Assessment and Management of Ligature Care Policy

Transcription

1 SH CP 150 Assessment and Management of Ligature Care Policy Summary: This policy sets out the Trust s approach to ensuring that ligature points are identified, assessed for level of risk and managed. This policy is supported by the Assessment and Management of Ligature Points Procedure and Standard Operating Procedure: The Use of Ligature Cutters in Mental Health and Learning Disabilities. Keywords (minimum of 5): (To assist policy search engine) Target Audience: Ligature, ligatures, ligature policy, ligature point, ligature points, suicide, ligature procedure, attempted suicide, selfharm, hanging. All staff who work in mental health and learning disability divisions. Next Review Date: February 2019 Approved and Ratified by: Patient Safety Group Date of meeting: 26 October 2017 Date issued: Author: Sponsor: Darren Hedges, Health and Safety Manager, Karen Thomas Ligature Project Manager, Nicola Bennett ADoN Rachel Coltart, Quality, Performance and Business Manager for Specialised Services Mark Morgan, Director of Operations Mental Health, Learning Disabilities 1

2 Version Control Change Record Date Author Version Page Reason for Change December 2013 November 2014 April 2015 June 2015 David White N/A An updated ligature point risk assessment scoring system is being adopted. Tim Coupland Pg 8 Updated to include addition of a clear requirement section to review ligature assessments after an incident 5.6 involving a serious incident involving a ligature. David White and 2 Policy review Rachel Coltart Rachel Coltart/Louise Hartland 2 Page 11 section 14.2 Page 13 Appendix 1 Updated to include Ligature Care training requirement for all clinical staff working in MH/LD in-patient units. Updated to reflect TNA for Ligature Care training. August 2015 Rachel Coltart Title Change of title. August 2015 Rachel Coltart Throughout Reference made to Standard Operating Procedure: The Use of Ligature Cutters within Mental Health and Learning Disabilities Assessment and Management of Ligature Care Policy. August 2015 Rachel Coltart Page 11 Ligature Care Assessment added. April 2016 October 2017 January 2018 Darren Hedges Karen Thomas Nicola Bennett Rachel Coltart Darren Hedges Karen Thomas Nicola Bennett Rachel Coltart Andrew Mosley Ben Lihou Helen Bonds Ivor Watson Kim Pullen Louise Salmon Marie Corner Nick Sargeant Sharon Craddock 3 Policy review 4 Policy review 5 Throughout Policy Review and minor updates as agreed at Ligature Management Group 23 rd January 2018 Name Position Version Reviewed and Date Nicky Bennett Associate Director of Nursing/ AHPs and V3, April 2016 Clinical Operational Manager Paul Johnson Head of Estate Services Karl Allen Senior Capital Programme Manager Shelagh Kent Capital Programme Manager Sharon Craddock Modern Matron Joe Jackson Out of Area Bed Manager Aimee Musgrave Practice Development Nurse Darren Hedges Health and Safety Manager Rachel Coltart Quality, Performance and Business Manager for Specialised Services Liz James Head of Nursing - Southampton Area Karen Thomas Ligature Project Manager Yvette Barrington Compliance and Contract Development Lead/PA Will Smith Associate Director of Nursing (Adult Mental Health) - Interim Kathy Jackson Head of Nursing - Inpatients John Stagg Associate Director of Nursing (Learning Disabilities) Marie Corner Capital Programme Manager 28/07/17 2

3 Name Position Version Reviewed and Date Andrew Mosley Associate Director of Estate Services Version Ben Lihou Matron (MHS East Area Business Unit Rep) Helen Bonds PA to John Stagg Ivor Watson Senior Capital Manager Kim Pullen Senior Health, Safety and Security Manager Louise Salmon Ward Manager (MHS West Area Business Unit Rep) Marie Corner Capital Programme Manager Nick Sargeant Acute Care Pathway Manager (AMH North) Sharon Craddock Modern Matron 3

4 CONTENTS 1 1. Introduction Scope Definitions Duties/ Responsibilities Ligature Assessment Adding and Removing Risks Outside of the Formal Review Process Development Projects, New Build or Refurbishments Determining the Risk Score for Each Ligature Point Acceptable Risk Scoring Threshold Options for the Management of Identified Ligature Points Evidence/ Audit Trail Risk Register Entries Financial Impact and Resource Implications Training Requirements Monitoring Compliance Policy Review Supported Policies / Procedures Associated Documents Supporting References Appendices A1 Environmental Care Plan A2 Ligature Information for Induction A3 LEaD (Leadership, Education and Development) Training Needs Analysis A4 Equality Impact Analysis Screening Tool

5 Assessment and Management of Ligature Care Policy This Policy is supported by the Assessment and Management of Ligature Points Procedure and Standard Operating Procedure: The Use of Ligature Cutters in Mental Health and Learning Disabilities 1. Introduction 1.1 Hanging is the most common method of suicide for mental health service users, whether they are in in-patient units or in the community. Hanging may involve strangulation or asphyxiation caused by suspending the body from a high ligature point, or by using a ligature point below head height. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2014) found that hanging remains the commonest method of suicide in both the general and patient populations. Figures show that deaths by hanging continue to rise. 1.2 A significant proportion of suicides are believed to occur through impulsive acts, using what may be seen as reasonably obvious ligature points. The National Suicide Prevention Strategy for England (2002) states that the likely ligature points in mental health services environments should be removed or covered up. 1.3 The Care Quality Commission (CQC) publication Essential Standards of Quality and Safety (March, 2010) refers to ligature points in outcome 10P: Safety and suitability of premises in the statement People who use services are protected from harm because fixtures, fittings and furniture are designed with regard to the avoidance of ligature points. The CQC explicitly states that the guidance contained within Essential Standards of Quality and Safety (March, 2010) (Outcome 10) referring to the management of ligature points applies to: Hospital services for people with mental health needs, and/or learning disabilities, and/or problems with substance misuse. Child and adolescent mental health services (CAMHS) (tiers 2, 3 and 4) Community-based services for people with mental health needs, including community mental health teams, assertive outreach, early intervention teams and crisis resolution home treatment teams 1.4 Southern Health NHS Foundation Trust acknowledges its responsibilities to identify all likely ligature points where service users access a service within the Trust. This policy sets out the Trust s approach to ensuring that ligature points are identified, assessed for level of risk and managed. It describes: Why action is required What action is required Who is responsible for taking action Where the process must be applied When (how often) the process must be applied The Health and Safety at Work etc. Act Section 2(1) and 3 states that employers have a duty to ensure, so far as is reasonably practicable that those not employed, but who may be affected by their work, are not exposed to Health and Safety risks. Whilst the importance of robust individual Clinical Risk Assessment, Observation and Workplace Risk Assessment processes for service users cannot be over-emphasised, this document also focuses on environmental issues. If these are managed optimally, will provide as safe an environment as is reasonably practicable for all service users in relation to the risk ligature from a fixed point. 5

6 1.5 Southern Health NHS Foundation Trust s ligature assessment tool has been developed to help staff to address the risk of ligature from a fixed point in a balanced, objective and systematic way. The process for completing and recording of the assessment and subsequent management controls (the how) is described in a separate document: Assessment and Management of Ligature Point s Procedure. This procedure must be read in conjunction with this policy. 1.6 Southern Health NHS Foundation Trust has also developed a standardised ligature care pack for all in-patient settings and community care teams. Guidance and training for this is provided under the Use of Ligature Cutters Procedure. This procedure must also be read in conjunction with this policy. 1.7 For directions regarding action to be taken by staff first on the scene of a self-strangulation, refer to the Standard Operating Procedure: The Use of Ligature Cutters in Mental Health and Learning Disabilities. 2. Scope 2.1 This policy applies to all staff within Mental Health and Learning Disabilities who are required to work in an environment where a ligature risk assessment is needed. NB: guidance to determine which service is required to complete a ligature point assessment can be found at Outcome 10P of The Care Quality Commission (CQC) publication Essential Standards of Quality and Safety March This policy should be seen as an integral part of other measures to reduce the risk of harm. Clinical Risk Assessment, Observation and Workplace Risk Assessment, CPA, and observation and engagement form part of the overall strategy for managing these risks. 2.3 The requirement of this policy is to conduct a risk assessment that must apply to all care settings as defined in section 10P of the Care Quality Commission (CQC) publication Essential Standards of Quality and Safety March Risk assessments must be completed on every room / area where a service user can be left unattended or is unobserved by staff. 2.5 Risk assessments must be carried out on all areas within inpatient units irrespective of whether service users have access or not. Where there is a no patient access area, this will be recorded as such on the ligature risk assessment, with information about the locking mechanism of the door. 3. Definitions 3.1 Ligature points can be defined as: Any fixed point which a ligature can be tied to, wedged around or behind or held in place by any means which enables the ligature to bear the weight, wholly or partially, of a person (CQC, 2015). Any item which can be used to make a loop or noose could be attached to a ligature point enabling a person to limit the supply of oxygen to an individual by hanging or asphyxiation. 3.2 Anti-ligature fittings: An anti-ligature fitting is any fitting that is designed in such a way as to seriously impede the tying of or prevent a ligature being attached to it or is designed to break away. 6

7 4. Duties/ Responsibilities 4.1 The Chief Executive Has overall responsibility for ensuring people who use our services are protected from harm because fixtures, fittings and furniture as far as reasonably practicable are designed with regard to the avoidance of ligature points within SHFT. Must ensure that the Trust complies with the Health and Safety at Work etc. Act. Must be aware of and comply with legal duties e.g. The Care Quality Commission (CQC) publication Essential standards of quality and safety (March 2010) to identify, assess and manage risks presented by ligature points in the workplace. 4.2 Trust Board Is responsible for ensuring the strategic context of this policy is appropriate and meets the needs of the Trust. Ensures there are clear lines of accountability between ligature assessors, risk management, quality and governance, health and safety and senior management. Ensure adequate additional funding is available as required for local management of ligature points. Ensure compliance with relevant legislation that pertains to the management of ligature risks within the care environment. 4.3 Director of Operations (Mental Health, Learning Disabilities and Social Care) Will be the lead Executive and has delegated responsibility for the management of ligature points and reports directly to the Chief Executive. Report directly to the Chief Executive if they have any concerns regarding the implementation of this policy. Has overall responsibility for the strategic and operational management of the ligature assessment process, but will delegate the daily management of ligature points to Clinical Ward Managers/Modern Matrons/Acute Care Pathway Leads. Assess the impact of plans/policies on ligature points and make recommendations for change. 4.4 Divisional Director Will oversee that ligature risk assessments are completed annually as a minimum. If new risks are identified or removed, the assessment should be updated. It must clearly show what management controls have been implemented to manage any identified and residual risks. There are clearly defined processes for decision making and escalation routes where disagreements arise relating to decisions regarding acceptability of identified ligature points. There is an agreed process within the Division for proposing a risk be added to the Divisional risk register. 7

8 Identified risks that require a solution, which cannot be promptly resolved within Divisional funding streams are recorded in the Divisional risk register or Trust risk register as appropriate. During the process, the clinical team have responsibility of managing the risks appropriately e.g. increased observation levels, environmental checks etc. Risks identified as requiring capital investment to resolve/reduce must have a Business Case CP1 capital bid submitted to the Capital Box for consideration and prioritisation in line with the Trust s Capital assurance process. Or an application made to the Ligature management group for funding from its funding allocation Records/ audit trails of all risk assessments and associated action plans are maintained. Appropriate governance arrangements are in place within the Division to monitor the completion of the risk assessments within agreed time frames and ensure that action plans are produced and implemented. 4.5 Associate Director of Estate Services To provide estate support for the delivery of the annual ligature risk assessment programme. Provide technical estate advice and guidance regards to appropriate and compliant ligature management products. Support the Estates Clinical Lead and Ligature Manager in providing Estate resource to audit ligature risk assessments relating to the building infrastructure. To provide capital management project support to deliver agreed ligature management projects. To act as one of the chairs of the Ligature Management Group. 4.6 Clinical Ward Managers/Modern Matrons/Acute Care Pathway Leads/Community Team Leaders To act as the clinical ligature lead for the clinical area they have responsibility for, or nominate a deputy that is a band 6 clinician or above. Ensure time is allocated to staff to undertake the assessment with the Estates Clinical Lead and Ligature Manager and a member of Estate Services. Ensure risk assessments are completed within the specified frequency. Ensure completed risk assessments are escalated through the ward and divisional management structures and appropriate management controls are implemented to manage identified risks. Ensure that all staff are aware of stated control measures. Ensure action plans are followed to conclusion and feedback where there are delays. Once work is complete, ward managers to sign it off and inform the Estates Clinical Lead and Ligature Manager. 8

9 Ensure that all new and agency staff receive an induction informing them of the ligature risk assessment and how to access it via SharePoint or where it is located on the ward, management of ligature risks and actions to be taken on finding someone that has ligatured (as per the mandatory training). This should be included in the area s induction pack. Ensure all staff undertake mandatory e-learning training on Ligature Care. Ensure suitable and sufficient training provisions are provided to all ward staff regarding the use of ligature cutters. Deliver regular scenario training to maintain confidence and competence in active ligature management. 4.7 Ligature Clinical Leads This will be the clinical manager or a designated deputy of Band 6 or above. To lead and be accountable for the management of ligature issues within their clinical area. To participate in the ligature risk assessment accurately in line with the policy and procedure. To provide support and guidance on the recommended actions to reduce/remove/manage risk to the appropriate Clinical Ward Manager/Modern Matron/Acute Care Pathway Leads/Community Team Leaders and the Estate Services. To ensure the ligature risk assessment has been agreed, is up to date, current and correctly documented, a local record kept and a central copy uploaded to Sharepoint, informing the Estates Clinical Lead and Ligature Manager. 4.8 Ligature Management Group To be chaired jointly by an Associate Director of Nursing and the Associate Director of Estate Services. To audit the results of the annual ligature risk assessments process. To monitor training compliance levels. To be responsible for capital allocation in relation to ligature management, apply for, monitor and approve expenditure for schemes. To provide quarterly ligature management assurance reports to the Patient Safety Group. To monitor the management of Trust wide ligature risks. To provide oversight and scrutiny for the management of ligature process and procedures across the Trust. To provide a forum for the discussion and management of ligature issues, Trust wide. To provide continuity of management in a consistent manner across the Trust. 9

10 To approve standardisation, regarding fixtures and fittings for use in applicable areas. To review and reflect on incidents and near misses to promote Trust wide learning by supporting the clinical investigations or SIRI processes to enable teams to share and disseminate the learning within services. 4.9 All staff within Mental Health and Learning Disabilities All staff members have a duty to safeguard their own health, safety and welfare and to that of colleagues and service users. This is achieved by having a working knowledge of the content of this policy and associated procedures. To complete mandatory e-learning training on Ligature Care. The Mental Health Act states that the nurse-in-charge of any shift is responsible for the care and protection of service users and staff and the maintenance of a safe environment. Remain vigilant in relation to ligature risks and reporting, or taking action if appropriate, in relation to any ligature or anchor point risk identified in the service users environment. Reporting all incidents or near misses involving ligatures or ligature points on the incident reporting Ulysses, immediately, irrespective of whether injury was sustained. Staff must be familiar with the location of the ligature cutter pack and how to access and use each item in it. All staff will receive training on how to use the different types of ligature cutters. All staff will ensure that all ligature cutters are kept in the ligature cutter pouch in the designated area. They are not to be carried around the ward by staff for example, attached to a clipboard or observation board. 5. Ligature Assessment 5.1 The Trust has a duty of care to ensure that environments are safe and be able to demonstrate that it has identified, assessed and managed the risks to service users so far as is reasonably practicable. 5.2 Regulation 3(1) (b) of the Management of Health and Safety at Work Regulations requires that every employer shall make a suitable and sufficient assessment of the risks to the health and safety as per policy SH HS The Department of Health has categorised Inpatient suicide using non-collapsible rails as a never event. Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. If any noncollapsible rails/runners remain in place within any Trust premises, they should be removed immediately following the ligature risk assessment. 5.4 Ligature assessments will be carried out annually or more frequently if significant changes occur, such as: The introduction/discovery of additional ligature points. Significant changes to the people using our services. Incident reporting data highlights increased risk in an area/building. 10

11 A serious incident involving a ligature (SIRI) -when this occurs there a clear requirement to review an existing ligature assessment for the area in which the incident took place. Any capital/ minor work completed on the infrastructure of the building/site/ward After any vandalism or destruction of the infrastructure of the building/site/ward 6. Adding and Removing Risks Outside of the Formal Review Process 6.1 If a new risk is identified or a risk is to be removed from the Ligature Point Risk Assessment, the following steps must be applied: 6.2 The clinical lead for the service will notify, by , the following people; The Estates Clinical Lead and Ligature Manager The Chairs of the Ligature Management Group The identified single point of contact for the service The Associate Director of Nursing The Associate Director of Operations 6.3 The Estates Clinical Lead and Ligature Manager will update the Ligature Risk Assessment. 6.4 Ensure that any new risk is communicated using the appropriate heading in the assessment tool. 6.5 Ensure that any new risk and mitigation is communicated to the relevant teams. 6.6 Ensure that any risks removed have been communicated to the relevant teams. 7. Development Projects, New Build or Refurbishments 7.1 At the early stages of project planning it is important that consultation includes clinical staff, Estate Services, members of the Corporate Health and Safety team, the Estates Clinical Lead and Ligature Manager and Infection Prevention and Control staff in order to ensure a detailed risk assessment of the environment. This should include consideration of the potential to create new ligature points which could lead to service user harm. 7.2 The assessment should consider such items and areas as building layout, building fabric, choice of furnishings, fixtures and fittings, equipment, hardware and ironmongery. 7.3 The assessment should also include a consideration of the potential for creation of ligature anchor points by service users themselves. 7.4 On refurbishment projects the opportunity should be taken to assess the whole of the existing environment to ensure that new risks are not introduced by those planned changes and that identified risks can be reduced or eliminated as part of the project. 8. Determining the Risk Score for Each Ligature Point 8.1 A ligature point in one care setting will not present the same level of risk as in another. The factors which combine to determine the degree of risk presented by a ligature point are: The service being provided. The type/function of the room. Height of the ligature point. Whether an anti-ligature item has been fitted. 11

12 Level of observation. 8.2 To determine the total risk score presented by a specific ligature point, it is necessary to apply a score to each issue and a rag rating, the score being higher or lower dependent on whether the issue increases or reduces the risk. 8.3 It is important to note that even if/ when the best available anti ligature product has been fitted, a ligature risk may still remain this is particularly true of doors and windows, as any window or door that opens and closes will offer the potential to trap or hold a ligature in place. 8.4 Operational mitigation must be included within ligature assessments where residual risks remain. 9. Acceptable Risk Scoring Threshold 9.1 Risk Assessment Guidance Tool: Likelihood Impact Extremely unlikely 1 Unlikely 2 Possible 3 Likely 4 Almost Certain 5 Negligible Low Moderate Major Catastrophic Risk Rating: Green Very Low Yellow Low Amber Moderate Red High There are a number of factors that should be considered when using the risk assessment guidance tool. For example, the kitchen tap was identified as a ligature point in a room that was fully supervised or locked when not supervised. The impact would be catastrophic but the likelihood would be extremely unlikely. This would give you a RAG rating of 5 Low. As the controls are already in place, the residue risk would remain the same. Controls for Managing Identified Risk: The list below provides risk management approaches (or risk controls) that can be applied to reduce risk (this is not an exhaustive list). Individual care planning Clinical risk assessment and management including care planning Increased observation and engagement levels Control of individual service user access e.g. to identified rooms such as kitchen Building management controls 12

13 Locking areas with potential risks or increased risk out of hours Fixtures with low weight bearing potential e.g. curtain and shower rails Emergency lock over-rides Outward opening doors Secure fitting of covers Window restraints Staff awareness Staff awareness of ligature points and patients at greater risk of suicide Resuscitation training and equipment Location, use and awareness of ligature equipment Managerial Controls Immediate removal of obvious risks Relational security In areas where patients have no access, the mitigation should be that the area is locked off, wherever possible with self-locking closures. 10. Options for the Management of Identified Ligature Points 10.1 Dependent on the nature of the ligature point and its location, a range of management options exist. These will be selected by the risk assessor and subject to approval via an agreed line management structure. Accept the risk as sufficient management controls are in place Remove the risk (if the item can be total removed example rail or door) Remove and replace (remove the risk item and replace with an agreed anti-ligature solution example: Tap) Protect the risk example: box in pipe work Operational Management (implement operational management controls example additional observation or positive risk management technics) 11. Evidence/ Audit Trail 11.1 All completed assessment forms, action plans and communications including requests for Estate Services and or clinical management actions must be retained for not less than five calendar years from the date of assessment. 12. Risk Register Entries 12.1 Risks can be added to the Divisional risk register following discussion at Service boards and with the agreement from the Divisional Director The risk register has been programmed to produce a range of reports relating to ligature risks, including: By Division / Locality / Service etc, by type of ligature point, by cost to remove or to introduce adequate control measures. 13. Financial Impact and Resource Implications 13.1 Where capital funding is required to address identified risks, Divisions must submit a Business Case to capital@southernhealth.nhs.uk Incomplete bids will be returned and may delay any capital investment. 13

14 13.3 Once the allocation is approved at Quarterly Prioritisation panel these funds will be available to the LMG to prioritise and agree works to be carried out, should a point be reached where there is insufficient funding available a new bid to the QPP via capital operating group will be required Agreed schemes will be allocated a capital project manager who will work with clinical teams to deliver the agreed scheme Senior Capital Manager to provide update reports to the Ligature management group on the status of ligature projects. 14. Training Requirements 14.1 All clinical staff who work in Mental Health and Learning Disability in-patient units and community based settings which service users access outpatient facilities are required to complete Ligature Care Training. All staff that are required to complete training are identified on the Training Needs Analysis (Appendix 1) All Estate trade staff must be aware of the ligature reduction design guide. All supervisors must ensure staff have a suitable and sufficient knowledge of ligature management prior to undertaking work in applicable areas 15. Monitoring Compliance 15.1 The Ligature Management group will provide oversight and scrutiny of all ligature assessments The Ligature management group will provide quarterly reports into agreed Trust forums 16. Policy Review 16.1 This policy will be reviewed by the Ligature Management Group annually or earlier if required to meet national guidance. 17. Supported Policies / Procedures SH CP 151 Assessment and Management of Ligature Points Procedure Standard Operating Procedure: The Use of Ligature Cutters in Mental Health and Learning Disabilities SH CP 37 Observation and Engagement Policy SH CP 27 The Assessment and Management of Clinical Risk Policy SH CP 145 Care of a Patient after their Death Policy SH CP 146 Care of a Patient after their Death Procedure SH NCP 25 Risk Management Strategy and Policy SH HS 4 Health and Safety Policy SH HS 15 Risk Assessment 18. Associated Documents DH Estates Alert DH (2006) 05 Shower head risk of use as a ligature point July 2006 DH Estates Alert DH (2007) 08 Cubicle curtain track rails (anti ligature) June

15 DH Estates Alert DH EFA/2010/002 Access hatches March 2010 DH Estates Alert DH EFA/2010/003 Anti-ligature curtain rails (including shower curtains) - Risk from incorrect installation or modification March 2010 DH Estates Alert DH EFA/2010/007 Window blinds with looped cords or chains, all types - July 2010 NHS Estates Alert HN (98) 04 Curtain tracks as points of ligature August 1998 NHS Estates Alert SN (01) 01 Cubicle rail suspension system with load release support systems January 2002 NHS Estates Alert (2004) 03 G-Rail 2301 Window curtain tracking system March 2004 NHS Estates Alert (2004) 05 Suspended ceilings as ligature points March 2004 NHS Estates Alert (2004) 08 Cubicle rail tracking and PVC dustcovers August 2004 NHS Estates Alert (2004) 10 Bed cubicle rails, shower curtain rails and curtain rails in psychiatric inpatient settings November Supporting References Appleby L, Shaw J, Kapur N, et al (2006) Avoidable Deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness. Manchester: University of Manchester Care Quality Commission (2009) Essential standards of quality and safety Care Quality Commission (2015) CQC Brief guide: Ligature points. Department of Health (2002) National suicide prevention strategy for England The Health and Safety at Work Act 1974 The Management of Health and Safety at Work Regulations 1999 The Office for National Statistics (2015) Suicides in the United Kingdom, 2013 Registrations. London: The Office for National Statistics The University of Manchester (2014) The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report. Manchester: University of Manchester 15

16 Appendix 1 A1 Environmental Care Plan IDENTIFIED NEED: Risk Relating to the Environment You have been admitted to XXXXX Ward. It is recognised that all environments have risks and we wish to work with you to keep you safe whilst you are on the ward. We have considered all of these environmental aspects with you and have agreed the areas in which we may need to support you whilst being cared for on this ward. The environment could increase the risk of ligature/ self-harm, absconsion or falls (this list is not exhaustive) If there are concerns relating to SERVICE USER s level of risk to him/ herself or others, staff should; Goals Complete an individualised self-harm/ ligature/absconsion/ falls care plan as required Consider increasing his/ her observation levels Consider moving him/ her to a bed space closer to the nursing office or a ligature reduced room, where there may be less risks Anticipated Outcomes: To maintain SERVICE USER s safety and the safety of others at all times For SERVICE USER to maintain an understanding of his/ her risk factors For staff to promote health, well-being, independence and recovery in a therapeutic environment Interventions Nursing Interventions: For SERVICE USER to be nursed on the Ward on a level of observation which is appropriate to his/ her perceived risk at the time. This is to be continually reviewed by nursing staff and increased / decreased where appropriate For staff to manage any risk behaviours in accordance with Trust Policies 16

17 Appendix 2 A2 Ligature Information for Induction Southern Health NHS Foundation Trust is committed to providing safe and therapeutic environments for service users. The Trust has a robust system of ligature risk assessment, recording, review and environmental management. In order to care for the service users and maintain a safe, therapeutic environment, there are care plans related to the environment and the risk of ligatures. There are also overarching care plans for every service user but those who are at greater risk of ligaturing will have a specific risk care plan in order to guide and support care in this area. All staff should ensure that they know where the ligature cutter pack is and how to use each of the cutters. All staff should also be aware of the known environmental ligature risks and how to access and view the ligature risk assessment for your area. Staff should also familiarise themselves with all service users risks and care plans. These can be found at the following link: px Staff member knows where the ligature cutter pack is kept Staff member has been shown how to use each ligature cutter Staff member has viewed the ligature risk assessment for their clinical area Staff member is aware of the environmental and risk care plans and how to access them Staff member is aware of the risks of current service users in the clinical area Staff member has completed the ligature care e-assessment Signed by inductee. Date Signed by mentor/ supervisor Date 17

18 Appendix 3 A3 LEaD (Leadership, Education and Development) Training Needs Analysis Training Programme Ligature Care Frequency Course Length Delivery Method Facilitators E-assessment -3 yearly N/A Directorate Service Target Audience e-video and e- assessment N/A Recording Attendance LEaD Strategic and Operational Responsibility Strategic Head of Nursing, AHP and Quality for MH. Operational Modern Matrons/Ward Managers Adult Health Mental All nurses, support workers, support time and recovery workers, trainee practitioners, practitioners, occupational therapists and OT technicians who work within services both inpatient and community based. MH/LD Specialised Services All nurses, support workers, support time and recovery workers, trainee practitioners, practitioners, occupational therapists and OT technicians who work within services both inpatient and community based Learning Disabilities All nurses, support workers, support time and recovery workers, trainee practitioners, practitioners, occupational therapists and OT technicians who work within services both inpatient and community based ISD s Older Persons Mental Health All nurses, support workers, support time and recovery workers, trainee practitioners, practitioners, occupational therapists and OT technicians who work within services both inpatient and community based ISD s Adults N/A ISD s Childrens Services N/A Corporate All N/A 18

19 Appendix 4 A4 Equality Impact Analysis Screening Tool Southern Health NHS Foundation Trust: Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team Name of policy/service/project/plan: Assessment and Management of Ligature Points Policy Policy Number: SH CP 150 Department: Lead officer for assessment: Patient Safety Karen Thomas, Ligature Project Manager Date Assessment Carried Out: September Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes This policy sets out the Trust s approach to ensuring that ligature points are identified, assessed for level of risk and managed. There is a balance to be maintained between the interests of treatment, care, the security / safety of the environment, and the human rights of service users. On occasion these issues may be in conflict with each other. This policy will give guidance regarding resolution. To provide service users with an environment where care and treatment is given in a safe, secure and therapeutic way. To ensure all Trust personnel understand why and when ligatures should be removed from service users, the procedures to be 19

20 followed, justification needed and the legal basis/authority for undertaking this activity. To ensure that staff act in accordance with the Trust s procedures, and at all times act professionally, in good faith, and for the benefit of service users, visitors, staff and public, as far as possible. 2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions Data, research and information that you can refer to 2.1 What is the equalities profile of the team delivering the service/policy? The Equality and Diversity team will report on Workforce data on an annual basis. 2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment 2.3 What is the equalities profile of service users? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis 2.4 What other data do you have in terms of service users or staff? (e.g. results of customer satisfaction surveys, Equality Delivery System which will allow a robust 20

21 consultation findings). Are there any gaps? Dignity The implementation of this procedure should be undertaken whilst respecting the service users need to feel respected and involved in their care. Where possible any items removed should be replaced with ones that are safer. Discussions should take place where possible with staff of the same gender and with due respect to the service users ethnicity and spiritual needs. Where there is a potential for comprising a service user s ethnicity and spiritual needs / advice should be sought from the Equality and Diversity Lead and/or Spirituality and Chaplaincy Team Human Rights Act 1998 It is important to maintain an environment that respects the human rights of a service user to a private life and their right to enjoy their property whilst considering the measures required preventing incidents involving ligatures. examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership The Trust recognises that efforts should always be made to respect the privacy and physical integrity of service users whilst providing safe accommodation in accordance with Convention rights. It is recognised that some service users will require access to potential ligatures for the practice of their faith i.e. wearing of turbans, crosses and amulets etc. Wherever possible efforts should be made to allow them to wear these items. If risk assessment dictates otherwise, then discussion should take place with Spirituality team and Equality and Diversity Lead to ascertain the availability of alternatives or use of the items during specific time periods or activities (i.e. during pray time). All these considerations / discussions need to be clearly documented within the clinical records. The relevant Articles and Protocols here are: - Article 1 This protocol requires the Trust to appreciate that every person is entitled to the peaceful enjoyment of their possessions and no one shall be deprived of their possessions except in the public interest and subject to the conditions provided by law. Therefore, to remove an article belonging to a service user will interfere with the service user s rights protected under Article 8 (below). However, this interference e.g. removing a belt which may be used to inflict self-harm may be justified and legal if the legitimate aim of removing the belt is to protect another fundamental right, here Article 2 (Right to Life) below. 21

22 To ensure any removal of an article will not fall foul of human rights scrutiny it must be documented that by removing the article it is in pursuit of a legitimate aim, was not an arbitrary decision or measure but in the service user s best interests, proportionate to the aim and in accordance with Article 2. Article 2 Right to Life 1. Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law. 2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary: (a) in defence of any person from unlawful violence; (b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained; (c) in action lawfully taken for the purpose of quelling a riot or insurrection. Article 2 imposes a positive obligation on the Trust to protect life and here requires the Trust to take all reasonable measures to protect service users who are vulnerable to ligature abuse. However, this positive obligation to protect life must be balanced with the other Convention rights which aim to protect the quality of life of a service user. The relevant Articles are Article 3 which respects a service user s freedom from inhuman or degrading treatment and Article 8 which looks to respect the private life and personal autonomy of a service user. The European Court of Human Rights stressed in Keenan v UK, the protection of the Article 2 right to life must be conducted in a manner compatible with the other Convention rights of a person and in particular the principle of personal autonomy. Article 3 Prohibition of Torture No one shall be subjected to torture or to inhuman or degrading treatment or punishment. Article 8 Right to Respect for Private and Family Life 1. Everyone has the right to respect for his private and family life, his home and his correspondence. 2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others. 22

23 It is important that staff consider a service user s privacy and dignity at all times as per Articles 3 and 8 when conducting a search which results in property being removed or if the perceived risk of self-harm necessitates removal without a search being undertaken. Article 14 is particularly applicable in relation to personal searches and the removal of property as interference with a human right must not be arbitrary and have a clear rationale for being undertaken. Any removal of property should not be undertaken, based on an individual s gender, sexual orientation, race or class. The rationale should always be documented. By contrast, the rationale for searching and removing of property from an individual could be based on one of the basic human rights, including: Right to Life to protect the right to life of the individual service user and the right to life of others that may come into contact with them. Right to Liberty and Security service users must be kept safe, as far as possible, on Trust premises and yet should not be deprived of their liberty, unless it is lawful and justifiable to do so. 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations Staff N/A In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this: 23

24 Age Positive impact (including examples of what the policy/service has done to promote equality) Negative Impact No adverse impacts have been identified at this stage of screening Action Plan to address negative impact Actions to overcome problem/barrier Trust Ligature Management group will ensure all completed risk assessments are audited. Resources required Responsibility Target date Disability The Trust will respond positively to provide information in alternative formats. The Trust will use a variety of communication methods to ensure service users understand and are involved in decisions that affect them No adverse impacts have been identified at this stage of screening Root cause analysis will be undertaken on all serious incidents and any learning cascaded to senior staff. Trust Ligature Management group will ensure all completed risk assessments are audited. Root cause analysis will be undertaken on all serious incidents and any learning cascaded to senior staff. Gender Recent studies show The ligature 24

25 Reassignment Marriage and Civil Partnership Pregnancy and Maternity The following research will help increase understanding: Appleby, L. (1996) Suicide behaviour in childbearing women. International Review of Psychiatry, 8, that Transgender people have significantly higher than average rates of anxiety, depression, self-harm and suicidal behaviour, as well as higher problem drug and alcohol use: UK s first ever large scale nationwide health study of LGBT populations (MIND 2003). No adverse impacts have been identified at this stage of screening No adverse impacts have been identified at this stage of screening management group will have overall scrutiny of all risk assessments Root cause analysis will be undertaken on all serious incidents and any learning cascaded to senior staff. The ligature management group will have overall scrutiny of all risk assessments Root cause analysis will be undertaken on all serious incidents and any learning cascaded to senior staff. The ligature management group will have overall scrutiny of all risk assessments Root cause analysis will be undertaken on all serious incidents and any learning cascaded to 25

26 Race Religion Belief or Wieck, A., Kumar, R., Hirst, A. D., et al (1991) Increased sensitivity of dopamine receptors and recurrence of affective psychosis after childbirth. BMJ, 303, The Trust will respond positively to provide information in alternative formats. The Trust will use a variety of communication methods to ensure service users understand and are involved in decisions that affect them This EqIA discusses key Human Rights considerations in regard to service users that practice their faith; ie. wearing turbans, crosses etc A large body of research in the UK and internationally shows that there are marked differences in suicide rates between different ethnic groups living in the same country. Previous research in the UK, now over 10 years old, indicated differences in suicide risk in BME groups in the UK and a particularly high risk of suicide in young Asian women. senior staff. Root c The ligature management group will have overall scrutiny of all risk assessments and analysis will be undertaken on all serious incidents and any learning cascaded to senior staff. Trust Ligature management group will ensure all completed risk assessments are audited. Root cause analysis will be undertaken on all 26