Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
22 items
1 source
8 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
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
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.
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
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
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
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 in Wales should ensure that their...
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
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
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
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.
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.
Matched on
terms: assessment
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