheriff or JP (16.25) The evidence need not be given on oath or affidavit (16.26).
Matched on
classifier match
Inquiry recommendation
32match
40 - Removal as last resort
Removal of a child should be recognised as a course to be considered where no alternative exists and the urgency of the risk requires it (16.9). Caution must be exercised (16.10). The gravity of the threat has to be considered (16.11) and the applicant must be satisfied that the situation calls for immediate removal of the child (16.12).
Matched on
classifier match
Inquiry recommendation
32match
WATE-(46) - Prohibit emergency admissions to all private residential schools
Emergency admissions should not be made to private residential schools.
Matched on
classifier match