Document level: Trustwide (TW) Code: GR15 Issue number: 4 Environmental clinical risk assessment policy Identification and assessment of ligature risks Lead executive Author and contact number Type of document Target audience Document purpose Document consultation AMH Wirral AMH West AMH East D&A services CAMHS LD services CCWC services Corporate services Staff side Other Groups / Committees Involvement taskforce Director of Operations Head of Capital and Property Management & Senior Health and Safety Advisor Policy All CWP staff To provide staff with a framework to identify likely ligature points Approving meeting Operational Board 15-Jan-14 Original issue date Apr-03 Implementation date Jan-14 Review date Jun-18 CWP documents to be read in conjunction with HR6 Mandatory Employee Learning (MEL) policy Training requirements Financial resource implications - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) Yes - Estates department require annual budget for ligature assessment works Equality Impact Assessment (EIA) Initial assessment Yes/ Comments Does this document affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Page 1 of 8
Initial assessment Yes/ Comments Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A Is the impact of the document likely to be negative? If so can the impact be avoided? N/A What alternatives are there to achieving the document without the impact? N/A Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? Low Document change history Changes made with rationale and impact on practice 1. Review of roles and responsibilities 2. Revised audit tool at Environmental Risk Assessment External references References 1. The National Suicide Prevention Strategy for England (DoH October 2002) 2. Preventing Suicide in England- A cross-government outcomes strategy to save lives(dh September 2012) Monitoring compliance with the processes outlined within this document Please state how this document will be Ligature Works update reports will be submitted to monitored. If the document is linked to the Committees and Sub Committees as per the NHSLA accreditation process, please complete business Cycles. the monitoring section below. Page 2 of 8
Content 1. Introduction... 4 1.1 Purpose... 4 2. Duties and responsibilities... 4 2.1 Chief Executive... 4 2.2 Director of Nursing, Therapies and Patient Partnership... 5 2.3 Service Directors and General Managers... 5 2.4 Estates Department... 5 2.5 Modern Matrons and Ward Managers... 5 2.6 Employees... 5 3. Approach to clinical risk assessment... 5 3.1 Environmental Risk Assessment Schedule... 5 3.2 Data collection and clinical risk assessment methodology... 6 3.3 Risk classification by room / area... 6 3.4 Basic risk scoring principles... 7 3.5 Mitigation Factors... 7 3.6 Consequential factors... 7 4. Review of clinical risk assessments... 7 Appendix 1 Environmental risk assessment... 8 Page 3 of 8
1. Introduction Cheshire and Wirral Partnership NHS Foundation Trust (CWP) is fully committed to developing, maintaining and promoting the highest standards of health and safety practice. CWP also acknowledges its obligations to comply with the statutory responsibilities laid down in the Health and Safety at Work etc. Act 1974 (HASAW) and other subsequent legislation relevant to the activities of our Trust and its employees. It is the duty of the Trust to ensure so far as is reasonably practicable, the health, safety and welfare of its employees, service users, contractors and members of the public. CWP acknowledges it has a responsibility to identify all likely ligature points in inpatient wards within the trust. Where ligature points are identified, CWP will develop suitable and sufficient measures to eliminate or minimise risks. Ligature points are risk assessed by a process involving the systematic examination of identified areas. Risk assessments are undertaken in partnership between Estate and Clinicians in order to provide a report that forms a basis for a structured, prioritised and costed rolling programme of building works and policy changes that can be implemented to significantly reduce incidents of self harm and ligature attempts. In summary, the roles and responsibilities of this partnership approach are as follows: Identification of potential ligature points via a visual inspection - Estates Confirmation of potential ligature point - Clinical Leads Risk Assessment of potential ligature point - Clinical Leads Identification of remedial actions (environmental) - Estates Identification of remedial actions (clinical and or operational) - Clinical Leads Cost preparation - Estates CWP recognises that: It has a responsibility to carry out risk assessments in accordance with the National Suicide Prevention Strategy for England (DoH October 2002) and Preventing Suicide in England- A cross-government outcomes strategy to save lives(dh September 2012); Death by hanging from a non collapsible rail in an inpatient setting is a never event (National Patient Safety Agency 2009). This policy should be implemented along side robust clinical management protocols as part of an overarching strategy for reducing the incidents of self harm and ligature attempts. 1.1 Purpose This policy intends to address the environmental risks present within inpatient ward areas that could assist in a self harm incident or ligature attempt. It includes guidance on the methods for assessing potential ligature points and recording the assessment. The aim of the policy is to ensure that the correct levels of clinical/operational management of ligatures are correctly maintained for the safety of service users and that the appropriate physical measures are prioritised and implemented accordingly. 2. Duties and responsibilities 2.1 Chief Executive As accountable officer, the Chief Executive must ensure that responsibility for identification and assessment of ligature risks, including safe systems with regard to use and competence in clinical risk assessment is delegated to an appropriate executive lead, as outlined in the executive portfolios. Page 4 of 8
2.2 Director of Nursing, Therapies and Patient Partnership Has delegated board level responsibility for ensuring systems are in place for identification and assessment of ligature risks. 2.3 Service Directors and General Managers Service Directors and General Managers are responsible for ensuring that: They bring the requirements of the policy to the attention of all their staff (including new and temporary staff) and ensure that it is observed at all times; Risk assessment procedures in relation to ligature points are operated throughout their service units; The resource implications of risk assessment recommendations are appropriately considered and remedial actions supported; Where emergency procedures are indicated by the risk assessment process, they are developed and resourced immediately. 2.4 Estates Department Estates Department have responsibility for the following: Undertaking initial visual inspections and data collection to identify potential ligature anchor point; Collation and preparation of final reports following completion of clinical risk assessments (by modern matrons and ward managers); Preparation of update reports on the remedial works programme relating to ligature management to relevant sub committees and groups; Ensuring new builds and refurbishments and other projects include assessment of potential ligature anchor points; Sourcing appropriate fixtures and fittings with consideration of technological advances and developments. 2.5 Modern Matrons and Ward Managers Modern Matrons and Ward Managers are responsible for: Undertaking the clinical risk assessments of potential ligature points identified by the estates data collection exercise. The assessment will identify all existing control measures and a risk score based on the basic principle scoring system- see below section 3; Assessments will be reviewed using appropriate documentation when there is reason to consider conditions have altered; tify Clinical Service Managers and General Managers of any clinical / operational controls that are required where a physical solution is not deemed appropriate or practical. 2.6 Employees Employees are responsible as individuals to: Be aware of the content of this policy; Identify or highlight any likely ligature points or concerns. Where they arise they must bring them to the attention of their manager; Report all incidents to their manager or person in charge and complete a Datix incident form. 3. Approach to clinical risk assessment 3.1 Environmental Risk Assessment Schedule CWP has formulated its own Environmental Risk Assessment Schedule (appendix 1). The scope of the environmental risk assessment schedule encompasses the following key areas: Access / Cross Corridor Doors; Ceiling Finishes; Windows; Sanitary ware & accessories; Page 5 of 8
Bedroom accommodation; Fixtures and fittings; Services; External areas. The risk assessment schedule provides a simple recommendations table listing the following items: Item: This relates to specific elements of the categories identified above. This takes a logical path through each room/ area and considers each element in detail. Criteria: A brief description of the required performance standard/ specification. Assessment: This questions whether the provision on site meets the relevant criteria. Yes - The provisions on site DO meet the relevant criteria. - The provisions on site DO NOT meet the relevant criteria. N/A - The item/criteria is either not present or not relevant. Existing Control Measure: Should the assessment identify that the provisions do not meet the relevant criteria; what procedures / policies (if any) are in place to assist in mitigating the potential risks of self harm or ligature attempts? Risk Assessment: An evaluation of the risk, based on the likelihood of an incident occurring and the resulting consequences. The assessment is based upon a generic 5x5 risk matrix. Recommendation: An explanation of the scope of the work needed to bring that particular element up to the required standard; so far as is reasonably practicable. Cost: Where appropriate, the provision of an approximate total cost of the work needed to improve/ remove or replace that particular feature will be given. 3.2 Data collection and clinical risk assessment methodology The initial visual inspection of the ward environment, in order to identify all potential ligature points, will be undertaken by the estates department. It is intended that an environmental risk assessment schedule will be completed for each room / space within inpatient ward areas. Upon completion of the initial data collection exercise it is the responsibility of the relevant Ward Manager (with support of Modern Matron as required) to identify existing controls measures and to complete the clinical risk assessment see appendix 1. To ensure that clinical risk assessments are broadly consistent for all inpatient ward areas, the risk assessment should consider the flowing: Risk classification of the room low, medium or high; Basic scoring methodology; Mitigation factors physical, clinical / operational; Consequential factors. 3.3 Risk classification by room / area Each room / area that has been surveyed must be assigned a risk classification of either low, medium or high in order to calculate the clinical risk in accordance with the basic scoring principles. The rationale for the risk classification is as follows: High Risk areas of the inpatient ward where a service user may spend extended periods of time with limited observation e.g. bedrooms, bathrooms, en suites etc. Page 6 of 8
Medium Risk areas of the inpatient ward that are generally not well occupied and are under moderate levels of observation e.g. quiet lounges, corridor areas leading to bedrooms etc Low Risk - areas of the inpatient ward that are fully occupied and are subject to almost constant staff observation e.g. day rooms, main corridors etc. 3.4 Basic risk scoring principles The scoring principles for the risk assessment have been established by a multidisciplinary group of clinicians, estates managers and health & safety. The group has established the following principles in terms of potential impact and likelihood: Impact All ligature points identified will score 5 (catastrophic). Likelihood All high risk areas e.g. bedrooms and en suites etc will score 3 (possible); All medium risk areas e.g. lounges will score 2 (unlikely); All low risk areas e.g. corridors will score 1 (rare). 3.5 Mitigation factors In addition to the basic agreed scoring principles, the clinical risk assessment exercise should consider what control measures are available that may affect the likelihood of the identified risk of occurring. What physical controls are present that could isolate or eliminate the potential ligature point? For example; controlled access to certain rooms, locking of windows / doors etc; What clinical / operational control measures are available to ensure that a service user does not have the opportunity to utilise the ligature point? For example; risk assessment, observation policy etc. 3.6 Consequential factors The clinical risk assessment must also consider the consequential factors of any proposed works to remove ligature risks. In some instances the removal of the ligature may cause greater risk / issues for service users; in terms of: Privacy and dignity; Manual handling; Slips, trips and falls; Disabled access. 4. Review of clinical risk assessments The risk assessment is a live document and will be reappraised on an annual basis and also when there is reason to believe that there are changes that may affect the original / current assessment. The reappraisal will consider the following: Has there been a change in the clinical patient group? Have any remedial works been carried out since the assessment? Have any incidents occurred that may affect the current risk score? Where it is identified that there are material changes to 1 of the above, it may be necessary to undertake a new inspection and risk assessment exercise. Page 7 of 8
Appendix 1 Environmental risk assessment ENVIRONMENTAL RISK ASSESSMENT Department/ Ward: Room Type: Room Identification: Assessor Name (Clinical): Assessor Name (Estates): Risk Level High Risk: Medium Risk: Low Risk: Assessment Survey Date: Review 1 Date: Review 2 Date: Review 3 Date: Risk Assessment Estates Review Recommendations Implemented Review 1 Review 2 Review 3 Ref. Item Criteria Yes N/A Existing Control Measures Impact Likelihood Score Status Recommendation Quantity Unit Rate Cost Yes Yes Yes Access/ Cross Corridor Doors MA001 Ironmongery Ironmongery to be anti-ligature specification Hinges Overhead Closer Ceiling Finishes Hinges to be anti-ligature specification e.g. continuous 'piano' hinge Overhead closers to be anti-ligature specification e.g. sliding track arm Ceiling Finishes Solid soffit ceiling types are preferable. Where fixed, suspended ceiling tiles are to be security specification e.g. clipped/locked. Windows Ironmongery Ironmongery to be anti-ligature specification Hinges/ Restrictors Blinds & Curtain Tracks Weather Sealant Strips Sanitaryware & Accessories Wash Hand Basin Bath Free of Ligature Points. Window to be restricted by no greater than 100mm. Tracks to be free of ligature points and/or collapsible under specific loadings Window seals to be either fixed in situ and/or cut into max. 100mm sections exposed pipework and bottle traps. Anti-ligature speciation taps. fixed plug and chainstay. exposed pipework and bottle traps. Anti-ligature speciation taps. fixed plug and chainstay. WC Anti-ligature specification flush control. Shower Anti Ligature specification shower head and controls Shower Curtain Rails Grab Rails Free of ligature points and/or collapsible under specific loadings Grab rails to be demountable or use of room controlled by risk assessment. Soap/ Gel Dispensers Dispensers to be free of ligature points. Sanitaryware & Accessories (Continued) Paper Roll Holders Hoists & Trackings Systems Bedroom Accommodation Bedside Rails Beds/ Bed-heads Bed-head lights Cubicle Tracking Systems Fixtures & Fittings Anti Ligature Specification. removable components e.g. springs. Hoist to be mobile type or use of room controlled by risk assessment. Grab rails to be demountable or use of room controlled by risk assessment. Free of ligature points where possible e.g built-in type and not 'Kings Fund' Lights to be flush fitting, kept to a minimum and fixed in inaccessible locations where possible Tracks to be free of ligature points and/or collapsible under specific loadings Coat Hooks Anti-ligature spec e.g. collapsible under specific loadings Mirrors Mirrors to be anti-break specification e.g. polished stainless steel Cabinet Ironmongery Ironmongery to be anti-ligature specification Cabinet Hinges Cabinet Rails Services Radiators Hinges to be anti-ligature specification e.g. continuous 'piano' hinge Rails to be free of ligature points and/or collapsible under specific loadings Low surface temperature specification or protected by radiator guards Pipework Pipework to be boxed in. Lighting Lighting to be anti-ligature specification Electrical Outlets Ventilation/ Extract Grilles Nurse Call Sounders & Receivers Fire Alarm Sounders & Detectors Outlets to be flush fitting, kept to a minimum and fixed in inaccessible locations where possible Grilles to be free of ligature points, flush fitting and fixed in inaccessible locations where possible Sounders and receivers to be flush fitting and fixed in inaccessible locations Sounders and detectors to be flush fitting and fixed in inaccessible locations Fire Alarm Call Points Manual call points to be protected by alarmed covers. External Areas Gutters & Downpipes Pipework to be boxed in. Exterior Ironmongery Ironmongery to be anti-ligature specification Exterior Hinges/ Restrictors Free of Ligature Points. Perimeter Fencing Fencing anti-climb specification Miscellaneous Page 8 of 8