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Within adult social care, people, issues, organisations and regulatory bodies are always involved in the discussions on risk and safety. Responsibility, duty of care, adult safeguarding and capacity are of concern. The balance of keeping service users who are viewed as vulnerable safe in society can be contradicted with living independent lives and being able to take the risks others take in everyday life. Therefore, perceptions and assessments of risk is an individual matter for each service user, the communities and society and is fraught with decisions and choices. Mitchell and Glendinning (2007) suggest that the state’s role and pre-occupation with risk management is under constant evaluation rather than exploring and seeking to understand service users’ perspectives of risk. They highlight the need for more service users and carers involvement in risks, decision making and protection (Parrott, 2006).
Events during the life course such as genetic/biological factors, and childhood experiences can have a huge impact on the ability of the mind and body to develop and maintain good mental health. Ones life course can encounter a combination of stressful events which can test the human body’s ability to cope emotionally, which sometimes can trigger anxiety, depression and/or other mental health conditions. Risk factors which can have a negative impact on ones mental health can be addressed by influencing supportive relationships, a healthy lifestyle, stress management techniques and emotional coping strategies, in which social workers can be apart of ensuring happens. On an individual factor John could be facing depression/grief from the loss of his wife who passed away a year ago. John could still be in the seven emotional stages of grief (Carers UK, 2012). This involves shock or disbelief, denial, bargaining, guilt, anger, depression, and acceptance/hope. Social workers and other professionals should be aware that, there are no time limits on grief and no set pattern of emotions and behaviours that people can follow, everyone is different and grief does not always happen straight away. The risk factors for experiencing more serious symptoms of grief/loss of a loved one is that John could be at an increased risk of being psychiatrically unstable due to a decline of his emotional well being. The change in John’s life events/situation could have a huge impact on his mental wellbeing, not only because he has lost his wife but he was also a carer for his wife which would have meant John would have had responsibilities daily. Therefore John also faces having to deal with the loss of his caring role, which he may include him feeling guilty/ relieved, exhausted and alone. John may also feel angry that someone has contacted social services as they feel worried about him, as at this moment in time John may be thinking he is coping fine. John’s family/social factors may be a potential risk as John lives alone and his two children live some distance away and only visit monthly. John could be feeling isolated and due to lack of family support and limited social networks, John could be at risk of deteriorating emotionally and physically. John could be feeling a loss of control over his life due to these changes and he could experience all types of symptoms such as significant loss of appetite, diminished energy levels, suicide thoughts, depression, anxiety and many more (NIMH, 2012). The issues around the perceptions of risk and rights for mental health service users are different as people are sometimes perceived as a risk rather than considered at risk in vulnerable situations. Therefore, John could be at risk of being overlooked by safeguarding practices and his individual rights comprised by the Mental Health 1983 if he is assessed as lacks capacity, when maybe all John needs is some support in getting his life back together and learning how to cope with all his life changes. This would be a multidisciplinary decision and user involvement in risk assessment and informed decision making about risks to John and others (Ray, Pugh, Roberts & Beech, 2008).
Regardless of whether John is assessed as having the capacity or not to make decisions under the Mental Health Capacity Act 2005, then professionals need to raise the awareness of human rights and enable John to have these rights realised. Independence, choice, control and experiences and feelings associated with danger, fear, abuse and safety would need to be addressed with John. Sheldon (2010) suggests that in any case of risk management, the service user should have their rights explained, including their human rights and risk management should not interfere with the service users rights to dignity, respect and privacy as also suggested by the Care Council Code of Practice for Social Workers (CCW, 2002, 1.3, 1.4, 3.1). It is important that the key role of assessments of adults allows people to make their own decisions whilst minimising risk or harm. By placing John at the centre of the caring process, it would be the social workers role to discuss options of support for John as a first option. Fair Access to Care Services would enable the social worker to focus on health, safety, autonomy and involvement with his family and the community but without overlooking risks of self harm, neglect, abuse and risks to carers and others. FACS was launched in 2003 by the Department of Health, so that adults in need can be assessed for eligibility of services (DOH, 2003). It focuses on four levels of risk to independent living, which would be of use in John’s case. Risk taking is a normal part of life, however the social worker needs to ensure they have taken all the steps needed to minimise risk. With John by considering the consequences of actions and the likelihood of harm he could cause to himself, and discussing the benefits for independence and well being, a support plan for managing risk could be put in place with Johns consent (CCW, 2002, 4.3). Risk assessment will help in developing risk management plans that minimize risks (Coulshed & Orme, 2006). The social workers role would be to provide John with support to enable him to help himself. Under the National Health and Community Care Act 1990, the local authority would have a duty to assess Johns needs and to ensure that’s services are available for John. Protecting and safeguarding John from harm, abuse and neglect including financial, physical, sexual, emotional and institutionally would be the social workers main role. An assessment based on the needs of John would enable the social worker to build a positive relationship with John, to gather the relevant information, form an overview of the situation and identify possible solutions for the best way forward (Parrott, 2006). Assessment and care planning will enable the local authority to provide practical and emotional support for John. During assessment and care plan the social worker would be able to treat John holistically, promote his independence whilst clarifying risks that can follow from decisions made independently and also being able to involve other health professionals to benefit John. Through the care plan, John would be able to access a wide range of information and services, designed specifically for him. Social workers use the Mental Health Act 2005 as a criterion to minimise risk of harm to self or others, however the downside for service users is that of potential threat to independence and freedom that sometimes makes seeking help a hard decision to make in some cases, therefore social workers working in multidisciplary teams and having the use of assessment and care planning tools, makes decision making easier. Therefore all professionals and John would have some responsibility for making decisions and every professional would have input into providing and sharing information to arrive at a considered decision (Milner & O’Byrne, 2009). This also minimises the risk of one person being involved and making decisions solely without having the right knowledge or support to reach appropriate outcomes with John. The autonomy of John to decide whether to engage with social services, and accept that he is not coping well at the moment, conflicts with social services and his neighbours concerns of him putting himself in danger/neglect. The professionals would need good social skills and value the principle of inclusion into society and autonomy to enable John to make his own decisions and make positive changes on his own behalf. The conflict in this case is that facing the social worker in assessing John’s needs. On one hand, John doesn’t seem to be coping well however he has been assessed as having capacity, but on the other hand, John is exercising his own right to self determination and autonomy as he won’t accept any support. The issue the social worker faces is that of John not engaging if John is able to understand some of the presenting problems in his current situation. In order to assess whether intervention is required, three categories of risk may be required. John’s physical risk could be causing harm to himself or others. John’s social risk of becoming isolated and acting in a way that is considered outside of the social norm and emotional risk, his physical and emotional health (Webb, 2006).
In the case of John lacking capacity the social worker and other professionals would be working under the framework The Mental Capacity Act 2005 (MCA) in order to provide protection for John, who is unable to make decisions for himself. The Act contains provision for assessing whether people have the mental capacity to make decisions, procedures for making decisions on behalf of people who lack mental capacity and safeguards. Professionals would be working under the philosophy of the MCA, which is any decision made, or action taken, on behalf of John who lacks the capacity to make the decision or act for himself must be made in his best interest (Coulshed & Orme, 2006). The Act is also supported by its own Code of Practice which has to be interpreted when using the Act. It is important that all professionals working with John understand his capacity might be affected only for a temporary period. The phrases used in the MCA section 2 ‘in relation to a matter’ and ‘at the material time’ means that capacity must be assessed on a decision-by-decision basis. Therefore, capacity may not be a permanent status and John should not be described as having or lacking capacity. The level of capacity needed by John would depend on the decision to be made. For example, John may need a lower level of mental capacity to make decisions about everyday matters, such as what to eat or where to go at this moment in time. Professional should ensure John has not been assumed as lacking capacity due to his age, appearance, and mental health diagnosis or disability/medical condition (Webb, 2006).
In 2007, under the Mental Health Act for England and Wales, Approved Social Workers were replaced by Approved Mental Health Practitioners (AMHPs) with the role and remit extended to other disciplines. The primary role of an AMPH is to act as the guardian of the patient’s rights. The AMHP has the responsibility of contacting the patient’s next of kin and to help any appeals against the order that the patient wants to make. In the case of John not having capacity, the AMHP may control access to some services such as day centres, respite care, residential care and other community support services, if needed (DOH, 2001). The social worker would also need to refer to other health/social care professionals if not already done so such as GP, community psychiatric nurse, physiatrist, counsellor, advice services, specific therapies to ensure an holistic approach is taken (Ray et al, 2008). The consultation report on safeguarding adults in Wales ‘In Safe Hands’ (WAG, 2000) found that people were concerned about the balance between safeguarding and personalisation, between choice and risk. Social workers and other professionals need to ensure people have informed choices and introduce support systems. Social workers will have a distinctive role in multiagency settings and will need to ensure they develop practices to enable service users with mental health to identify and realise their own needs. The team involved in working with John will need to have broad experiences and social views of mental health problems especially in regards to discrimination, oppression, civil rights and social justice. They will need to co-ordinate efforts to support John so that he does not have negative experiences and /or perceptions of mental health and ensure he received services fairly and equably. The social worker will work with John to ensure he is not a victim of social isolation, poverty, unemployment, insecure housing and limited social and support networks and will have an independent view in assessment and care planning (Faulkner, 2012).
In John’s case risk management will minimize the dangers both to and from John. However risk factors are individual and differ from professional to professional due to personal factors and the degree of control they have over the risk. A risk can be viewed as negative and positive. Risk is associated with decision making processes and should never be made in isolation. Social workers must take every precaution to protect the service user and the public, as the law makes people responsible for behaviours whether or not they were the ones who took the risk, intended or not. Practitioners can be held liable for negligence and a breach of duty. Trying to predict possibilities and risk assessing is a very important part of the social workers role (Parrott, 2006).
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