Managing risks: inadequate

S2. How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected?

Characteristics of services we would rate as inadequate in this area

There is limited or no action to assess, monitor or improve the safety of the service. There is wilful or routine disregard of standard operating or safety procedures.

Where action is taken to address risks, plans are not clear or coordinated. People are not assured that they will be safe and sometimes do not feel safe.

People are not involved in managing risks that may affect their safety.

Practice at the service places people at risk of harm or does not protect them from actual harm.

Risk management includes unjustifiable restrictions on people, which significantly limits their control over their lives and their independence.

There are disproportionate restrictions on people's liberty. People are not properly involved in decisions that lead to restrictions on liberty, and staff do not meet legal requirements about making decisions when people do not, or may not, have the mental capacity to do so for themselves.

The service may deprive some people of their liberty without legal authority to do so.

There may be limitations or 'blanket rules' that inappropriately restrict people’s choice and control, whether or not they have mental capacity.

Information about risks to people is not passed on to the staff and others who need it. People are likely to or may have been harmed as a result.

Staff are afraid of, or discouraged from, raising concerns and there is a culture of blame. When concerns are raised or things go wrong, the approach to reviewing and investigating the causes is insufficient or too slow. There is little evidence of learning from events or action taken to improve safety.

Where action is taken to address risks, plans are unclear or uncoordinated.

The service does not gather or monitor safety-related information to look for themes and trends. The service does not learn from concerns, accidents, incidents and adverse events.

The service has a track record of failing to provide good standards of safety.

Where the service is responsible, people have been or probably will be harmed because equipment is avoidably unsafe.

The service does not assess or properly manage environmental and equipment-related risks.

External referrals and engagement are not made when they should be. Staff do not know how and when they should refer concerns. People are or may be harmed as a result.