APPROVAL OF MENTAL HEALTH CLINICAL RISK ASSESSMENT & MANAGEMENT POLICY

FOR DECISION AGENDA ITEM 7.2 June 19 th 2012 APPROVAL OF MENTAL HEALTH CLINICAL RISK ASSESSMENT & MANAGEMENT POLICY Report of Paper prepared by Executive Nurse Director Divisional Nurse Mental Heath Executive Summary This policy replaces the previous Cardiff and Vale NHS Trust document. It details the framework for the assessment and management of service user risk in Cardiff and Vale University Health Board (UHB). To deliver effective care, staff must be able to demonstrate sound judgement in clinical risk assessment and develop a risk management plan which is derived from that assessment. Risk areas to be considered include, suicide, self harm, violence and aggression, dangerousness, self neglect, physical and psychological abuse and falls. It should also be carefully considered whether a service user poses a risk to children with whom they may have contact, irrespective of whether they are the service user s children or those of a partner (National Patient Safety Agency (NPSA) 2009). Mental Health Clinical Risk Page 1 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION Action/Decision required Link to other Board Committee (s) and subcommittees Consultation Arrangements Equality Impact Assessment Resources Required to Implement Document Monitoring arrangements To approve the Mental Health Clinical Risk Assessment and Management Policy. Mental Health Quality and Safety Group April 2012 Consultation has been across the Mental Health Division and with service user and carer groups linked to mental health provision across Cardiff and the Vale of Glamorgan. The document has been posted on the intranet for comments which have been included where applicable. The EQIA has been undertaken following the update of an existing policy on clinical risk assessment and management within the mental health division. The Policy will therefore be applicable to all individuals receiving care and support from a secondary mental health team, including employees of the UHB working within the mental health division and may include members of the voluntary services sector and carers. The evidence gathered indicates a low impact rating. The policy directs mental health professionals in the undertaking of clinical risk assessments. The current risk assessment format is not in the medium of the Welsh Language, this may impact against legislation in relation to the provision of health care through the medium of Welsh. No resources required The prevalence of risk assessment and risk management tools will be identified via the monitoring of the CPA process. Mental Health Clinical Risk Page 2 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION Link to Standards for Health Services in Wales Link to Public Health Agenda Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework Link to relevant evidence base Standards1, 2, 3, (Safe & clinically effective care), 8 (care planning), 11 (safeguarding children and adults), 22 (Risk management). minimise the potential for: social vulnerabilities, harm to self (including deliberate self harm); suicide; harm to others (including violence); self neglect; neglect or abuse of children, neglect or abuse of adults for whom they provide care, adverse risks associated with the abuse of alcohol or substance, risk of becoming institutionalised. Linked to the Care Programme Approach and in future the Mental Health Measure (2010), and supports the Mental Health Act 1983/2010 Cardiff and Vale UHB Admission, Discharge and Transfer Procedure Cardiff and Vale UHB Level of Observation Procedure Cardiff and Vale UHB policies relating to the Mental Health Act 1983 Mental Capacity Act Cardiff and Vale UHB Child Protection Good Practice Guidelines All Wales Child Protection Procedures Cardiff and Vale UHB Guidelines on t Sharing of Information South Wales Guidance on the Protection of Vulnerable Adults Cardiff and Vale UHB Care Programme Approach Policy and Procedure Mental Health Clinical Risk Page 3 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION MENTAL HEALTH CLINICAL RISK ASSESSMENT AND MANAGEMENT POLICY INTRODUCTION The Committee is being asked to approve this updated policy which replaces the previous organisation s document. It supports professional and clinical standards and supports staff in their decision making regarding clinical risk. The Risk Assessment and Risk Management Policy details the principles and framework currently utilised in the Mental Health Division to identify risk areas and manage those risks effectively. The UHB is committed to ensuring that the mental health division has robust clinical risk assessment and risk management strategies in place that will reduce risk of harm to service users and others in contact with mental health services, whilst supporting recovery and ensuring the safety of patients, carers, staff and members of the public. SCOPE The scope of the mental health clinical risk assessment and management policy is primarily for use across the Division. However it may be helpful and advise other clinicians across the UHB when managing clinical risk in varying settings such as Primary Care and Community. AIM The aim of Mental Health Clinical Risk Assessment and Management Policy is to ensure that:- 1. A formal risk assessment of all service users in secondary mental health services is undertaken. Secondary mental health services are currently defined as community mental health teams, inpatient services, and specialist community teams such as low and medium secure community teams and specialist inpatient services such as medium and high secure inpatient and residential services (WAG 2010). 2. To highlight the importance of risk management plans which are aligned to the risk assessment. Mental Health Clinical Risk Page 4 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION 3. To highlight the requirement to reassess a service users risk status at regular intervals and as their presentation dictates. 4. To ensure that there is a clear understanding of individual professional responsibilities in relation to risk assessment and risk management. CONSULTATION ARRANGEMENTS Consultation has been across the Mental Health Division and with service user and carer groups linked to mental health provision across Cardiff and the Vale. The document has been posted on the intranet for comments which have been included where applicable. Postholders/ Groups/Organisations Consulted Date Consulted/ Rationale for not Consulting Executive Directors* Via intranet No Divisional Directors* Via intranet Yes Divisional Nurses* Via intranet Yes Divisional Managers* Via intranet Yes Staff Representatives* Via intranet No Appropriate Subject Committee/Group(s) (please specify) Relevant Professional Group(s) / Subject Specialist(s) (please specify) Service User Representatives/ Stakeholder Groups (please specify) 1. Quality and safety strategy & policy task and finish group 2. Mental health quality and safety committee 1. Mental health policy group 2. Adult and older peoples directorates meetings 3. Mental health professional Nursing advisory group. Sefyll service user representative group Comments Received: Y/N Yes Yes Yes Yes Yes Yes Mental Health Clinical Risk Page 5 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION The document was posted on the UHB Intranet Consultation page on 9 th November 2011 and comments were invited by 21st November. No other comments were received other than those above. EQUALITY IMPACT ASSESSMENT The EQIA has been undertaken following the update of an existing policy on clinical risk assessment and management within the mental health division. The Policy will therefore be applicable to all individuals receiving care and support from a secondary mental health team, including employees of the UHB working within the mental health division and may include members of the voluntary services sector and carers. The evidence gathered indicates a low impact rating. The Equality Manager has been consulted during this process IMPLEMENTATION The policy and procedure are currently in place. This document replaces the previous organisation s clinical risk assessment and management policy. RESOURCES Form 4 on the PARIS electronic system or the FACE risk profile documentation, is to be used as a baseline risk assessment tool. All service users in contact with secondary mental health services will have form 4 or risk profile completed. This is routine practice. Further in depth risk assessment tools may be used if the practitioner is suitably qualified to use such as HCR -20. Selected staff have been training to undertake these more detailed assessments. The Welsh Applied Risk Research Network (WARRN) Formulation tool may be used to aid risk management planning. Training of staff within the mental health division is in place. Risk management must be incorporated into the agreed care and treatment plan. Mental Health Clinical Risk Page 6 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION MONITORING AND REVIEW This is monitored by the current Care programme Approach performance indicators and in future will be monitored via the Mental Health Measure. PUBLICATION AND DISSEMINATION Publication within the UHB will be via the intranet and clinical portal. Documents are also routinely made available externally via the UHB internet site. This ensures that the UHB fulfils the requirements of its Publication Scheme under the Freedom of Information Act. External publication of the Mental Health Clinical Risk Assessment and Management Policy will not present such a risk. CONCLUSION The approval of the Mental Health Clinical Risk Assessment and Management Policy will ensure that robust clinical risk assessment and risk management strategies are in place that will reduce risk of harm to service users and others in contact with mental health services, whilst supporting recovery and ensuring the safety of patients, carers, staff and members of the public. RECOMMENDATION The Committee is asked to: APPROVE the policy Acronyms and abbreviations CPA Care Programme Approach UHB WARRN Welsh Risk Research Network SOURCES OF INFORMATION Morgan S. Clinical Risk Management, A clinical tool and practitioner manual, The Sainsbury Centre for Mental Health (2000) Mental Health Clinical Risk Page 7 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

FOR DECISION Department of Health Best Practice in Managing Risk (June 2007) Welsh Assembly Government - The Role of Community Mental Health Teams in Delivering Community Mental Health Services Interim Policy Guidance and Standards (July 2010) Welsh Assembly Government Delivering the Care Programme Approach in Wales Interim Policy Guidance (July 2010) Care Programme Approach Association The CPA and Care Standards Handbook (2008) Welsh Assembly Government Mental Health Policy Guidance, The Care Programme Approach for Mental Health Service Users (February 2003) Wales Applied Risk Research Network (WARRN) Asking difficult questions and formulating risk training course (2009) Mental Health Clinical Risk Page 8 of 8 UHB Quality and Safety Committee Assessment and Management Policy June 19 th 2012

Cardiff and Vale University Health Board MENTAL HEALTH CLINICAL RISK ASSESSMENT & MANAGEMENT POLICY Mental Health Division Reference No: Issued by Policy Manager Version No: 1 Previous Trust / LHB Ref No: Documents to read alongside this Policy, Procedure etc (delete as necessary) Cardiff and Vale UHB Admission, Discharge and Transfer Procedure Cardiff and Vale UHB Level of Observation Procedure Cardiff and Vale UHB policies relating to the Mental Health Act 1983 Mental Capacity Act Cardiff and Vale UHB Child Protection Good Practice Guidelines All Wales Child Protection Procedures Cardiff and Vale UHB Guidelines on the Sharing of Information South Wales Guidance on the Protection of Vulnerable Adults Cardiff and Vale UHB Care Programme Approach Policy and Procedure Classification of document: Area for Circulation: Author: Clinical University Health Board (UHB) Wide CPA Lead, Low Secure Community Nurse Manager, Senior Nurse Manager Crisis team services. Executive Lead: Group Consulted Via/ Committee: Approved By: Medical Director / Divisional Director Mental Health Quality and safety strategy & policy task and finish group, mental health quality and safety committee, mental health policy group, adult and older peoples directorates meetings, Sefyll service user representative group Quality and Safety Committee Date of approval: Date Published: Reference Number: Page 1 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board Date of Review: Reference Number: Page 2 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board Disclaimer When using this document please ensure that the version you are using is the most up to date either by checking on the UHB database for any new versions. If the review date has passed please contact the author. OUT OF DATE POLICY DOCUMENTS MUST NOT BE RELIED ON Reference Number: Page 3 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board Version Number Date of Review Approved Date Published Summary of Amendments 2 TBA TBA Replaces previous Trust policy Reference Number: Page 4 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board RISK ASSESSMENT & MANAGEMENT POLICY CONTENTS PAGE 1. Introduction 4 2. Policy Statement 5 3. Aims and Objectives 5 4. Responsibilities 6 5. Resources 8 6. Training 8 7. Procedure 9 8. Equality 10 9. Audit 10 10. Distribution 10 11. Review 10 12. References 11 Reference Number: Page 5 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board 1. INTRODUCTION Risk assessment is an essential and ongoing element of good mental health practice and a critical and integral component of all assessment, planning and review processes (DoH 2007). All service users assessed at any point in their contact with secondary mental health services must have a risk assessment completed (WAG 2010) This policy details the framework for the assessment and management of service user risk in Cardiff and Vale University Health Board (UHB). To deliver effective care staff must be able to demonstrate sound judgement in clinical risk assessment and develop a risk management plan which is derived from that assessment. Risk areas to be considered include, suicide, self harm, violence and aggression, dangerousness, self neglect, physical and psychological abuse and falls. It should also be carefully considered whether a service user poses a risk to children with whom they may have contact, irrespective of whether they are the service user s children or those of a partner (National Patient Safety Agency (NPSA) 2009). Clinical Risk Assessment must not be considered in isolation from other UHB mental health policies and procedures. This policy should therefore be read and acted upon in conjunction with: Cardiff and Vale UHB Admission, Discharge and Transfer Procedure Cardiff and Vale UHB Level of Observation Procedure Cardiff and Vale UHB policies relating to the Mental Health Act 1983 Mental Capacity Act Cardiff and Vale UHB Child Protection Good Practice Guidelines All Wales Child Protection Proceedures Cardiff and Vale UHB Guidelines on the Sharing of Information South Wales Guidance on the Protection of Vulnerable Adults Cardiff and Vale UHB Care Programme Approach Policy and Procedure There are many definitions of risk. For the purposes of this Policy risk is considered 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; with an additional range of other positive or negative service user experience). (Morgan,s. 2000) It should be acknowledged and emphasised that, while we focus on negative risks there is a need for practice positive risk taking and in doing so mental health staff Reference Number: Page 6 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board work collaboratively with service users, carers and other service providers, irrespective of whether they are statutory or non statutory providers. Modern risk assessment and management should be based on the principle that the assessment of risk is structured and informed by a holistic needs assessment, which is consistent to evidence base. Consistency in practice is essential for effective communication across services and agencies. The use of clinical risk assessment tools, specialist or generic, are an aid to the clinical decision making process and are not a substitute for it. The findings of tool based assessments must be combined and balanced with information on many other aspects of the person s life and current situation. (DoH 2007) 2. POLICY STATEMENT The UHB is committed to ensuring that the mental health division have robust clinical risk assessment and risk management strategies in place that will reduce risk of harm to service users and others in contact with mental health services, whilst supporting recovery and ensuring the safety of patients, carer s staff and members of the public. 3. AIMS AND OBJECTIVES The Risk Assessment and Risk Management Policy details the principles and framework currently utilised in the Mental Health Division to identify risk areas and manage those risks effectively. The objectives of the Policy and Procedure are: 1. To ensure that a formal risk assessment of all service users in secondary mental health services is undertaken. (Secondary mental health services are currently defined as community mental health teams, inpatient services, and specialist community teams such as low and medium secure community teams and specialist inpatient services such as medium and high secure inpatient and residential services (WAG 2010) 2. To highlight the importance of risk management plans which are aligned to the risk assessment. 3. To highlight the requirement to reassess a service users risk status at regular intervals and as their presentation dictates. 4. To ensure that there is a clear understanding of individual professional responsibilities in relation to risk assessment and risk management. Reference Number: Page 7 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board 4. RESPONSIBILITIES Cardiff and Vale UHB undertakes a responsibility to ensure that all mental health service users have an assessment and consideration regarding risks of suicide, self harm, dangerousness, self neglect, violence and aggression, abuse (both psychological and physical) and falls. The Mental Health (Wales) Measure 2010 does not prescribe a particular risk assessment process or tool LHBs and Local Authorities should ensure that in all cases risk assessments should seek to identify and minimise the potential for: social vulnerabilities harm to self (including deliberate self harm); suicide; harm to others (including violence); self neglect; neglect or abuse of children neglect or abuse of adults for whom they provide care adverse risks associated with the abuse of alcohol or substance. risk of becoming institutionalised In practice terms assessment of risk is an aid rather than a substitute for decision making about what outcomes need to be achieved, and assessments should be translated into a formulation of any risks, and subsequent management of those risks. All care and treatment planning processes should take into account risk management arrangements. All referrals / admissions should have a risk assessment following a holistic assessment of their needs (WAG) 2003). It is the responsibility of all members of a team delivering care to ensure that service users have a credible risk assessment and a subsequent risk management plan to ensure the effective delivery of safeguarding measures. Service users should initially be assessed regarding the appropriateness of having a more in depth risk assessment completed and management plan formulated which must be reviewed on a regular basis. Reference Number: Page 8 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board Risk is assessed by all workers, but formal risk assessment should only be carried out by someone with the appropriate training and experience, as agreed locally. (CPAA 2008) Risk assessments may be completed by all appropriately qualified clinicians who must ensure that any noted risks are communicated to all team members and clearly evidenced within the documentation. It is imperative that risk assessments and information regarding risk is shared amongst the MDT and where appropriate, other agencies such as child protection or public protection. It may also be necessary to share information about risk with other sectors including voluntary housing agencies. This may only be on a need to know basis. Staff must be aware of and consider the national and local sharing of information and confidentiality procedures when disclosing information. Agencies should have clear agreed policies on information sharing, which advise on the need to know. If someone other than the service user is at risk, advice must be sought from the police public protection team or multi agency public protection arrangements (MAPPA) so that an appropriate public protection plan can be activated. The rationale for any disclosure without consent, e.g. to prevent harm, should be clearly documented. (DoH 2008) The Responsible Clinician / Responsible Medical Officer will have overall clinical responsibility but the co-ordination of the assessment and management process will be the responsibility of the Care Programme Approach (CPA) Care Coordinator. Where conflicts arise between professional responsibilities, accountabilities and service user autonomy, individual professionals are still responsible for attempting to reduce risk to an acceptable level. This level should be agreed both with the service user and the multi disciplinary team. Risk assessment must take place at regular intervals (admission to hospital, admission to caseload, discharge from hospital or caseload, part of Section 117 meeting, at CPA review meetings, during care plan review and updates or at any change in circumstances which may increase or decrease risk status). Risk / potential risk to children must be considered in both the shortened and in depth risk assessment. Contact must be made with relevant disciplines involved with children if a risk / potential risk is perceived. 5. Positive Risk Management Positive risk management as part of a carefully constructed plan is a desirable competence for all mental health practitioners, and will make risk management more effective. Positive risk management can be developed by using a collaborative approach. (DoH 2007) Reference Number: Page 9 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board The key to effective risk management is a good relationship with the service user and all those involved in providing their care (DoH 2007) Positive risk management must include working with the service user to identify and develop plans and actions that support positive outcomes and priorities as stated by the person, and minimise the risk to the service user or others. There must be consideration of the views of carers and others when deciding a plan of action. The service user, carer and others who may be affected must all be fully informed of the decision, the reasons for it and the associated plans. All who are involved in the decision making of positive risk management must be aware of the potential benefits and the potential risks and the decision must weigh up the benefits and harm of choosing one action against another. Positive risk management means being aware that risk can never be completely eliminated, and aware that management plans inevitably have to include decisions that carry some risk. This should be explicit in the decision making process and should be discussed openly with the service user (DoH 2007) 6. RESOURCES Form 4 on the PARIS electronic system or the FACE risk profile documentation, is to be used as a baseline risk assessment tool. All service users in contact with secondary mental health services will have form 4 or risk profile completed. Further in depth risk assessment tools may be used if the practitioner is suitably qualified to use such as HCR -20. The Welsh Applied Risk Research Network (WARRN) Formulation tool may be used to aid risk management plan. Risk management must be incorporated into the agreed care and treatment plan. 7. TRAINING Cardiff and Vale UHB is committed to ensuring that the opportunity for staff to attend risk assessment training is made available. All staff involved in risk management should receive relevant training, which should be updated at least every three years. (DoH 2007) Training will be delivered as part of basic CPA sessions, the Wales Applied Risk Research Network course and more specific risk focused days. Reference Number: Page 10 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board A central record will be maintained of staff attending risk assessment training. The assessment of staff competency to undertake risk assessment is the responsibility of line managers through performance review. All staff members will be individually responsible for ensuring that they are applying up to date knowledge and skills in practice and must identify any training needs to line managers. 8. PROCEDURE All service users must be assessed for a significant risk of suicide, self harm, self neglect, abuse, violence, substance misuse, risk of absconding or falling A baseline risk assessment must be established following a holistic assessment of needs, `this will be either the form 4 on the PARIS electronic system or a FACE risk profile in paper format. An initial risk assessment must be completed within two weeks following a routine review / non urgent referral A risk assessment must be completed at the time of any urgent / emergency referrals or assessments A new risk assessment must be undertaken within seventy-two hours of inpatient admission If risks are identified there must be a formulated risk management plan with consideration to the use of more specialised tools The risk management plan must be embedded in the overarching care plan Risk assessment must be undertaken when there is any change in the venue of care including the voluntary sectors. All risks are to be identified in the care planning process and with the use of risk alerts Any risks identified must be communicated to the relevant team, staff must ensure acknowledgement and adherence to the consent to share information agreement Risk assessments and risk management plans (including risk alerts) must be reviewed by the care co-ordinator / primary nurse at each CPA review meeting. Reference Number: Page 11 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board 8. EQUALITY Identified risks must be documented in a descriptive manner containing as much information as possible Information to aid risk assessment must be gathered from a range of sources such as, service user, family, carers, historical, partner agencies, voluntary agencies. All service users within secondary mental health care will receive a risk assessment as a minimum on an annual basis. Cardiff and Vale UHB is committed to ensuring that, as far as is reasonably practicable, the way in which we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups. We have undertaken an Equality Impact Assessment and received feedback on this policy and the way it operates. We wanted to know of any possible or actual impact that this policy may have on any groups in respect of gender, race, disability, sexual orientation, Welsh language, religion or belief, transgender, age or other characteristics. The assessment found that there was little impact to the equality groups mentioned. Where appropriate we have taken the necessary actions required to minimise any stated impact to ensure that we meet our responsibilities under the equalities legislation 9. AUDIT The prevalence of risk assessment and risk management tools will be identified via the monitoring of the CPA process. 10. REVIEW This policy and procedure will be reviewed every three years or sooner if appropriate. 11. DISTRIBUTION This policy and procedure will be made available on the UHB clinical portal, Intranet and Internet sites. The document will also be circulated to the members of the mental health policy group and mental health quality and safety group. Reference Number: Page 12 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Cardiff and Vale University Health Board 12. FORMS The Form 4 risk assessment is accessed via the PARIS electronic record system. All inpatient areas and CMHT s must ensure they have access to the paper format of the FACE risk profile. Clinical areas may also hold copies for use of the WARRN formulation tool and where required HCR 20 risk assessment. 13. REFERENCES Morgan S. Clinical Risk Management, A clinical tool and practitioner manual, The Sainsbury Centre for Mental Health (2000) Department of Health Best Practice in Managing Risk (June 2007) Welsh Assembly Government - The Role of Community Mental Health Teams in Delivering Community Mental Health Services Interim Policy Guidance and Standards (July 2010) Welsh Assembly Government Delivering the Care Programme Approach in Wales Interim Policy Guidance (July 2010) Care Programme Approach Association The CPA and Care Standards Handbook (2008) Welsh Assembly Government Mental Health Policy Guidance, The Care Programme Approach for Mental Health Service Users (February 2003) Wales Applied Risk Research Network (WARRN) Asking difficult questions and formulating risk training course (2009) Reference Number: Page 13 of 13 Mental Health Clinical Risk 1 Assessment & Risk Management Policy Original Approval Date:

Form 1: Preparation Part A must be completed at the beginning of a Policy/function/strategy development or review, and for every such occurrence. (Refer to the Step-by-Step Guide for additional information). Step 1 - Preparation 1. Title of Policy - what are you equality impact assessing? Mental Health Risk Assessment and Management policy 2. Policy Aims and Brief Description - what are its aims? Give a brief description of the Policy (The What, Why and How?) To offer guidance on undertaking clinical risk assessment and management within the mental health division 3. Who Owns/Defines the Policy? - who is responsible for the Policy/work? Executive Director of Mental Health Divisional Director of Mental Health Divisional Nurse of Mental Health Divisional Manager of Mental Health Clinical Directors of Mental Health Professionals who undertake clinical risk assessments and work within the CPA Framework, Team Managers, CPA Lead officer, Senior Divisional Team 4. Who is Involved in undertaking this EqIA? - who are the key contributors to the EqIA and what are their roles in the process? 5. Other Policies - Describe where this Policy/work fits in a wider context. Is it related to any other policies/activities that could be included in this EqIA? Dave Semmens, CPA Lead officer (policy author) Risk assessment and management is a fundamental component of the overall assessment process for achieving outcomes and identifying mental health service delivery The policy has been written in line with recently passed legislation, the

Step 1 - Preparation Mental Health (Wales) Measure, passed 2010 and due to be implemented in 2012 as well as recent national (interim) policy guidance on delivering the CPA. This policy has also used reference form the Department of Health guidance on risk assessment and risk management. 6. Stakeholders - Who is involved with or affected by this Policy? The policy may be applicable to all involved within secondary mental health care including service users, carer s, voluntary sector and professionals at all levels. Consultation was made via the UHB mental health policy group 7. What factors may contribute to the outcomes of the Policy? What factors may detract from the outcomes? These could be internal or external factors. The policy follows national guidelines (both the Welsh Government (WG) and Department of Health (DoH) and for undertaking clinical risk assessments the outcomes of the policy rely upon individuals adhering correctly to the guidance within the policy and the frameworks / tools used within Cardiff and vale mental health services Training is currently provided to clinical staff involved within the risk assessment process The outcome of the policy are dependant upon practitioners undertaking assessments of clinical risk factors

Equality Strand Evidence Gathered Form 2: Evidence Gathering Does the evidence apply to the following with regard to this Policy/work? Tick as appropriate.

Race Disability Cwm Taf health board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. Internet search 17/11/2011 on existing EIA for similar policies proved limited. The internet search did not indicate specific risk assessment polices within other health boards. EIA from Avon and Wiltshire Mental health trust (Care Pathways and Risk) identify NO negative impact in any group, but may be differential access and intervention rates for race. Care Quality Commission (2011). Count me in 2010, London: Care Quality Commission. Admission rates remain higher than average among some minority ethnic groups, especially Black and White/Black Mixed groups The numbers of detained patients under the Mental Health Act are higher than average among the Black, White/Black Caribbean Mixed and Other White groups (but not in other ethnic groups). The rates for detained patients who were placed on a community treatment order (CTO) are higher among south Asian and Black groups. Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Eliminating Discrimination and Eliminating Harassment Encouraging participation in Public Life Promoting Good Relations and Positive Attitudes Promoting Equality of Opportunity Take account of difference even if it involves treating some individuals more favourably*

Gender Sexual Orientation Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. EIA form Avon and Wiltshire Mental health trust (Care Pathways and Risk) identify NO negative impact in any group, but may be differential access and intervention rates for disability. People with severe and enduring mental health problems are more likely to have co-existing physical health problems, have poor social functioning and be stigmatised. National Institute for Clinical Excellence (2003). Schizophrenia: Full National Clinical Guideline on Core Interventions in Primary and Secondary Care, London: Gaskell & the British Psychological Society. Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Cwm Taf policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. EIA form Avon and Wiltshire Mental health trust (Care Pathways and Risk) identify NO negative impact in any group, but may be differential access and intervention rates for gender. Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups

Age Religion or Belief Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. EIA form Avon and Wiltshire Mental health trust (Care Pathways and Risk) identify NO negative impact in any group. National Institute for Mental Health England (2007) Mental disorders suicide and deliberate self harm in lesbian, gay and bisexual people, London: NIHME. Our findings show that LGB people are at significantly higher risk of mental disorder, suicidal ideation, substance misuse, and DSH than heterosexual people Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. EIA form Avon and Wiltshire Mental health trust (Care Pathways and Risk) identify NO negative impact in any group, but may be differential access and intervention rates for age. Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. EIA form Avon and Wiltshire Mental health trust

Welsh Language (Care Pathways and Risk) identify NO negative impact in any group. Cwm Taf Health Board Clinical Risk Assessment Policy EIA obtained 18/11/2011. Identifies NO negative impact on any of the equality groups Cwm Taf Health Board policy identify no baseline information or research data or available evidence. Internet search 17 /11/ 2011 supports this. People have a human right to: life; not to be tortured or treated in a degrading way; to be free from slavery or forced labour; to liberty; to a fair trial; not to be punished without legal authority; to respect for private and family life, home and correspondence; to freedom of thought, conscience and religion; to freedom of expression and of assembly; to marry and found a family and to not be discriminated against in relation to any of the rights contained in the European Convention. Human Rights The principles of the legislation will be adhered to and with particular regard to not being treated in a degrading way and to respect for private and family life, home and correspondence and the right to liberty. The Policy directs staff to treat each person as a unique individual who will receive non-judgemental care that sustains dignity, respect and privacy. * This column relates only to Disability due to the specific requirement in the Equality Act 2010 to treat disabled people more favourably to achieve equal outcomes. This is not applicable to the other equality strands.

Form 3: Assessment of Relevance and Priority Equality Strand Evidence: Existing evidence to suggest some groups affected. Gathered from Step 2. (See Scoring Chart A) Potential Impact: Nature, profile, scale, cost, numbers affected, significance. Insert one overall score (See Scoring Chart B) Decision: Multiply evidence score by potential impact score. (See Scoring Chart C) Race 2-1 L Disability 2-1 L Gender 2-1 L Sexual 2-1 L Orientation Age 2-1 L Religion or Belief Welsh Language Human Rights 2-1 L 1 0 L 2-1 L Scoring Chart A: Evidence Available Scoring Chart B: Potential Impact Scoring Chart C: Impact Decision 3 Existing data/research -3 High negative -6 to -9 High Impact (H) 2 Anecdotal/awareness data only -2 Medium negative -3 to -5 Medium Impact (M) 1 No evidence or suggestion -1 Low negative -1 to -2 Low Impact (L) 0 No impact 0 No Impact (N) +1 Low positive 1 to 9 Positive Impact (P) +2 Medium positive +3 High positive

FORM 4: (Part A) Outcome Report Policy Title: Organisation: Name: Title: Department: Risk Assessment and management policy Cardiff and Vale University Health Board Dave Semmens CPA Lead Mental Health Division Summary of Assessment: The EQIA has been undertaken following the update of an existing policy on clinical risk assessment and management within the mental health division. The Policy will therefore be applicable to all individuals receiving care and support from a secondary mental health team, including employees of the UHB working within the mental health division and may include members of the voluntary services sector and carers. The evidence gathered indicates a low impact rating. The policy directs mental health professionals in the undertaking of clinical risk assessments. The current risk assessment format are not on the medium of the Welsh Language, this may impact against legislation in relation to the provision of health care through the medium of Welsh. Decision to Proceed to Part B Equality Impact Assessment: Yes/No Please record reason(s) for decision There is no requirement to proceed to part B, because of the outcome of the assessment and because are no identified changes from an equalities perspective since this policy was last updated.

Action Plan You are advised to use the template below to detail any actions that are planned following the completion of Part A or Part B of the EqIA Toolkit. You should include any remedial changes that have been made to reduce or eliminate the effects of potential or actual adverse impact, as well as any arrangements to collect data or undertake further research. Action(s) proposed or taken Reasons for action(s) Who will benefit? Who is responsible for this action(s)? Timescale 1. What changes have been made as a result of the EqIA? Updated policy. Policy updated according to recently passed legislation. No changes made following EqIA We have added an equality statement to the policy to publicly demonstrate our commitment to equality, diversity and human rights issues. Service users, carers Professionals within the mental health division CPA Lead, Divisional management team, Completed 2. Where a Policy may have differential impact on certain groups, state what arrangements are in place or are proposed to mitigate these impacts? Use of Interpreters or other appropriate communication services such as sign language, may be required to ensure full Diversity of mental health population Service users, carers Professionals within the mental health division UHB Divisional management team, Ongoing

involvement of service users in clinical risk assessment. 3. Justification: For when a policy may have adverse impact on certain groups, but there is good reason not to mitigate. 4. Describe any mitigating actions taken? N/A n/a n/a n/a n/a n/a n/a n/a n/a n/a 5. Provide details of any actions planned or taken to promote equality. We have included an equality statement into the policy that clearly states that the The UHB want to be explicit about its commitment to the equality agenda/legislation. Patients will be primary benefit which will impact positively on their families and/or Appropriate staff and Managers. Already completed within the document There is no policy is patients as timescale as this applicable to all To ensure that are applicable will be responsive

as appropriate to individual, service area and organisational circumstances. We would provide copies of the document in alternative formats, including Welsh if required as via appropriate Single Equality and Welsh Language Schemes. policies are accessible to all Any individual making the request as well as the organisations reputation. to individual need.

Date: 18/11/2011 Monitoring Arrangements: CPA Lead, Divisional management team. Audit structure in existence via Annual Quality Framework monitoring Review Date: June 2012 Signature of all Parties: D.Semmens D.Semmens