Purpose
To manage risk proportionately so that people are protected from avoidable harm without unnecessary restriction of their rights and choices.
Scope
All care and environmental risk assessments across the service.
Assessing risk
Each risk is scored for likelihood and consequence, with controls recorded and a residual score agreed.
The person, and where appropriate their family or advocate, participates in the assessment and their view is recorded verbatim.
Positive risk-taking
Where a person with capacity chooses to accept a risk, the decision, discussion and mitigations are documented and respected.
Restrictions must be the least restrictive option, lawfully authorised, time-limited and reviewed.
Review triggers
Any incident, change in condition, hospital discharge, medication change or family concern triggers immediate reassessment.
All risk assessments are reviewed at least monthly.
Training and competency
All staff receive induction training on this policy before working unsupervised, refreshed at least annually or sooner following incident learning or a change in guidance.
Competency is confirmed through observation of practice, supervision discussion and reflective questioning — not attendance records alone.
Training records are maintained centrally and gaps are reviewed monthly against the training matrix.
Governance, monitoring and accountability
The registered manager holds overall accountability for this policy. Day-to-day implementation is delegated to named leads recorded in the service's accountability matrix.
Compliance is monitored through the service audit calendar, with findings reported to the monthly governance review and escalated to the provider board where risk is rated high.
Every audit finding is converted into an entry on the improvement action tracker with a named owner, priority rating, target date and evidence of completion.
Learning is shared with the whole team through team meetings, supervision and reflective practice sessions. Where a theme recurs, the policy itself is reviewed rather than the individual blamed.
- Falls, skin integrity, nutrition, choking, moving and handling, self-neglect and behaviour support assessments held for every person as indicated.
- Environmental and fire risk assessments reviewed annually and after any change to the premises.
- Monthly audit of risk assessment currency and quality.
- Post-fall and post-incident protocols with clinical observation and same-day reassessment.
- Trend analysis of incidents by time, location and staffing to identify systemic causes.
- Risk assessments avoid defaulting to restriction for people with dementia, learning disability, autism or mental ill health.
- Cultural and religious practices are supported rather than treated as a hazard.
Evidence of compliance
- Risk assessment audits
- Incident trend reports
- Best-interests and least-restrictive records
Suggested review cycle: Annually.