All for want of a conversation: let’s talk about positive risk taking

I have recently had a couple of visits to the Coroner’s Court following the death of residents who were living in Rose Court. Anyone who has had this experience will acknowledge that it is both demanding and exhausting. The process involves a wide range of stakeholders, including healthcare, social care, legal teams etc. It is emotionally draining, requiring a significant investment of both time and resources to ensure that everything (including staff) is prepared for the hearing.

The question I have found myself asking is ‘what is the learning?’ Although in all cases we (the home) have received positive feedback throughout the process about our honesty, our care and our documentation, I have found myself asking e.g. ‘How did we get here?’ ‘What could/should we have done differently?’ Reflecting on these questions, I now realise that we made assumptions about relatives’ knowledge and understanding of the progressive nature of their family member’s condition and I also recognise that a common theme was positive risk taking.

Positive risk taking for residents is a key element to our philosophy of care within the home. This was made evident recently when a visitor to the home (Kate Sanders from FoNS) asked one of the carers about her understanding of ‘positive risk taking’. She was able to articulate that it meant identifying possible risks; having conversations about these risks with residents (and their families), including ensuring that residents are aware of possible consequences; enabling residents to take risks of their choice; and documenting discussions and decisions. Some examples of this might be enabling and encouraging residents to walk around the home, even though they might be at risk of falling; or helping someone go to the local shops, even though this includes crossing a road. It goes without saying that risk-assessments are undertaken and appropriate strategies to mitigate risks are used such as hip protectors. It often requires staff to act as advocates for residents as it is not unusual for family members to feel more cautious about risk-taking. Such an approach is in line with the Joseph Rowntree Foundation report (2104) How can ‘positive risk-taking’ help develop dementia-friendly communities? It is also supportive of resident ‘choice, voice and control’, key principles underpinning best practice within care homes (Owen et al., 2012). It is not an easy option but it is the right thing to do because it is what we would want and we should be working with residents, not doing things to them. See the below for a couple of examples.

• The daughter of a resident with a brain injury raised concerns about her dad being allowed out of the home unaccompanied in his electric wheelchair because he has restricted communication. We discussed with the resident what he wanted and how we could support him to achieve it. This involved a risk assessment, and then planning, implementation and reviewing. The resident is now able to go into the community, using the road and pathways safely, to shop independently and to manage his own money.

• Asked about positive risk taking, another resident said: ‘I enjoy my independence … because I am still allowed to lead a normal life, even in a care home.’ Feedback from this resident’s family was positive, saying that they were aware of the risk that he was taking but pleased that he is maintaining his independence.

So how can we continue to practice positive risk taking but avoid the Coroner’s Court? In conversation with staff it was agreed that it would be helpful to firstly identify the key areas of risk. We decided that these were choke and the risk of aspiration, infection and falls. We then recognised that we needed to be much more intentional about having conversations with all those involved. This requires that the team are clear about who these people are. We then needed to ensure that we developed our documentation to ensure that we could evidence these conversations.

I suppose that this might all sound quite obvious, but we recognised that in the busyness of everyday practice and care, it was easy to make assumptions about what had been said to whom and what their understanding was. Such assumptions were key to one of the coroner’s cases and we are keen to ensure that this never happens again. In summary, we recognised that it was essential that we had honest conversations relating to ‘high risk’ assessments. The aim was to ensure that all parties were aware of the risk; that everyone understood that we cannot and should not reduce risk to zero; and that the discussions about the individual risk are enabling, consensual and focus on enhancing the person’s wellbeing.

The next step was to review all residents to identify those who were at potential risk. Then, either through care planning meetings or opportunistically, staff (unit managers, senior carers and nursing assistants) needed to have conversations with residents and their families about their choices in relation to positive risk taking. They are also having wider conversations with other care home staff and members of the multidisciplinary team. Where residents do not have the capacity to make their own decisions, the risk assessment is shared and discussed with the multidisciplinary team enabling a joint decision to be made. All of these conversations are documented and appropriate dates for review are created.

With permission from residents and relatives, we asked for some feedback about this positive risk taking initiative to help us to continue to improve, but also to include in this blog. Here’s what they said.

• The daughter of a resident at risk of choking and falling said:

‘We were given a very detailed explanation about why the home holds these [multidisciplinary] meetings. It’s a good way of informing us of key issues and the risks posed – we didn’t feel it was a difficult conversation as the staff were professional – happy that the risk have been brought to my attention.’

• The daughter and sister of a resident at risk of choking said:

They felt that the care that their relative ‘receives here is much better standard and quality than pervious homes. Staff approachable and friendly… [They] felt much better after the meeting… now fully aware of the issues and risks identified… [They were] included with the resident in the decision making – very beneficial for all.’

• The husband of a resident at risk of choking said:

‘Simple questions helped me understand and I wasn’t confused.’  When asked what was different from previous experiences in other provisions, he said: ‘Here you are attentive, you have attention to detail.’

• The sister of a resident at risk of choking said:

I ‘find it very difficult in regards to talking about risks or any issues’ [because of resident’s diagnosis of dementia] … not something discussed in any other setting … feels very involved and included regarding any changing needs.’ When asked how she felt about the meeting she said she ‘felt had been given all the relevant information to help make informed decisions… [My] sister has always presented in this way but [this is the] only home to take time to sit and explain fully even if it is difficult to say … very open and honest … very thankful and trust your judgement 100%. [She] feels meetings are very useful as highlights any risks giving relatives the opportunity to discuss fully with professionals and air their views.’ Additionally, we invited feedback from a GP and a nurse practitioner.

• The GP stated that ‘the assessment and discussion process is a very good idea in order to prepare everyone involved for what may occur with a resident in the future.’
• The nurse practitioner stated that her involvement with the assessment process ‘was very positive … it supports people/the provision in not being risk averse, preparing people for their progression in their condition. It could prevent unnecessary hospital admission, and concerns and complaints arising.’

References

Morgan, S. and Williamson, T. (2104) How Can ‘Positive Risk-taking’ Help Develop Dementia-friendly Communities? Joseph Rowntree Foundation. Available from: https://www.jrf.org.uk/report/how-can-positive-risk-taking-help-build-dementia-friendly-communities

Owen, T. and Meyer, J. et al., (2012) My Home Life: Promoting quality of Life in Care Homes. Joseph Rowntree Foundation. Available from: https://www.jrf.org.uk/report/my-home-life-promoting-quality-life-care-homes