4.1 Complex Adult Risk Management (CARM) Policy

1. Introduction

The South Tyneside Safeguarding Adults Board (STSAB) have agreed the CARM approach to manage complex risks. Such risks may arise within specific circumstances when working with adults deemed to have the mental capacity to make decisions for themselves, but who are at risk of serious harm or death through:

• Self-neglect (Care Act 2014) (see also Self Neglect Guidance);
• Behaviours that place them at risk/chaotic lifestyles; or
• Lack of engagement with services.

The aim of the CARM policy is to provide professionals with a framework to facilitate effective multi-agency working with adults who are at significant risk.

2. Legal Considerations

All agencies/organisations have a duty to uphold the law, and the CARM framework should not be seen as a substitute for legislation and existing processes.

Agencies should follow existing legislation and their internal processes, including the Human Rights Act 1998, Mental Health Act 1983, Mental Capacity Act 2005, Care Act 2014, Data Protection Act 2018, Multi Agency Public Protection Arrangements (MAPPA), Multi-agency risk assessment conference (MARAC) etc. These processes will be seen as having primacy over the CARM process.

The CARM framework does not replace any current policies and procedures. The CARM is a framework that sits within the multi-agency adult safeguarding procedures and should only be applied if the criteria are met (see Section 4, Criteria for a CARM). The CARM Framework is for concerns that sit outside of the Care Act 2014 Section 42 enquiry decision but within the ‘wellbeing principle’ of the Care Act (see also Promoting Wellbeing chapter).

Information sharing is key to promoting an adult’s rights and protecting then from significant harm. The Care and Support Statutory Guidance explains that if the adult has the mental capacity to make informed decisions about their safety and they do not want any action to be taken, this does not preclude the sharing of information with relevant professional colleagues. This is to enable professionals to assess the risk of harm and to be confident that the adult is not being unduly influenced, coerced or intimidated and is aware of all the options. This will also enable professionals to check the safety and validity of decisions made. It is good practice to inform the adult that this action is being taken unless doing so would increase the risk of harm.

3. Complex Adult Risk Management (CARM) Process

The CARM is a multi-agency adult assessment risk management process to:

• Identify the relevant risks for the individual;
• Discuss and agree agency responsibilities/actions;
• Record, monitor and review progress with an agreed action plan;
• Agree when the risks have been managed, and evaluate the outcome.

The CARM will only be called where the adult at risk does not fall within the existing multi-agency processes, or if it is felt that a CARM meeting will help to reduce the risk of serious harm or death. The CARM is not a substitute for:

• Formal adult safeguarding procedures;
• Multi-Agency Public Protection Arrangements (MAPPA) see Multi-Agency Public Protection Arrangement);
• Multi-Agency Risk Assessment Conference (MARAC) see Multi-Agency Risk Assessment Conferences;
• Channel (multi-agency meeting within the Prevent programme) see Adults Vulnerable to Radicalisation and Violent Extremism;

Each agency has a responsibility to ensure that their staff are aware of the CARM policy/process and of the need to contact their safeguarding lead/manager if/when the process is required. The agency that identifies the adult at risk who would benefit from a CARM meeting should ensure the criteria in Section 4 are met and familiarise themselves with the CARM processes, including Section 6, Chairing a CARM Meeting.

4. Criteria for a CARM

One or more of the following conditions must apply for a CARM to be called:

1. the adult has the mental capacity to make decisions and choices about their life;
2. there is a risk of serious harm (physical or psychological) which is life-threatening and/or traumatic, and which is viewed to be imminent or very likely to occur, or death due to non-engagement with services,  and they do not meet the criteria for a safeguarding referral;

OR

1. here is the potential of death and or life changing injuries and/or a potential risk to the health and safety of others in the community;
2. There is a high level of concern from partner agencies.

 The principles of the Mental Capacity Act (2005) must be followed to establish whether the adult has the mental capacity to make the relevant decisions. Further information and guidance on Mental Capacity assessments and best interests decision-making can be found in the Mental Capacity and Best Interests chapters.

It is essential that every effort is made to engage and involve the adult deemed to be at risk throughout the CARM process, where they will engage.

CARM is an opportunity to ensure all agencies have offered the appropriate support/options to the person. All relevant legislation must be considered throughout the process.

5. Preparation for a CARM Meeting

Consent for holding a CARM meeting should be obtained from the adult wherever possible. The adult should be encouraged to participate in the process and given the ‘What to Expect’ information leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy). However, a lack of consent must not prevent the meeting from taking place.

Referring to CARM is not dependent on gaining consent to share information. Each agency will have their own Memorandum of Understanding that sets out the legal framework for partners to share information where they believe that an adult is at risk of death or serious injury, or where sharing information is in the public interest. The adult’s views should be sought throughout all interactions as part of a Making Safeguarding Personal Approach (see Making Safeguarding Personal chapter).

Where the criteria are met and a CARM meeting is agreed, the nominated Chair will ensure:

• The appropriate agencies are invited to the meeting including non-statutory, voluntary sector and local community groups to facilitate the best opportunity to encourage positive engagement with the adult at risk;
• Consider whether there are agencies not currently involved with the adult that should be invited to attend;
• Where children are part of the household or are linked to the person, ensure Children’s Services are invited to the meeting and a safeguarding children referral has been made (see Safeguarding Children Procedures).
• Ensure the views of the adult can be included – the adult, or an appropriate advocate, may attend;
• Consider the resources necessary, should the adult wish to attend and have communication/physical needs.

All partner agencies must ensure that an appropriate member of staff, with the required seniority to make decisions on behalf of their organisation, attends the CARM meeting.

6. Chairing a CARM Meeting

See also Safeguarding Adults Forms, Leaflets and Posters where the CARM Meeting Agenda and Reporting Template can be downloaded.

The purpose of the meeting is to formulate a multi-agency risk assessment and identify actions to reduce the risk. The nominated Chair will chair the meeting and ensure completion of the CARM Reporting Template at every meeting (a copy can be downloaded from Safeguarding Adults Forms, Leaflets and Posters).

See also CARM Practice Guidance.

The CARM Report Templates must be circulated securely to all attendees within two weeks of the meeting: however, actions agreed must be initiated at the earliest opportunity by partner agencies. A copy of the completed CARM Report Templates must be submitted to the CARM Administrator who will collate records for the purpose of quality assurance and data collection.

The meeting date can be brought forward if the situation changes at any time, and it is the responsibility of the professionals involved to contact the CARM Administrator.

When all actions are completed for the identified risks, the CARM process must be closed. Where there is any disagreement about the process and/or proposed closure this must be escalated to the Head of Safeguarding within the respective organisation(s). See also Escalation and Challenge Protocol.

Where the adult refuses support and, despite all efforts, the risks cannot be mitigated, the following must be recorded on Form 4 of the CARM Report Template (which can be downloaded from Safeguarding Adults Forms, Leaflets and Posters):

• Action taken to date by each agency;
• Rationale for closing the case;
• Evaluation of the process;
• Potential for future review.

Once the CARM process is closed it may be reconvened at any time and by any agency in response to the person’s changing circumstances/risks.

7. Death of a Person within CARM Process

Where a person dies whilst within the CARM process:

• HM Coroner must be informed;
• Consider a Safeguarding Adults Review (SAR) referral and discuss with Adult Social Care/ICB Adult Safeguarding Leads.
• Consider a Learning Review.

8. Information Sharing

Each agency needs to be aware of the principles of sharing information and be aware of the threshold of sharing information on a ‘need to know basis’. Information can be shared to protect the vital interests of the adult at risk See Data Protection Act.

9. Evaluation of CARM and Quality Assurance

Each agency must maintain records of the CARM meetings in which they are involved. Agencies are responsible for collating and reporting information to the South Tyneside Safeguarding Adults Board as required.

At the closure of every CARM the Chair and members must review the process and complete the evaluation in Section 2 of Form 4 in the CARM Report Template (which can be downloaded from Safeguarding Adults Forms, Leaflets and Posters).

Following closure of the CARM the Adult at Risk, the Chair and members must complete the respective CARM Evaluation.

Audit of the CARM process will be agreed via the Performance Management and Evaluation Sub-Group of the Safeguarding Adults Board.