1. Criteria for a Complex Adult Risk Management (CARM)

See Safeguarding Adults Forms, Leaflets and Posters where the CARM Referral and Risk Assessment Form can be downloaded.

As agreed by the South Tyneside Safeguarding Adults Board, the agency identifying a risk(s) to the adult will refer to the CARM. The referral will be considered to determine that the CARM criteria is met. Where there is a decision to progress to a CARM meeting, the CARM Administrator will inform the Chair and will coordinate the CARM. In South Tyneside this will be the administrator from the MASH.

Consent for holding a CARM should be obtained from the adult whenever possible, and they should be encouraged to participate in the CARM process. However, a lack of consent does not prevent a CARM from taking place. Under common law, a person may act to prevent serious harm from occurring if there is a necessity to do so.

Referring to CARM is not dependent on gaining consent to share information. The Memorandum of Understanding 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).

In order to consider a person for a CARM meeting, one or more the following conditions must apply:

a. the adult has the mental capacity to make decisions and choices about their life;

b. 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 risk of death due to non-engagement with services, and they do not meet the criteria for a safeguarding referral; OR

c. There is the potential of death and or life changing injuries and/or a potential risk to the health and safety of others.

d. There is a high level of concern from partner agencies.

CARM referrals should be sent via email to [email protected]

All referrals will be triaged upon receipt to ensure they meet the CARM criteria. Should a CARM referral not meet the criteria, the referrer will be informed by the CARM Administrator via email. There may be other options available to support the adult and the referrer will be advised of these, where applicable, in the CARM Referral Notification (see Safeguarding Adults Forms, Leaflets and Posters for the Referral Notification Form).

The CARM, ‘What to Expect’ Leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) should, whenever possible, be completed with the adult or their Advocate.

The report templates for Complex Adult Risk Management (CARM) Meeting contains 4 forms, each with a specific use within the CARM process (see  Safeguarding Adults Forms, Leaflets and Posters to download a copy).

2. Chairing a CARM Meeting

The purpose of the CARM meeting is to formulate a multi-agency risk assessment and identify actions to reduce the risk.

The Chair of the CARM meeting will always be one of the Safeguarding Adults Board statutory partners (ICB, Police, local authority Adult Safeguarding).

It is the responsibility of the CARM Chair to ensure the correct forms are completed and are used appropriately to record risks, actions outcomes and reviews for the whole process.

The CARM Administrator will be responsible for arranging the minute taker at CARM meetings.

3. Referral and Invitation to Attend a CARM Meeting

The Referring Agency will complete the CARM Referral and Risk Assessment form (see Safeguarding Adults Forms, Leaflets and Posters to download a copy), paying close attention to appropriate and meaningful information regarding professional concerns, the views of the adult (where known), and the initial risk(s) identified. The record should include:

• the adult’s history and current situation;
• the adult’s views and expectations;
• work that has already been undertaken to reach this point/ reduce the risk;
• agencies which need to be invited / form part of the CARM process;
• the identified risk of serious harm or death;
• how the views of the adult can be included. The adult, or an appropriate Advocate, may attend.

Once the referring agency has completed the CARM Referral and Risk Assessment Form, they will email it to [email protected]

The CARM Administrator will arrange the CARM meeting and any subsequent review meetings. It is essential that attempts are made to include full participation of the adult’s views, whether these are given directly or through an Advocate.

Form 1 of the CARM Report Templates is used by the CARM Administrator to inform and invite partner agencies to a CARM Meeting along with clear instructions for agencies to complete sections 2 to 6 of the form (see Safeguarding Adults Forms, Leaflets and Posters to download a copy).

CARM meetings will be held via MS Teams unless requested. Consideration should be given by all agencies involved about any barriers that may impact on the adult’s ability to attend the meeting, for example:

• venue accessibility;
• how the adult can be included in the meeting process;
• are there any risks / concerns to consider?

The ‘What to Expect’ Leaflet (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) acts as the invite for the adult and/or their Advocate to attend the CARM meeting and provides an opportunity for them to give their views. It can be discussed with the adult either at a face to face or remote meeting prior to the CARM Meeting or posted to the adult with a stamped addressed envelope for them to return their comments.

The CARM Chair should allow time to seek the adult’s views and ascertain whether the adult will be attending the CARM meeting. It is important to make reasonable adjustments to support the individual to be able to attend their own CARM meeting (see also Equality, Diversity and Human Rights in a Safeguarding Context).

4. Receiving an Invitation to Attend a CARM Meeting

The CARM Administrator will circulate the CARM Agency Report (Form 1) to inform and invite the referrer and relevant agencies to a CARM Meeting. Clear instructions for agencies to complete Sections 2 to 6 of the CARM Agency Report (Form 1) will also be provided (see Safeguarding Adults Forms, Leaflets and Posters to download a copy of the Report Template) .

It is recommended that 10 working days are allowed for partner agencies to prepare information and assess any risks prior to the CARM meeting.

Agencies receiving an invitation to attend a CARM meeting must complete Sections 2 to 6 of the CARM Agency Report (Form 1) in order to:

• gather information held within their organisation about the adult;
• take reasonable steps to gather further information if required;
• liaise with the CARM Administrator to confirm attendance or submit a detailed information report to support the CARM process if required.

Please note: the adult may attend the meeting, but consideration should be given to whether their full or partial attendance is necessary, It is recognised that there may be some circumstances where it is not appropriate for the adult to attend. For example, there may be occasions where full disclosure by professionals may increase the risks or impact on the adult’s ability to engage with the process, or where the adult’s presence may impede candid discussion between professionals. In such circumstances, a pre-meeting might be helpful, prior to the arrival of the adult.

Each agency should consider professional representation; ideally from someone with the appropriate knowledge and expertise in their field and the authority to make decisions on behalf of their agency.

5. The CARM Meetings

The CARM approach involves a series of meetings, and the nominated Chair is responsible for chairing and coordinating these.

The CARM Meeting Agenda (see Safeguarding Adults Forms, Leaflets and Posters to download a copy) provides an aide memoir for the Chair as to what needs to be covered in the CARM meetings. The Chair is also responsible for ensuring the completion of all relevant forms within the CARM Report Templates.

Meeting format

• Introductions: (All Meetings) – The Chair will ask all attendees to introduce themselves, clarifying roles and the agencies represented. The Chair will also ask the adult or their Advocate (if they are in attendance) to introduce themselves.
• The Chair will read out the CARM Information Sharing Confidentially Statement, which makes specific reference to the legal basis for the information sharing in relation to CARM. The Chair will confirm any apologies received and that Form 1 CARM Agency Reports have been submitted. These details will be recorded in Section 3 of Form 2 CARM Meeting, within the CARM Report Templates.
• Is the adult present? Whilst efforts should be made to have the adult present at meetings, at times this may not be achievable or appropriate. The details of a representative/Advocate should be recorded, including the nature of the relationship to the adult.
• The Chair should ensure consideration is given to the appropriateness of the representative/Advocate in attending meetings. The representative/Advocate should be appointed or permitted attendance on the basis of ‘best interests’. (Remember, the CARM meeting may highlight or raise sensitive, confidential information which may not ordinarily be accessible)
• The Chair and those in attendance should consider the value of information sharing on a case-by-case basis, having careful regard to the context of the risk or cause for concern. For example, matters of fire risk may not require disclosure of the adult’s health needs or specific diagnoses. However, factors affecting the adult’s ability to escape fire (e.g. their mobility) may be relevant when considering risk reduction.
• Does the adult understand the purpose of the meeting? All reasonable efforts should be made to explain the reasons for the meeting (i.e. professional concerns) to the adult. This may be explained in writing; however, an additional verbal discussion might be helpful.
• What is important to the adult at risk/What is important for the adult at risk? This is Section 4 of CARM Management Meeting (Form 2) within the CARM Report Templates, and requires the Chair (and those attending) to provide a distinction between what is important to the adult and factors which professionals feel contribute to the identified risks. It provides an opportunity for everyone present to indicate what they think it is important for the CARM process to achieve. This may reflect actions raised in the Risk Management Plan (contained in the Report Templates, see Safeguarding Adults Forms, Leaflets and Posters to download a copy). It also provides an opening to explore different, and potentially conflicting, points of view. Effort should be made to negotiate outcomes, but not at the expense of hazard/harm mitigation. For example, in the case of a person who hoards, the adult may want to keep belongings in their home that present a fire hazard. However, the objective of professionals might be to encourage de-cluttering (by regulatory intervention or otherwise).
• Description of risks (including a risk rating): Set out the risks known to the group. It may be necessary to write a short explanation of the risk.
• Rating the risk: Each specific risk should be rated using the Risk Matrix (Appendix 1 CARM Report Template, see Safeguarding Adults Forms, Leaflets and Posters to download a copy) by the most appropriately qualified attendee. The rating does not require complex calculation but should broadly reflect the likelihood of harm given the circumstances of the adult, for example low, medium, high or very high.
• Actions to reduce the risk: The Risk Management Plan (CARM Management Meeting Form 2, Section 5) is a list of actions agreed during the meeting which may reduce the adult’s exposure to harm. The extent to which risk is reduced will initially depend on the predictions (and professional expertise) of those attending the meeting, and whether the agreed actions are successfully achieved. For this reason, the impact of the actions listed must be evaluated by agencies present, and the need for any CARM Review Meeting considered.
• The plan may include a diverse list of actions, some which directly reduce risk and others that may seem less tangible.
• The CARM Management Meeting record (Form 2) should specify the individual/agency that has been tasked with an action and any anticipated completion or review dates.
• Description of any conflicts identified: Conflict of opinion may arise for any number of reasons. This is an opportunity to describe the nature of the conflict and the persons/agencies involved. For example, a Fire Officer or Environmental Health Officer may demand the removal of materials from a hoarded property for the purpose of fire prevention and/or vermin management, but another attendee may feel that this is a violation of the lifestyle choices of the adult.
• Legal Powers and Duties considered: Those in attendance should consider any legislation, policies or codes of practice which might be relevant to the case. Duties, with associated powers, should be identified and statutory interventions specified within Form 2 .
• Agencies may have discretionary powers which could be applied, and these should be recorded, where appropriate, even if not enacted. In all cases, any impact on the provisions of the Human Rights Act 1998 (e.g. Article 8 – the right to respect for private and family life) must be considered. This includes where a third party is affected directly or indirectly by the behaviour or life choices of the adult.
• Outcome of the Meeting: The Chair should verbally summarise the recorded risks and agency actions identified and record these in Section 6 of Form 2. It is the responsibility of the individual agency to ensure agreed actions are completed within the timescale identified, and the impact on the identified risk is evaluated.
• The Chair may task an action to an agency if they are absent or unable to attend. It remains the responsibility of the individual agency appointed, rather than the Chair, to complete such actions.
• A decision may be made during the CARM that another pathway is more appropriate to manage the risks. For example, those present may identify that the adult meets the criteria for safeguarding procedures. In these cases, it may be necessary to close the CARM and conduct a meeting under Safeguarding procedures (see Safeguarding Enquiries Process).
• Where it is identified that the risks have been reduced or removed, a decision will be made that the CARM can be closed. This needs to be recorded in Form 4 CARM Closure Meeting.
• Review Meeting Required: The Chair will decide in consultation with the agencies involved in the CARM process whether a further meeting is required, and the timeframe for this to happen. It is more than likely that a Review Meeting will be required to record actions taken and evaluate the impact of these on the identified risks. The Chair will need to consider whether any other agencies could usefully contribute to a Review Meeting and invite them accordingly. The CARM Review Meeting (Form 3) template of the CARM Report Templates should be completed for Review Meetings.
• The Review Meeting may decide that the adult no longer meets CARM criteria. In such cases, the CARM process should close, and the decisions should be recorded appropriately in Form 4 CARM Closure Meeting.
• Following the CARM Management Meeting: It is the Chair’s responsibility to ensure that all relevant forms are completed accurately and circulated to invited agencies (whether in attendance or not), using secure email. Where a minute taker has formally recorded the meeting, the minutes should be included where relevant . The Chair must agree with the agencies involved how information from the CARM will be shared with the adult and should communicate details of any review meetings to the adult or their Advocate using the guidance detailed in this document.

6. CARM Review Meeting

The Chair should complete CARM Review Meeting (Form 4) record (see CARM Report Template, Safeguarding Adults Forms, Leaflets and Posters to download a copy).

Agency Update: Each agency will provide an update on the impact of agreed actions taken and details of any outstanding actions. It is the responsibility of each of the attendees, and not the Chair, to follow up and complete actions assigned to them.

Additional actions: CARM attendees may identify appropriate actions in addition to those specified in previous meetings. Any additional actions that may be required should be recorded in this section, with details of the individual / agency responsible for the action and the agreed time scales. This section of the record should not include outstanding actions.

The Chair will decide whether a further Review Meeting is required and make the necessary arrangements (if applicable). See Section 7, Closure of CARM.

The CARM Administrator will circulate the updated CARM Forms  following the meeting.

7. Closure of CARM

The Chair should complete the CARM Closure Meeting (Form 4) of the Report Templates when it has been agreed that the CARM process can be closed.

Information which should be recorded includes:

• Date of closure: This identifies the date that the CARM process concludes. This does not prohibit the re-opening of a CARM should it be necessary at a later point.
• Reason for closure / update from Chair / Evaluation of Meeting: This gives the Chair the opportunity to summarise and conclude discussions and actions agreed, as well as any legislation applied, in reaching the conclusion of the CARM.

CARM meetings are often complex by nature and any conflicting views, lack of engagement by the adult, or other relevant factors should be detailed by the Chair. The Chair can also comment on shortfalls and triggers for re-referral into the process.

Where an adult chooses to remain in a situation that places them at risk from identified harms this should be noted in Section 3 of the CARM Closure Form. The views of each agency in respect of the CARM closure and details of the risks which remain should be documented. It is recognised that it may not be possible to address all concerns/risks identified, but the role of CARM is to ensure that each agency has taken all reasonable steps to support the adult to recognise and reduce risks of death and serious harm.

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.