policy: c27 clinical risk policy - west london nhs …...west london nhs trust page 6 of 33 guidance...

West London NHS Trust of 33

Guidance C27 First date of issue: Nov 2009 This is current version C27/v8.1 Oct 2018

Policy: C27 Clinical Risk Policy

Version: C27/08.1

Ratified by: Quality Matters

Date ratified: 17th October 2016

Title of Author: Consultant Forensic Psychiatrist Interim Clinical Director

Title of responsible Director Director of Nursing and Patient Experience

Governance Committee Quality Matters

Date issued: 15th October 2018

Review date: January 2019

Target audience: All staff

Disclosure Status Can be disclosed to patients and the public

EIA

C27 EIA October 2016 approved on 211016 by mmv.doc

The following policies are in place to support the assessment and management of risk.

(a) C2: Care Programme Approach: (b) R1: Risk Management Strategy and Policy;



Equality & Diversity Statement

The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed.

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed.



C27 – Clinical Risk Policy

Version Control Sheet

Version Date Title of Author Status Comment

C27/0. 1

C27/0. 2

C27/0. 3 05.02.10 Deputy Medical Director

Draft new policy circulated as working document whilst under consultation ending 05. 03. 10

Initial draft Policy developed and presented to Nov 09 Operations board.

Following process of focused consultation, in particular by CAMHS and Older People’s Service the draft Policy was re-presented to Feb 10 Operations board and approved as working document to under with 4 week consultation period.

C27/0. 4 Nov 2010

Deputy Medical Director

Working Document

Policy to be reviewed for NHSLA compliance. To be presented at Policy Review Group for approval 15th September 2010 – approved.

C27/0. 5 Oct 11 Associate Director – Risk Reduction (Now Head of Governance)

Out for consultation

07. 10. 11 to

04. 11. 11

Draft C27/05 presented to clinical risk sub group 20th May 2011.

Reviewed in line with NHSLA feedback. Update progressed with working group. Present to TMT for approval.

C27/0. 6 Sept 12 Head of Nursing Education and Standards

Policy reviewed and updated

To be presented to Dec 2012 TMT. Approved subject to minor changes, uploaded 3rd January 2013

C27/0. 7 May 2015 Consultant Forensic Psychiatrist Clinical Lead for Low Secure and Community Forensic Services

Policy reviewed Policy approved, to be reviewed again in Dec 2015

C27/0.8 October 2016

Consultant Forensic Psychiatrist Interim Clinical Director

Policy ratified and issued

C27.08.1 October 2018

Issued Review date extended to January 2019 with approval of Responsible ED



Contents Page No.

1. Risk Assessment Process overview flowchart ................................................... 5

2. Introduction ....................................................................................................... 6

3. Scope ................................................................................................................ 6

4. Definition of clinical risk assessment and management ..................................... 7

5. Duties ................................................................................................................ 9

6. The assessment of risk .................................................................................... 11

7. Gathering information ...................................................................................... 12

8. When to assess risk ........................................................................................ 13

9. Essential components of clinical risk assessment and management ............... 16

10. Recording risk information ............................................................................... 19

11. Risk assessment tools ..................................................................................... 20

12. Communicating an opinion of risk .................................................................... 20

13. Safeguarding children ...................................................................................... 21

14. Training .......................................................................................................... 21

15. Fraud statement .............................................................................................. 21

16. References ...................................................................................................... 21

17. Supporting documents ..................................................................................... 23

18. Glossary of terms / acronyms .......................................................................... 23

19. Appendices ..................................................................................................... 23

Appendix 1 – Baseline Risk Assessment .................................................................... 24

Appendix 2 – RIO risk assessment update: (Risk update as part of CPA and care planning) ..................................................................................................................... 28



1. Risk Assessment Process overview flowchart

Client enters service

Risk assessment conducted on initial assessment

(within 72 hours for inpatient area)

RiO risk assessment or Form 4 (Broadmoor) Completed

Risk formulation completed

Crisis plan agreed and developed

Care plan to manage identified risk in place

Risk shared, if appropriate

Risk reviewed at key intervals and plans updated as required

Points at which risk must be assessed or reviewed:

At first presentation to a Trust service or following re-presentation to services;

At the point of assessment which can often be preadmission;

On admission to an inpatient service (within 72 hours);

When granting leave or discharging from a section;

At community follow up within 7 days of discharge from inpatient care;

Assessment of risk before deciding about moving a client to or from CPA (Department of Health, 2008);

Prior to (and during) CPA review and when not managed under CPA as frequently as clinically required.

Prior to an individual moving from one service to another or prior to discharge from a ward or from Trust services;

The detaining doctor/AMHP (approved Mental Health Professional) must undertake an assessment of risk at the point of detaining a patient under the Mental Health Act, granting leave or discharging from a section.

Other points at which risk should be reviewed include:

Routine assessments;

Following an incident;

During discharge planning;

At known times of stress such as anniversaries of bereavement;

When new information is received significantly changing the individual’s risk status



2. Introduction

2.1 Risk assessment and effective management is a core component of mental health care and the Care Programme Approach (CPA). All staff, both clinical and non-clinical, have a responsibility to contribute to the safety and welfare of service users (See, Think, Act; DH 2010).

2.1.1 “Safety is at the centre of all good health care. This is particularly important in mental health but it is also more sensitive and challenging. Patient autonomy has to be considered alongside public safety. A good therapeutic relationship must include both sympathetic support and objective assessment of risk.” (Best Practice in Managing Risk (BPMR) 2007 P. 5)

2.2 Risk assessment and management is a collaborative process between the service user, care team and other relevant agencies involved.

2.2.1 Risk should be managed in the least restrictive way possible and should take into account and balance the benefits that a person may be getting from taking a risk with the possible negative consequences. (Risk in decision making -Independence, choice and risk DH 2007). The assessment of risk commences when first meeting the service user and having assessed the written history made available to the referring team.

2.3 The National Confidential Inquiry into suicide by children and young people (May 2016) identified ten common themes: family factors such as mental illness, abuse and neglect; bereavement and experience of suicide; bullying; suicide-related internet use; academic pressures, especially related to exams; social isolation or withdrawal; physical health conditions that may have a social impact; alcohol and illicit drugs; mental ill health; self-harm and suicidal ideas.

2.4 The National Confidential Inquiry into suicide and homicide by people with mental illness (July 2015) noted that there has been a rise in suicide rates in male patients and that this should be seen as a priority. The factors that increased risk included alcohol misuse, isolation and economic problems such as debt and unemployment. It was highlighted as important that these patients have access to psychological services and are not lost to follow up, and that risk is monitored through the course of treatment. It was noted that there needed to be greater awareness of opiate-containing pain killers, the prescription of which should be time limited to reduce the risk of accumulating a lethal quantity. The importance of family and carer input was also highlighted. With regard to reducing suicide risk, the report noted that good physical healthcare may help reduce suicide risk in mental health patients and that these needs should be care planned and subject to regular review by a GP or specialist clinic in conjunction with the mental health team.

3. Scope

3.1 This policy sets out the Trust’s requirements relating to mental health staff working with service uses and carers and other service providers to assess and manage risk. The policy cannot cover all eventualities and practitioners are expected to exercise their clinical judgement in applying



this policy, and in managing risk. This policy is designed for use with people who experience mental health problems.

3.1.1 The aims and purpose of this policy are to:

Promote service user safety;

Promote staff safety;

Promote a systematic approach to risk assessment and safety management at individual practitioner, team and organisational levels;

Minimise clinical risk within the Trust, to the community and to the public;

Support members of staff in developing safety-focussed care plans to manage risk in collaboration with service users;

Promote positive risk-taking;

Outline the responsibilities of the Trust, teams and individuals in assessing and managing risk and recording risk information.

3.1.2 Decision making about risk can cover a multitude of situations. Therefore members of staff may need to refer to relevant Trust policies or relevant legislation.

3.1.3 The Trust acknowledges the importance of clinical supervision in promoting safe practice. It is therefore essential for clinical staff to be aware of the Trust’s clinical supervision policies. Where appropriate, members of staff will also need to refer to other guidance such as the National Institute for Health and Clinical Excellence (NICE) guidance (e.g. Violence, 2005, and Self-harm, 2004 and longer term management 2011); the Trust’s Care Programme Approach Policy and Procedural Guidance (C2); the Therapeutic Engagement and Observation Policy (O1) and the Incident Reporting and Management Policy (I8). Any incident of risk behaviour may be subject to investigation under the Trust’s adverse incidents procedures, or under guidance such as local vulnerable adult policies.

4. Definition of clinical risk assessment and management

4.1 Risk is defined as “The likelihood of an event happening with potentially harmful or beneficial outcomes for self and others. (Possible behaviours include suicide, self-harm, aggression and violence, and neglect).”(Morgan, S. (2000) Clinical Risk Management: A Clinical Tool and Practitioner Manual. (The Sainsbury Centre for Mental Health)

Risk Assessment is defined as “A gathering of information and analysis of the potential outcomes of identified behaviours. Identifying specific risk factors of relevance to an individual, and the context in which they may occur. This process requires linking historical information to current circumstances, to anticipate possible future change.” (Morgan, S. (2000)



Clinical Risk Management: A Clinical Tool and Practitioner Manual. The Sainsbury Centre for Mental Health

4.2 A clinical risk assessment seeks to answer four related questions (NHS National Patient Safety Agency, 2007):

“It is not usually possible to eliminate all risks but healthcare staff have a duty to protect patients as far as ‘reasonably practicable’. This means you must avoid any unnecessary risk. It is best to focus on the risks that really matter – those with the potential to cause harm. Keep risk assessment simple – do not use techniques that are overly complex for the type of risk being assessed.” (NHS National Patient Safety Agency, 2007, Page 3)

“Risk assessment is an essential and on-going element of good practice and a critical and integral component of all assessment, planning and review processes.” (Department of Health, 2008, page 20).

4.3 The Trust considers clinical risk assessment to be one component of good clinical risk management.

4.4 Clinical risk management is:

“The actions taken, on the basis of a risk assessment, that are designed to prevent or limit undesirable outcomes. Key risk management activities are treatment (e.g. psychological care, medication), supervision (e.g. help with planning daily activities, setting restrictions on alcohol use or contact with unhelpful others, and so on), monitoring (i.e. identifying and looking out for early warning signs of an increase in risk, which would trigger treatment or supervision actions), and, if relevant, victim safety planning (e.g. helping a victim of domestic violence to make herself safe in the future and know better what to do in the event of a perceived threat).” (Department of Health, 2007a, citing Mersey Care NHS Trust, 2006).

4.5 While this definition is helpful in supporting staff to consider risk management options, WLMHT believes that a service user’s strengths and aspirations lie at the heart of reducing risk. Staff should focus their expertise on identifying major risks such as the risk of harm to self and others while recognising that helping service users meet their needs and aspirations (e.g. housing, finances, relationships, psychological recovery and employment) in order to build a meaningful life may at times be the most effective way to reduce these risks.

4.6 The emphasis of the risk assessment and management process should be to strive to support and enable service users to recognise their role in developing strategies to maximise their potential for recovery and to support the maintenance of their own wellbeing and safety as well as the



safety of others. Focussing on engagement and developing a therapeutic relationship which promotes trust is possibly the most powerful tool in enabling mutual risk assessment and effective risk reduction.

4.7 There are times where actions must be taken by staff to reduce risk and any intervention to manage risk must be proportionate to the seriousness of potential harm and the likelihood or imminence of that harm occurring. Any risk management plan must balance the wishes of the individual with consideration of their wellbeing, their human rights and the need to minimise risk.

4.8 Positive risk taking balances the risks and benefits of one course of action against another. Judgement with respect to positive risk- taking requires a good knowledge of the risks in a given situation. The likelihood and seriousness of the harms should be appropriately considered and any intervention to reduce risk should be proportionate.

5. Duties

5.1 Chief Executive

The Chief Executive is responsible for ensuring effective clinical risk management within WLMHT in conjunction with partner Directors of Social Services.

5.2 Accountable Directors

5.2.1 The Medical Director is responsible for the development of this policy and for ensuring the effective management of clinical risk within WLMHT. This responsibility is delegated to Clinical Directors and is monitored via approved committee structures. The Director of Nursing and Patient Experience is the chair of the trust-wide Quality Matters Meeting. This committee is responsible for ensuring that learning from incidents is integrated into clinical risk management across the trust.

5.2.3 The Director of Nursing and Patient Experience is responsible for ensuring effective risk management practice within the nursing and allied health professional work force. They are also responsible for ensuring that implementation and monitoring is communicated effectively throughout the Trust via CSU / Directorate leads and that monitoring arrangements are robust

5.3 Managers

5.3.1 It is the responsibility of CSU senior management team to ensure that staff members are made aware of this policy, are sufficiently trained in risk assessment and management and that this policy is implemented in their services. This is monitored through clinical audit and via reported compliance with mandatory training, clinical supervision and PDR.

5.4 Policy Author

5.4.1 The Policy Author is responsible for the development and review of this policy



5.5 Local Policy Leads

5.5.1 Local policy leads are responsible for ensuring this policy is communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised at the CSU / Directorate SMT meetings.

5.6 Mental Health Clinicians

Individual practitioners are responsible for assessing risk and planning risk management strategies; this includes as a minimum conducting a risk assessment using the RiO risk assessment tool, recording risk information, formulation of the risk identified, setting up a crisis/care plan and sharing risk information where indicated.

The process of this is outlined below:

Identify client;

Gather information;

Initial meeting;

Establish rapport;

Set interview structure;

Collaboratively assess risk;

Consult others where indicated;

Formulate risks;

Develop a risk management plan/care plan/crisis plan;

Record;

Appropriate sharing of information;

Review and reassess as required.

5.7 Service and team responsibilities

5.7.1 Risk assessment should be appropriately detailed and documented depending on the clinical presentation of the service user.

5.7.2 If the service user is being referred on to a community mental health team, this should be identified. A case formulation of risk should be documented in the notes with an interim management plan.

5.7.3 For other teams, when a more detailed assessment is indicated, this may include identifying someone to seek further information and a more thorough review of the notes. This may lead to a referral to other services, e.g. personality disorder services or forensic services. Specialist teams may choose to use more specific assessment tools, for example: Beck’s Depression Inventory, Beck’s Suicidal Intent Scale or the HCR-20 (Historical Clinical Risk Assessment).

5.8 MDT members

5.8.1 All members of the multidisciplinary team (including Doctors, Nurses, Allied Health Professionals and Social Workers) are responsible for considering risk assessment and management as a vital part of their practice and to adequately record those considerations and outcomes.

5.8.2 It is the responsibility of all team members to consult with the most senior clinician involved in a service user’s care regarding concerns about risks.



These concerns and their communication should be documented in the service user’s RiO record or clinical notes.

5.9 Care Co-ordinators

Care coordinators are responsible for coordinating the risk assessment and management process for those in their care.

5.10 Consultant Psychiatrists

Consultant Psychiatrists are responsible for ensuring risk assessment is conducted for all patients under their care.

5.11 Clinical supervision – role of line managers

A line manager as part of their management responsibilities must carry out supervision as outlined in policy C16 – Clinical Supervision for Nurses and policy S26 – Supervision policy; this includes a review of clinical competency in relation to the assessment and management of risk.

5.12 All WLMHT staff

All WLMHT staff (both clinical and non-clinical) have a responsibility to act on information they receive regarding risk and to liaise with the relevant mental health practitioner to reduce the risk of harm occurring.

6. The assessment of risk

6.1 “Best practice in risk assessment and management involves making decisions based on knowledge of the research evidence, knowledge of the individual service user and their social context, knowledge of the service user’s own experience, and clinical judgement” (BPMR 2007 p.5.)

6.2 The cornerstone of good risk assessment and management is the completion, recording and appropriate sharing of a comprehensive clinical assessment which any multidisciplinary team should be able to undertake.

6.3.1 The Department of Health (DH) guide Best Practice in Managing Risk identifies a risk factor as:

“A personal characteristic or circumstance that is linked to a negative event, and that either causes or facilitates the event to occur” (P.13).

6.3.2 Risk factors can help us to predict what types of risks are potentially present and may be categorised as follows:

Static factors: these are factors that are known to be correlated with increased risk which do not change. These include historical indicators, for example a history of suicide attempts, violence or childhood abuse.

These factors will always be present although their relevance will vary across individuals and over time.



Dynamic factors: factors which change over time, for example the misuse of alcohol or drugs. These factors may be aspects of the individual or of their environment and social context or indeed all of these. Examples of these are: current mental state, substance misuse, financial status, and social deprivation. These factors may change over time and are therefore more amenable to management. Dynamic factors may change slowly (stable factors) or rapidly (acute factors), the impact of these factors on the level of risk may be short-lived or longer-term (BPMR 2007).

Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. (NICE 2011).

6.4 Types of risk assessment

The Best Practice in Managing Risk (2007) guide identifies three types of risk assessment and management.

Unstructured clinical approach: this type of approach would take the form of an unstructured conversation, it is not systematic and therefore less reliable; this method is not recommended.

Actuarial approach: this approach focuses on static factors known to be associated with increased risk. For example, people who have self-harmed in the past are at a statistically higher risk of suicide. Actuarial risk assessment (applying a mathematical model to known risk factors) is of value in placing people in risk categories for the likelihood of an adverse event happening. They do not however predict that the event will or will not occur in an individual case.

Structured clinical: this approach combines the use of a structured method of assessing risk with the use of actuarial information to assess clearly defined risk factors, risk triggers and ameliorants of risk and makes use of:

Clinical experience and knowledge of the client;

The service user’s view;

Takes into account views of carers and other professionals.

The structured clinical approach is the approach which WLMHT Trust staff should use.

7. Gathering information

7.1 The key to effective risk assessment is obtaining information via interview and collateral history from various sources. Interview with the service user is the basis of an initial risk assessment, however this is seldom sufficient and in all cases where possible, risk related information must be collected from informants, e.g. referral source, GP, community



team, family, social or criminal justice services. Careful attention to these sources of information will help reveal any past history of risk (for example, self-harm, harm from others, self-neglect, and/or violence, plus its pattern, frequency, severity and how recently it occurred).

7.2 A clear record must be made of the sources of information on which any risk assessment is based. Past records both from within and outside of WLMHT must always be sought in the preparation of an initial risk assessment. Historical information must always be taken into account when assessing risk. Prior interventions that proved effective will also help inform the risk management plan.

8. When to assess risk

8.1 Mandatory Risk Assessment

An initial risk assessment must be completed at the point of entry to the care team. The completion of a risk assessment will inform the care management plan and identify recovery indicators that are relevant to the individual. The RiO risk assessment is in place in Local and Forensic services and must be completed on admission and updated if indicated at each MDT ward review (or sooner following a change in risk status, for example, post incident).

8.1.2 Within Forensic and High Secure Services initial risk assessment will be undertaken prior to admission and a pre-admission risk assessment completed. This will help to determine levels of risk posed and allow the clinical team to prepare a treatment plan that will meet the needs of the patient on admission.

8.1.3 Risk must be assessed or reviewed at certain key points in a service user’s care pathway. Points at which risk must be assessed or reviewed are:

At first presentation to a Trust service or following re-presentation to services;

At the point of assessment which can often be pre-admission;

On admission to an inpatient service (within 72 hours);

When granting leave or discharging from a section;

At community follow up within 7 days of discharge from inpatient care, recognising the key findings that the first two weeks are a high risk time (The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness July 2014)

Assessment of risk before deciding about moving a client to or from CPA (Department of Health, 2008);

Prior to (and during) CPA review and when not managed under CPA as frequently as clinically required.

Prior to an individual moving from one service to another or prior to discharge from a ward or from Trust services;



The detaining doctors/AMHP (Approved Mental Health Professional) must undertake an assessment of risk at the point of detaining a patient under the Mental Health Act, granting leave or discharging from a section.

8.1.4 Other points at which risk should be reviewed include:

Routine assessments;

Following an incident;

During discharge planning;

At known times of stress such as anniversaries of bereavement;

When new information is received significantly changing the individual’s risk status;

Once early relapse signs are identified or following a significant deterioration in an individual’s mental state;

Prior to any reduction in risk management interventions (terminating seclusion or being granted leave);

When a longstanding relationship with a clinician is coming to an end;

Loss or change in social support

At the point of initiation of or change to treatment.

8.2 First assessment

8.2.1 At first contact, the assessment should always include a proper evaluation of risk, including the risk of harm to self or others. In mental health the following areas should be considered:

Degree of engagement

Risk factors: mental state examination, substance use, environment, lack of social support, physical health problems and compliance with treatment and monitoring etc.

History;

Ideation/mental state;

Intent;

Planning

Actual incidents with dates, causes, ameliorants/protective factors and consequences;

Service user’s awareness of risk

Benefit and harm of risk

Protective factors and strengths

Formulation.

8.2.2 Where the assessment covers more than mental health, e.g. learning disability, other risks will need to be assessed. Examples of other risks may include risks due to physical health, or environmental and social risk, vulnerability from others.



8.3 Routine management of severe mental disorder

8.3.1 At care reviews for service users suffering from severe mental disorder, an assessment of risk should be repeated and the risk management plan updated. The degree of detail should be commensurate with the clinician’s judgement of the severity of the disorder, and will be related to whether or not the client is supported by CPA.

8.3.2 In addition, there will usually be previous notes which will provide a more comprehensive picture of the history. It will also be important to consult with other professionals and carers involved in the service user’s care. Careful attention to these sources of information will help reveal any past history of self-harm, harm from others, self-neglect, and/or violence, plus its pattern, frequency, severity and how recently it occurred.

8.3.3 Where a worker is concerned about the service user’s risk to self or other, it is their responsibility to discuss this with their line manager, clinical supervisor (where appropriate) and multi-disciplinary team.

8.4 Care Programme Approach (CPA) and risk 8.4.1 The national confidential inquiry into suicide and homicide (Avoidable

Deaths: five year report into suicide and homicide by people with mental illness, University of Manchester, 2006) states that services can improve clinical risk management by:

“aligning CPA and risk management more closely, ensuring comprehensive assessment of risk at CPA review” and by “jointly reviewing the management of the most high risk patients with other clinical teams” “careful and effective care planning is needed on discharge, including for patients who discharge themselves”. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness July 2014

8.4.2 Clinical risk assessment and management should also form part of the

care for service users not subject to CPA (Department of Health, 2008). Clinical risk assessment is an integral part of deciding if a client needs the support of CPA (Department of Health, 2008). Service users should be supported by CPA if they are at higher risk (Department of Health, 2008).

8.5 Following an incident

Staff should report the incident, update the risk assessment/management plans (if indicated) and make an entry in the clinical notes. For further guidance members of staff should refer to the Trust’s Incident management and reporting policy (I8), Violence reduction and management policy (V2), Carer’s strategy, Safeguarding Children policy C18, safeguarding adult’s policy S28, and local procedures.



9. Essential components of clinical risk assessment and management

Essential components of clinical risk assessment and management include engagement, good history- taking, and formulation of risk.

9.1 Risk formulation

9.1.1 Risk formulation is an explanation of how risks arise for a particular service user in the context of conditions that are assumed to be risk factors for a hazardous outcome that is to be prevented (Department of Health, 2007a). The risk formulation should account for both protective factors and risk factors (Department of Health, 2007a). Essentially a risk formulation is a summary of all of the risk and protective factors identified, coupled with the professionals’, patient’s and carers’ impression of what that means and what can be done to minimise risk. Describing the risks and explaining their context in the formulation is a vital step in coming to a decision about the level of risk.

Formulation should try to answer:

How serious is the risk?

Is the risk specific or general?

How immediate is the risk?

How likely is the risk?

What specific treatment or management plan might reduce the risk?

What is the possible impact of the risk to self or others

In devising the risk formulation, the clinician should:

Summarise dynamic and static risk factors, and protective factors;

Try to give an idea of how much impact individual risk factors have and what the current event is that has increased risk now ;

Discuss the summary of risk with the patient and get his/her views to incorporate in the formulation;

Together, look at what outcome the patient would like and what can be done to modify individual risk factors to minimise (not eliminate) risk;

Incorporate contingency planning and include how the patient can seek help if things change in the formulation;

Note down names and roles of all people involved in the discussion about risk management in the formulation.

9.2 The role of the care (safety) plan in risk management 9.2.1 Fundamental to risk management is engagement with clients and a focus

on finding out what they would want to prioritise in terms of making their mental health stable and ensuring a meaningful valued life.

9.2.2 All care plans relating to risk should be considered as safety plans, be

drawn up in collaboration with the client and where possible take into



account the views of carers. Safety plans represent a shift in thinking about incorporating risk management in to the care planning process.

9.2.3 The emphasis of the care plan should be to engage the service user and where possible carers and others in considering how best to plan to maximise safety. This could relate to any risk domain e.g. how best for the service user to minimise the risk of violence to others which maintains both their safety and the safety of others,

The care (safety) plan should:

Outline risk areas identified e.g. risk of self-harm and suicide, risk to others and risk from others

Indicate the likelihood and severity of risk;

Identify any potential harm/benefits from risk;

Identify trigger factors and ameliorants;

Outline a risk management plan.

9.2.4 The following components of care, although not exhaustive, should be considered:

Treatment including:

Treatment of mental illness ;

Treatment of substance misuse;

Treatment of personality disorder;

Treatment of cognitive impairment;

Treatment of physical health conditions. Every service user should be monitored for cardiovascular risk, as recommended by NICE guidelines. Front line clinical staff should be familiar with assessing cardiovascular risk, and be suitably trained to advise on influencing modifiable cardiovascular risk factors.

Social situation, including interventions to support:

Housing;

Financial safety;

Meaningful structured day (training, employment, recreation, etc);

Improving access to meaningful activities;

Improving social skills.

9.2.5 The plan should be constructed and agreed with the service user and carers. It may reflect what they feel would be most effective in reducing the risk, particularly in respect of crisis and contingency plans. It is also helpful to be clear with the service user as to what are the identified antecedents or causal links to their risky behaviour (as far as possible) so everyone can be aware of the potential consequences. Some service users may not wish to participate in this process and the plan may represent more of a service response; this should be recorded in the management plan. It is also important to note any differing views about the plan, should any be present. As a minimum, all service users should know who to contact in a crisis. Copies of the plan should be given to service users and carers as per the Trust CPA policy.



9.2.6 If an intervention is indicated to reduce risk (e.g. increased medication, access to psychological therapies, monitoring by staff, access to supported housing) and is not available, this should be clearly recorded in the management plan and/or fed back to the service manager. A realistic management plan within the resources available still needs to be made, recognising that treatment options may be limited. This should be fed back to the client.

9.3 Crisis planning 9.3.1 The crisis and contingency plan should also be completed as soon as is

practicable. The crisis plan alongside the care plan should be constructed in collaboration with the service user and carers.. Doing this can help the clinician, carers and service user to better understand the risks, help to form a supportive relationship and identify and agree on actions to take to maintain safety in a crisis.

The crisis plan should contain:

Information on what might precipitate a crisis and what to do to deal with this;

Relapse indicators/warning signs: these should be identified in conjunction with the service user. There are many types depending on the risk, including increasing insomnia, agitation, stress, lack of self care, thoughts of death, hopelessness or worthlessness; feelings of desperation or of being trapped and withdrawal from usual activities, thoughts to harm others, paranoia or command hallucinations;

Contingency Arrangements: Actions to be taken in the event of noticing the warning signs. These can be diverse but examples include: going to stay with a friend, seeing a health professional, reviewing medication, phoning the Samaritans or if in a severe crisis attending the accident and emergency department.

As a minimum, the crisis plan and contingency plan should contain:

The names, roles and responsibilities of the care team and their contact details

Who the person has trust in and will be most responsive to

How to make contact with that person

Previous coping strategies that the person has found to be helpful and supportive in similar situations.

The emergency out of hours telephone number to ring should an emergency or crisis arise.

Contingency plans are directed at helping an individual stay in control of his/her decision making to keep him / herself well and to help prevent a crisis. They must include instructions that are based on the person’s own identified needs and unique early warning signs of becoming unwell. This may include what to do in the event of choosing to stop medication or other treatment regimes, including no longer attending scheduled appointments. The plan should ideally be seen as a dynamic agreement between the person and his/her care team and must be updated as indicated by the changing personal circumstances affecting the individual’s wellbeing.



9.4 Decision-making 9.4.1 Any risk-related decision is likely to be the best decision that can be

made at the time and will be acceptable if:

it conforms with legislation;

it conforms with relevant guidelines;

it is based on the best information available;

it is documented;

the relevant people are informed.

9.4.2 The rationale for any decisions must be recorded and this record must note

The persons /agencies involved in the decision-making process;

The recognition of the risks identified;

Action taken to reduce the risk;

The contingency plan in place to support the individual.

9.4.3 This information must be clearly documented and shared with the relevant individuals.

10. Recording risk information 10.1 An initial risk assessment must be completed at the first clinical contact

with a service user. This should either be documented on RiO or local risk assessment documents. The crisis and contingency plan should be completed as per the notes above and care (safety) plans should be entered into the care planning section in RiO.

The RiO risk assessment consists of the following areas:

Harm to self;

Harm from others;

Harm to others;

Accidents;

Other risk behaviours;

Factors affecting risk;

Summary.

10.2 For each of the areas the appropriate tick boxes must be completed alongside a narrative summary for the reason and context of the identified risk.

Rather than simply leaving areas of the assessment blank it is necessary to state:

‘not established’ and indicate the actions required to source further information to better inform the risk assessment for example, contact the care co-coordinator in the morning, speak to the probation officer.



10.3 The summary box at the bottom of the RiO risk assessment

documentation is a good place to record your risk formulation. 10.4 In Broadmoor Hospital in addition to the CPA risk assessment

documents (form 4a) and six core nursing care plans, the HCR-20 v3 and high risk register assessments and care plans must be completed for each patient. This information should be recorded in RiO and reviewed within clinical team meetings weekly and during six monthly CPA meetings. On admission to high security it is essential that all domains of risk are considered. Care plans must be in place in advance of admission to high security and supported by a narrative summary.

10.5 Risk information must be recorded on RiO by the relevant member of staff as soon as a risk is identified, in the relevant RiO section/s (e.g. progress notes; RiO risk summary; RiO risk alerts; specialist risk assessment tools).

11. Risk assessment tools 11.1 Training is required to use some supplementary risk assessment tools,

and in these cases the Trust expects members of staff to have undertaken this training before use. In forensic and high secure services the main supplementary risk tool used is the HCR-20. This tool must be completed for all service users in Broadmoor and in men and women’s medium and low secure, WEMSS, and community forensic services. The tool may be used in other settings but its use is not mandatory. Before using HCR-20 staff must access the Trust training as described in the mandatory training policy.

11.2 For other risk tools, the risk assessor is responsible for documenting

what tools have been used and why. The additional assessment should be either uploaded onto RiO, or stored electronically in the patient’s file. The title of any uploaded clinical risk assessment documents should include the name of the clinical risk assessment tool used, the date and the document type marked “RISK”.

12. Communicating an opinion of risk 12.1 An opinion of risk, whether based on a contemporary risk assessment or

not, must be communicated to everyone who needs to be aware of it or act upon it. Issues of confidentiality and information sharing must be considered but may be overridden in order to prevent serious harm. Whilst such decisions are usually made by senior clinicians, any employee of WLMHT who genuinely believes that disclosure of information will prevent serious harm and is unable to get a timely opinion from a senior, must act to minimise the risk of harm. Please see the Trust Information Governance Policy (I5) for further guidance.



13. Safeguarding children 13.1 It is a requirement of the safeguarding children policy (C18) that adult

services, including mental health services, know whether their service users have children or are in contact with children (CPA briefing 2008).

13.2 In situations where children are at risk, it is staff’s “paramount duty to

put the welfare of children first” (Children Act, 1989, amended 2004). 13.3 Staff working with adults as well as children should routinely ask patients

in contact with our services about children they have contact with and pay regard to the impact of parental mental health and the needs of children as part of their assessment and ongoing work with service users. This information must be recorded in RiO and within Broadmoor Hospital requires that the risk to children form is completed by the Responsible Clinician and Social Worker.

14. Training 14.1 Clinical Risk Assessment training requirements for staff are described in

the Mandatory Training Policy (M12). Staff should refer to this to ascertain their training requirements.

14.2 In addition, clinical risk assessments, formulation and clinical risk

management plans in the care plans should always be discussed with the clinical supervisors and where additional training needs are identified, support for this implemented in annual PDR.

15. Fraud statement N/A

16. References

Department of Health, 2011. No health without mental health: a cross-government mental health outcomes strategy for people of all ages. Department of Health: London

Department of Health, 2010. See, Think, Act; your guide to relational security. Department of Health: London - referenced from 2.1

Department of Health, 2008. Refocusing the care programme approach: Policy and positive practice guidance. Department of Health: London.

Department of Health, 2007a. Best Practice in Managing Risk. Department of Health: London.

Department of Health, 2007b. Independence, choice and risk: a guide to best practice in supported decision making. Department of Health: London.



Department of Health, 2006. Dual diagnosis in mental health inpatient and day hospital settings. Guidance on the assessment and management of patients in mental health and day hospital settings who have mental ill-health and substance use problems. Department of Health: London.

Department of Health, 2002. Mental health policy implementation guide: Dual diagnosis good practice guide. Department of Health: London.

Department of Health, 1999, amended 2001. The Mental Health Policy Implementation Guide. Department of Health: London.

Department of Health, 1999. Effective Care Co-ordination in Mental Health Services. Department of Health: London.

Department of Health, 1999, amended 2007. National service framework for mental health: modern standards and service models. Department of Health: London.

Mersey Care NHS Trust, 2006. Proposal for a unified system of clinical clinical risk assessment for Ashworth Hospital. Mersey Care NHS Trust: Liverpool

Morgan, S. 2000. Clinical Risk Management: A Clinical Tool and Practitioner Manual. The Sainsbury Centre for Mental Health

NHS National Patient Safety Agency, 2007. Healthcare clinical risk assessment made easy. Department of Health: London.

National Institute for Clinical Excellence, 2011 –Self harm: longer term management. National Institute for Health and Clinical Excellence. - added in as referenced in 3.1.3

National Institute for Clinical Excellence, 2005. Violence. The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. National Institute for Health and Clinical Excellence: London.

National Institute for Clinical Excellence, 2004. Self-harm. The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. National Institute for Health and Clinical Excellence: London.

National Institute for Clinical Excellence ,2011 Psychosis with coexisting substance misuse: assessment and management in adults and young people

Rethink and Turning Point, 2004. Dual diagnosis toolkit: Mental health and substance misuse. A practical guide for professionals and practitioners. Rethink and Turning Point: London.

Turning Point, 2007. Dual diagnosis good practice handbook: Helping practitioners to plan, organise, and deliver services for people with co-existing mental health and substance use needs. Turning Point: London.



The University of Manchester, 2006: Avoidable Deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness. The University of Manchester: Manchester. The University of Manchester, 2014: Annual report of the national confidential inquiry into suicide and homicide by people with mental illness. The University of Manchester: Manchester. The University of Manchester, July 2015, National Confidential Inquiry into suicide and homicide by people with mental illness. The University of Manchester May 2016 National Confidential Inquiry into suicide and homicide by people with mental illness: Suicide by children and young people in England.

17. Supporting documents C2: Care Programme Approach

C16: Clinical Supervision for Nurses

C18: Safeguarding Children

I5: Information Governance Policy

I8: Incident Reporting

M8 Representation on Multi-Agency Public Protection Panels.

M12 Mandatory Training Policy

O1: Enhanced Engagement and Observation Policy

P1: Missing Persons and Patients Absent Without Leave (AWOL) Policy

R1: Risk Management Strategy and Policy

S26 Supervision Policy

S28: Safeguarding Adults Policy and Reporting Procedure Policy

V2: Violence Reduction and Management Policy

18. Glossary of terms / acronyms

CPA - Care Programme Approach;

CSU - Clinical Service Unit;

MDT - Multi-disciplinary team;

PDR - Personal Development Review;

SMT - Senior Management Team;

WEMSS - Women’s Enhanced Medium Secure Services;

WLMHT - West London Mental Health Trust.

BPMR - Board Performance Monitoring Report

DOH - Department of Health

NICE - The National Institute for Health and Clinical Excellence

NHS – National Health Service

19. Appendices Appendix 1 – Baseline Risk Assessment

Appendix 2 – RiO Risk assessment update



Appendix 1 – Baseline Risk Assessment

FIRST ASSESSMENT: RiO Pathway

Clinical task RiO page RiO task action

1

Before appointment

Schedule appointment

Check service user’s demographic details

HCP Diary

Case Record

Schedule appointment by RiO number or name

Select link to service user’s record

Click on link to ‘client demographics’

Confirm correct details

2

Before appointment

Review existing risk information

Case Record

Confirm ‘latest risk information’ has ‘none recorded’

Click on ‘progress notes’ to review any previous documentation

Click on ‘clinical documentation’ to review any previous documentation

BASELINE RISK ASSESSMENT




3

Conduct Interview and Risk Assessment

Make a progress note entry

- State site of meeting, those at meeting, and reason for meeting

- Make at least a statement about risk in all cases - Include statement of risk to children - State client +/- carer view - State actions to be carried out pertaining to risk ie

risk management plan - Direct reader to risk assessment, crisis and

contingency plan, +/- care plan - State date of next contact

Case Record

Progress Notes

Click on link to progress notes

Click on ‘Add note’

Enter note with recommended minimum content and essential information (see left)

Select date of assessment NOT date of entry

Validate (check box)

Select ‘add to risk history’ and ‘this is a significant’ event if there is a significant risk.

Click on ‘Save Changes’.

RiO will now prompt to outcome the appointment

Click yes to go to unoutcomed appointments list

4

Outcome appointment Unoutcomed Appointments

Select appointment by clicking on it

Proceed to Appointment Outcome

Click Outcome icon, fill information required, save

Select link (name) to case record




5

Complete Clustering Assessment and Allocation

Case Record

Clustering Assessment

HoNoSCA

Clustering Allocation

Click on link to ‘Outcome Measures’

Select relevant link according to care group

Click ‘create new’

Complete and Click on ‘save’

Return to ‘Outcome Measures’

Select ‘Clustering Allocation’


Complete and click on ‘save’


6

Complete Risk Assessment Form

- Fill out ALL domains of harm to self, harm to others, accidents, other risk behaviours, factors affecting risk and summary

- Identify sources and dates of information - Identify areas of uncertainty and gaps in

information rather than leaving anything blank - Direct reader to crisis and contingency plan,

progress note with risk management plan, +/- care plan (if client on enhanced CPA)

Case Record

Risk Assessment

Click on link to ‘Risk information’

Select ‘Risk Assessment’


Complete with recommended minimum content and essential information (see left)



7




Complete Safeguarding Children Form

- ‘Safeguarding Children – Adult Client – Form 1’ should be completed for ALL adults, even if there is no regular contact with children

- ‘Safeguarding Children – Adult Client – Form 2’ and ‘Safeguarding Children – Child – Form’ are to be completed if indicated

Case Record

Safeguarding Children


Select relevant ‘Safeguarding Children’ link




8

Complete Crisis, Relapse and Contingency Plan

Case Record

Crisis, Relapse and Contingency Plan

Click on link to ‘Care Planning, CPA and reviews’

Select ‘Crisis, Relapse and Contingency Planning’ link

Click ‘add’



V1. 0 September 2011



Appendix 2 – RIO risk assessment update: (Risk update as part of CPA and care planning)


1

Before meeting

Schedule CPA in RiO (Should be done at previous review)

TO BE DONE BY THE PERSON COORDINATING CARE BEFORE THE REVIEW

HCP Diary

Case Record

HCP Diary or select ‘Care Planning, CPA and Reviews’ from Case Record

Select ‘CPA Review’

Select ‘Schedule CPA Review’



2

Before meeting

Record new Clustering Assessment/HoNOSCA/HoNOS Secure score


Case Record

Clustering assessment

HoNoSCA

HoNOS Secure

Click on link to ‘Outcome Measures’

Select ‘Clustering Assessment’ or HoNOS according to care group

Click ‘create new’ – NOT EDIT CURRENT






3

Before meeting

Update existing risk information

Include any risk to children

- Update ALL domains of harm to self, harm to others, accidents, other risk behaviours, factors affecting risk and summary

- Identify sources and dates of information - Identify areas of uncertainty and gaps in

information rather than leaving anything blank - Direct reader to crisis and contingency plan, and

care plan


Case Record

Risk Assessment


Select ‘Risk Assessment’

If previous risk assessment exists, select ‘edit current’ – DO NOT SELECT CREATE NEW

Update with recommended minimum content and essential information (see left)

Click on ‘save’ when completed


4

Before meeting

Consider Safeguarding Adults and Children

Case Record

Safeguarding Children


Select relevant ‘Safeguarding Children’ link

If previous form filled out, click ‘edit current’.

Update relevant form with latest details and click on ‘save’




- ‘Safeguarding Children – Adult Client – Form 1’ should be completed for ALL adults, even if there is no regular contact with children

- ‘Safeguarding Children – Adult Client – Form 2’ and ‘Safeguarding Children – Child – Form’ are to be completed if indicated


If no previous form, click ‘create new’



5

Before and At Meeting

Update Care Plan relevant to risk in collaboration with the service user / carer

- ‘Problem/Need’ types regarding risk include ‘Bullying’, ‘Physical Abuse’, ‘Risk from Others’, ‘Risk to Others’, ‘Risk to Self’, ‘Sexual Abuse’, ‘Sexual offences’

- The client’s view should ideally be documented as a quoted first person statement

TO BE DONE BY THE PERSON COORDINATING CARE FROM THE REVIEW FORWARD

Case Record

Care Plan


Select ‘Care Planning’

Review and select ‘New Problem/Need’ and enter

Or select ‘Update Problem/Need’ and modify

For all ‘Problem/Needs’ relevant to risk, enter ‘Interventions/Actions and Frequency’

For all ‘Problem/Needs’ relevant to risk, enter ‘Anticipated Outcome and Clients View’





6

At the Meeting

Update the Crisis, Relapse and Contingency Plan risk in collaboration with the service user / carer


Case Record

Relapse Crisis and Contingency Plan


Select ‘Crisis, Relapse and Contingency Planning’ link

Click ‘add’



7

At the Meeting

Complete the CPA Management and Review Forms

- CPA ‘REVIEW DETAILS’: The client and carer views are to be recorded in ‘Client View’ and ‘Carer View’ respectively. Ideally these should be documented as quoted first person statements

- CPA ‘GENERAL DETAILS’: Remember to link to latest HoNOS and validate the review before clicking ‘Save’


Case Record

CPA Management

CPA Reviews

Do not make a Progress Note entry relating to the CPA Review

Click on ‘CPA management’ and edit all fields as necessary

Click on ‘CPA Reviews’

Click on green button to outcome scheduled CPA

Enter CPA ‘Review Details’ in free text boxes (see note on left)

Complete CPA ‘General Details’ (see note on left)

Click on ‘save’





8

At the Meeting

Print Clare Plan. Invite the Service User to agree and sign their Care Plan. Give this to them ensuring that they understand its importance.


Case Record

CPA Review


Select ‘Care Planning’

Select ‘Printable Care Plan’ and print updated Care Plan – this will include service user/carer views and crisis and contingency plan

Ask service user to sign

Make a copy of the signed Care Plan and store in paper record folder

Save a copy of the Care Plan on your computer


9

After the Meeting (Within 24hrs)

Upload a copy of the Care Plan into RiO


Case Record

Clinical Documentation

Select ‘Clinical Documentation’ then ‘Document Upload’

Browse to find the saved Care Plan

Upload as ‘Document Type’ Care Plan, Title ‘Care Plan (Date)’





10

After the Meeting (Within 24hrs)

Distribute Care Plan to relevant people / services


Case Record

Clinical Documentation

THEN

Care Plan Distribution

Select ‘Care Plan Distribution’

Create new form

Indicate date that all copies of the care plan were given/sent out

Indicate date signed by service user or why not given

Mark as complete and save


policy: c27 clinical risk policy - west london nhs …...west london nhs trust page 6 of 33 guidance...

Documents