Document Title Clinical Risk Assessment and Management Policy Document Description Document Type Policy Service Application Trust Wide Version 1.2 Policy Reference no. POL 025 Lead Author(s) Name Bob Yardley Jo Seward Neil Tong Job Title Clinical Process Manager Electronic Systems Development & Training Consultant Risk and Assurance Facilitator Change History Version Control Version Date Comments 1.0 20/01/2010 Final policy document ratified by Integrated Governance Committee 20/01/2010 1.1 02/02/2012 Policy Amended following consultation Changes made to risk assessment documents used within the Organisation To include Sainsbury Risk Assessment and FACE risk assessment. Document agreed with minor changes by Policies and Procedures Focus Group (02/02/2012) 1.2 23/04/2015 Policy Review due to adopting FACE Risk Profiles. Formally ratified by Policies and Procedures Focus Group 23/04/2015 Link with National Standards National Heath Service Litigation Authority Care Quality Commission National Institute of Clinical Excellence (NICE) Guidance National Patient Safety Agency West Midlands Quality Review Essence of Care Aims Standards Key Dates Day Month Year Ratification Date 23 04 2015 Review Date 23 04 2017 1
Executive Summary Sheet Document Title: Clinical risk assessment and management policy Please tick ( ) as appropriate This is a new document within the Trust This is a revised document within the Trust What is the purpose of this document? This policy aims to introduce overarching guidance for the Trust in respect to clinical risk assessment and risk management processes. The policy acknowledges that the assessment and management of risk is an essential element of the work undertaken within Dudley and Walsall Mental Health Partnership NHS Trust and offers guidance for frontline staff and managers concerning how such clinical risk assessments should be undertaken What key issues does this document explore? Local processes for ensuring effective clinical risk assessments are implemented, local processes for enabling clinicians, service users and carers to plan to manage any risk highlighted How risk assessments should not be carried out in isolation past history should be considered as should the views of service users, other professionals and carers Monitoring arrangements within the Trust for ensuring compliance Who is this document aimed at? All staff working within Dudley and Walsall Mental Health Partnership NHS Trust who undertake clinical risk assessment What other policies, guidance and directives should this document be read in conjunction with? Mental Health Act (1983 and 2007), Observation and Engagement Policy, Prevention and Management of Violence Policy, Medicines Management Policy, Care Programme Approach Policy, Safeguarding Adult Policy, Safeguarding Children Policy, Data Protection Act, Freedom of Information Act, Risk Management Policy. How and when will this document be reviewed? This policy will be subject to review every 2 years. 2
Document Index Pg No 1 Introduction 4 2 Scope 4 3 Definitions 4 4 Aims 5 5 Duties 6 6 Principles and Values 6 7 Training 7 8 Confidentiality 7 9 Service User Involvement 7 10 Communication 8 11 Process 8 12 Risk Information Checklist 9 13 13.1 13.2 13.3 13.4 13.5 13.6 Guidelines for the clinical risk assessment process, use of clinical risk checklist and clinical risk assessment tools Who Completes the risk assessment? When should the Assessment Form be completed? What should be written on the form? Service User and Carer involvement Discharge from inpatient units Review of care plan 10 10 10 11 11 11 11 14 Risk Management / Mitigation Plan 11 15 Guidelines for specific problems arising from inpatient care / 11 Leave Requirements 16 Summary 13 17 Monitoring 13 18 References 14 3
1. Introduction 1.1 This policy applies to all service users who receive Secondary Mental Health and functional services from Dudley and Walsall Mental Health Partnership NHS Trust, including service users undergoing initial assessment on referral to this Trust. 1.2 The assessment and management of risk is an essential element of all clinical work undertaken within Dudley & Walsall Mental Health Partnership NHS Trust. 1.3 The process of clinical risk assessment and management is seen as a core component of the safe delivery of the service users overall care programme and therefore this policy should be read in conjunction with the Trusts Care Programme Approach Policy and guidance 1.4 The policy also takes into account the Trust s Risk Management Strategy, The National Service Framework (NSF) for Mental Health, NHSLA standards for Clinical Risk Management, Safety First (Department of Health 2001) and Effective Co-ordination in Mental Health Services Modernising the Care Programme Approach (CPA), Safety First five year Report of the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness (2001) and National Confidential Inquiry into Suicide and Homicide by people with Mental Illness Annual Report July 2014, the Department of Health Guidance Best practice in managing risk in mental health services (2007), the document outlining the 7 steps to patient safety in mental health (National Patient Safety Agency) and New Horizons. 1.5 This policy is concerned with the following principles: Ensuring effective work with individuals to manage and, where possible, reduce the risk of harm. Action, including multi-agency work, which is designed to protect potential victims from harm or to protect the individual from self harm 2. Scope 2.1 The principles of good risk assessment and management described in this policy are relevant to all health & social care staff working for Dudley and Walsall Mental Health Partnership NHS Trust. All staff should be aware of these standards of good practice. However the standards of practice and training set out in this policy specifically relate to practitioners who have responsibility for assessing and managing individual s service user risk, (care coordinator, primary nurse, key worker, assessment officers & doctors). 3. Definitions (see glossary in DoH Best practice in managing risk ) 3.1 Risk: The probability that a specific adverse event will occur in a specific time period or as a result of a specific situation. The level of risk comprises a combination of the likelihood and the consequence of the event (hazard) being realised. 3.2 Risk Assessment: The process of assessing the likelihood of a harmful event occurring, and estimating the likely impact should the event take place. Risk assessment must involve a calculation of both probability and impact. 3.3 Dangerousness: The potential or capacity to present harm to others of a physical or psychological nature. 4
3.4 Clinical Risk Management: The case management strategies and interventions used by practitioners to control and minimise risk. Central to any risk management plan in Mental Health is the CPA process. 3.5 Public Protection & Client Safety: The desired outcome of risk assessment and risk management. 3.6 While the overall aims of service activity involve protecting both the service user and the public, this policy focuses on the following categories of risk: Risk to self, including risk of self harm, abuse / exploitation / vulnerability and risk of relapse (including discontinuation of medication or drug errors, non adherence to treatment plans / non-compliance of prescribed medication, risk of absconding and non-engagement). Risk to others, including carers, staff and the public Risk to children (Consideration must be given to any potential or known risk indicators regarding children and liaison with the Trust s Vulnerable Adults and Children s Lead. The recency, severity, frequency and pattern of any previous identified risk aspects should be considered when conducting any risk assessment and compiling a risk management plan 3.7 Accurate history taking plays a vital role in any risk assessment and subsequent management/mitigation plan. Persons and organisations worth considering when compiling a risk assessment should include checklist prompts as seen in Section 12 3.8 On occasions it may not be possible to obtain all necessary information to conduct a comprehensive assessment, but this must be recorded and communicated to colleagues to ensure this is addressed at a later stage. Consideration must also be given to expressions of risk: Is there a risk of harm? What sort of harm and of what likely degree? What is the immediacy or imminence? How long may the risk last? What contributory factors relate to the level of risk? How can the factors be modified or managed? 4. Aims 4.1 The aim of this policy is to set out good clinical risk assessment and management practice, which should be followed for all service users. It should be read in conjunction with the Trusts Care Programme Approach Policy and guidance. 4.2 The Policy aims to provide staff with robust guidance in respect to clinical risk assessment and management, defining agreed standards of practice in accordance with Trust policy and national directives and standards such as those enshrined within the National Service Framework for Mental Health (Department of Health) and NHS Litigation Authority Risk Management and Effective Care coordinator in Mental Health Services: Modernising the Care Programme Approach. 5
5. Duties 5.1 The Trust has an obligation to deliver a service that strives to provide the best possible outcomes for service users, and safeguards service users, staff, visitors and the general public. A robust and integrated approach to care provision is a vital component of such a service and this Clinical Risk Assessment and Management Policy is an important foundation of that approach. A suitable infrastructure is required to establish and continue support for those activities outlined in the Policy. 5.2 The Director of Operations and Nursing and the Medical Director will have strategic responsibility for the policy. 5.3 Heads of Service Will have operational responsibility for policy distribution, implementation and compliance within their particular area of service. 5.4 It is the responsibility of all staff involved in the assessment and management of risk to be aware of and adhere to this policy in the course of their practice. 6. Principles and Values 6.1 The DoH Best practice in managing risk (2007) documents outlines a basic philosophy underpinning risk assessment and management as follows: The philosophy underpinning this framework is one that balances care needs against risk needs, and that emphasises: Positive risk management; Collaboration with the service user and others involved in care; The importance of recognising and building on the service user s strengths; and the organisation s role in risk management alongside the individual practitioner s. 6.2 The assessment and management of risk is the responsibility of all clinical staff working within Dudley and Walsall Mental Health partnership NHS Trust in collaboration with the service user themselves. It is not a one off activity but is a continuing process. 6.3 Risk assessment is a dynamic, ongoing process, informing the management of risk, and enables services to meet their responsibility to reduce risk to service users and public. 6.4 Risk assessments are intended to assist safer working practices. 6.5 It is recognised that there is a limit to the responsibility of staff and services. Risk can only be reduced and not eliminated, and there remains the potential for tragedies to occur. 6.6 Services, rather than individual staff are responsible for cases. Risk assessment and management ensures that accountability is shared within the agency and between agencies. 6.7 In the event of an Incident happening, it must be reported in line with the Trusts incident reporting mechanisms. 6.8 Multi-agency collaboration at all levels is essential to ensure effective risk assessment and management. 6
6.9 High quality supervision, support and training for staff is crucial in promoting effective practice. 6.10 The Trust provides comprehensive Clinical Supervision to clinical staff. Additionally, staff are supported by the Trusts ongoing Clinical and Managerial Supervision Policy. 6.11 All individuals have an annual Personal Development Review. Identification of training needs relating to risk assessment and management should be highlighted and addressed. 7. Training 7.1 High quality supervision, support and training for staff are crucial in promoting effective practice. It is expected that all staff responsible for clinical risk assessment will have access to training provided by the Trust. 7.2 The Trust will seek to ensure that appropriate training is provided to all relevant staff in order to implement this Policy. Training will be provided as detailed in the Training Needs Analysis. 8. Confidentiality 8.1 Public protection and client safety may under certain circumstances take priority over the right to confidentiality of service users. Effective risk management involves sharing information with other agencies. Information should be shared on a need to know basis, and what they need to know criteria, in accordance with the Trust s Information Sharing Protocol. 8.2 Negotiations and decisions about confidentiality must take place within the CPA process, rather than being left to the discretion of a lone practitioner. The only exception to this would be in the case of an emergency. 8.3 There are often tensions in terms of managing the sometimes conflicting interests and wishes of carers and service users. A service user should never be transferred back into the care of the carer without that carer being given details of any incidents of harm done by the client to themselves or others. 9. Service User Involvement 9.1 Service users should be actively involved in the process of risk assessments and management plans. 9.2 It is expected that completed risk documentation will be shared and discussed with the service user. It should be an open and participative process and requires considerable skill, sensitivity and careful planning by the practitioner. 9.3 It is important for the professional working with the service user to discuss any reasons why the service user may be or become non concordant with any of the suggested or agreed management and care plans. 7
9.4 Consideration should be given to early warning signs of relapse, discontinuation of medication and non-attendance at any arranged appointments of care provisions. 9.5 Such alerts should be noted on the service user s risk assessment and associated care plan and a crisis/contingency plan should be formulated to highlight any potential risks of non-engagement or/and non-concordance. This should include contact details and involve, where appropriate, the views of carers and relatives. 9.6 In a minority of cases, it may not be appropriate to share risk assessments and management plans with the service user. Possible reasons for this would be where disclosure would compromise public protection / staff safety or undermine the mental health of the individual. 9.7 All decisions around non-disclosure should be discussed at the CPA review, agreed and the reasons clearly recorded in the case file (refer to Care Programme Approach Policy for further guidance). 10. Communication 10.1 On-going risk management of individuals requires frequent reviews, sound information and good communication. Effective risk management will often involve several workers sometimes from a variety of agencies. 10.2 When conducting risk assessments, practitioners need to be curious and actively seek information that they do not have rather than waiting for others to provide this information. Assessors also need to listen and take into account the concerns of nonprofessionals such as carers, employers, neighbours and the service users themselves. 10.3 All staff conducting risk assessments must be aware of how to obtain details of the individual s criminal convictions from the Police. 10.4 Record keeping is a key component of risk assessment. All information relating to risk issues should be clearly and accurately recorded in the case notes/electronic patient record at the earliest opportunity. It is important that practitioners are familiar with and follow policies and procedures relevant to local and Trust wide guidance. 10.5 The statutory form used to document the initial baseline and ongoing risk assessment is the FACE Risk Profile. 11. Process 11.1 The risk assessment / management process is initiated when a person is referred to mental health services. 11.2 Risk assessment and management should be viewed as an integral and ongoing part of the CPA and clinical care process. 11.3 Agreed risk assessment / management tools will be used as required throughout the Trust. These tools can help to further inform clinical risk management practice due to systematic information gathering. The Trust uses FACE Risk Profile tool across the organisation. 8
11.4 The Department of Health Best practice in managing risk guidance suggests however to use tools with caution: When thinking about risk assessment tools, two key warnings must be borne in mind. Risk assessment tools must be used with caution. A tool can only contribute one part of an overall view of the risk presented by a particular individual at a particular time. Tools should only ever be used as part of a general clinical assessment conducted with a service user. The results of the tool-based assessment must always be combined with other information on many aspects of the service user s life and current situation. 11.5 Practitioners should be aware of, and make use of existing risk management forums in their working area, for example Safeguarding Children procedures. 11.6 It is noted that within the Trust the use of the risk assessment / management tools will be subject to audit on at least an annual basis. Such audit will be utilised to inform the growth and development of improved practice 11.7 It is also noted that the practice of clinical risk assessment and management will be supported by supervision, advice from senior colleagues and second clinical opinions. 12. Risk Information Checklist 12.1 In order to assess and manage an individual s risk, it is essential to seek information from a wide variety of sources. It is the intention of this checklist to signpost all practitioners to where risk information can be sought. It is not intended that practitioners need to contact people from all the areas outlined below, but to simply refer to areas thought to be of importance: Family / Carer / Partner / Significant other Accommodation Provider o Landlord / landlady if renting privately o Estate manager in the case of social housing o Warden in the case of sheltered housing o Matron / manager in the case of Nursing or Residential homes General Practitioner Hospitals / Community Mental Health Teams (CMHTs) Probation Service Local Police Local Intelligence Units are particularly helpful with regard to risk issues. They often have additional information, which they will disclose when there are public protection issues are at stake. Telephone your nearest police station and ask to speak to a local intelligence officer. Prisons Following a recent remand in custody, prison establishments may well have a significant amount of risk information about an individual. Key contacts include: staff working in hospital/medical wings, psychology and probation departments. Any difficulties in obtaining information should be referred to the Duty Governor. Child Protection Services Social Services Children & Family teams are the lead agency with regard to Safeguarding Children matters. Practitioners must familiarise themselves with the Safeguarding Children procedures for their locality. Staff are advised to remember that safeguarding children and adults is everyone s responsibility (see Safeguarding children policy). Voluntary Organisations Services from this sector provide a wide range of support to users, e.g. advocacy, assistance with housing, substance misuse etc. It 9
is important therefore that information about risk is communicated on a reciprocal basis with voluntary organisations. Multi Agency Risk Assessment Conference Panels (MARAC s) A small number of individuals have the potential or capacity to cause serious harm to others. Such risks should be managed on an inter-agency basis rather than by individual services alone. In the first instance, referring the individual case to the local MARAC Panel should do this. For specific information about the MARAC s in your area, contact the Trust Vulnerable Adult and Children s practitioner. 12.2 The main purpose of these meetings is to share information, jointly assess risk, and devise strategic plans to manage, reduce and contain an individual's risk of dangerousness. To agree and document the role of each respective agency / individual in the management of the case. 13. Guidelines for the clinical risk assessment process, use of clinical risk checklist and clinical risk assessment tools 13.1 Who completes the Risk Assessment? 13.1.1 In-Patient Areas On admission the admitting nurse and admitting Doctor should complete the risk assessment documentation, as part of the admission process. Any member of the care team, when carrying out a risk assessment and / or risk management plan review. Any member of the care team in the event that there is a significant incident involving the patient, or following any change in their presentation, or where significant information about the patient has been received. It is considered best practice for the patients risk assessment and risk management plan to be reviewed within the MDT meeting. 13.1.2 Community Settings The designated Assessment coordinator or the allocated Care coordinator (or deputy), nominated to carry out an initial mental health needs assessment following receipt of a referral. Any other community team member in the absence of the allocated Care coordinator, where there is a significant incident involving the service user, or following any change in the service user s presentation, or where significant information about the service user has been received as well as within the context of clinical reviews. 13.2 When should the Assessment Form be completed? 13.2.1 In-Patient Areas On admission as part of the admission documentation. It is essential that the risk assessment and risk management plan must be reviewed if there is a change in presentation of the client or a change in care circumstances. Any subsequent reviews of the risk assessment and risk management plan should occur as per review standards guidelines and be documented in progress notes. See section 13.6 below. 13.2.2 Community Settings As part of every initial assessment following referral. 10
It is essential that the risk assessment and risk management plan must be reviewed if there is a change in presentation of the service user or a change in care circumstances. Prior to the service user s care being transferred between teams or from an inpatient setting to the community or from other community services, by the allocated community Care coordinator/lead Professional. The Care coordinator/lead Professional should not just adopt the previous management plan without review, as the interventions and needs may not be the same in different settings. Consideration must be given to all previous risk indicators which must be highlighted and included as appropriate in the ongoing risk documentation. 13.3 What should be written on the form? The FACE Risk Profile, as used by the organisation outlines a number of key areas through which the practitioner should identify what risks the service user is currently presenting with? All risk factors and warning signs should be completed. The practitioner should also include key historical data, i.e. certain incidents, events or occurrences that have happened in the past. 13.4 Service User/Carer Involvement Wherever possible, the service user and their carer should be an active participant in the formulation of the risk assessment and management plan, but it is recognised in some circumstances their mental state may preclude this, or due to the risks identified that may be detrimental to the service user if shared with them. 13.5 Discharge from inpatient units A full re-assessment of existing risks needs to take place prior to discharge. Joint case review between in-patient and community teams prior to discharge from in-patient care. Discharge plans should include specific reference to seven day/48 hour follow up. The discharge summary should include a paragraph on risk assessment and management. 13.6 When to Review the Risk Management plan Following any significant incident involving the service user, and/or any major changes in their clinical presentation or circumstances. Where significant information related to the service user and their risk has been received. Prior to a review meeting with the service user. The service user will be reviewed every six months. 14 Risk Management / Mitigation Plan 14.1 When formulating the plan the following will be considered: The purpose of the Risk Management / Mitigation Plan is to focus on how the person will remain safe when feeling unwell. Where possible the service user should lead the conversation in thinking about their personal safety issues. The plan must include responses to early warning signs of relapse. 11
The plan should include trusted people who can support the service user in times of crisis. The plan will identify any supervision and monitoring strategies around the area of identified risk. 14.2 When to Review the Risk Management plan Following any significant incident involving the service user, and/or any major changes in their clinical presentation or circumstances. Where significant information related to the service user and their risk has been received. Prior to a review meeting with the service user. The service user will be reviewed every six months. 15. Guidelines for specific problems arising from Inpatient Care/Leave Requirements 15.1 To ensure that the safety of the inpatient is considered before any period of leave is granted then the following directions should be followed: Risk should be assessed by the Consultant or deputy and nurse (and ideally in the context of multidisciplinary meetings): prior to granting leave for the first time, prior to granting repeated periods of leave or overnight leave All detained in-patients must have relevant, appropriate authorised leave in accordance with Section 17 MHA (1983) prior to any period of leave be agreed. Communication is paramount when authorising periods of leave and carers (where appropriate) and community services should be notified when a person has been granted leave and in case the service user is taking overnight leave to stay in the community. Should the patient be of informal status and should risk be deemed an issue with the person leaving the ward, then there should be discussion held with the patient and the team regarding the increased level of risk and possibly, consideration given to the assessment for a detention order under MHA (1983) 15.2 Once Leave is agreed: 15.2.1 Every effort should be made to ensure that the agreed leave is accommodated. For example a member of staff is available to escort, should the leave requirements stipulate this. The MDT member on duty should: Make sure that any new information, a change in the service users mental state and/or any new concerns will be taken into account prior to the service user leaving the ward Establish where the patient is going Request a time of return To be in line with section 17 leave if on appropriate Make note of the above in the progress case notes Ensure that the patient (and any relevant carer) has a contact number for the ward/unit Request that the patient supply the ward/ unit with a contact number for staff to be able to contact them 15.2.2 Should leave not be accommodated e.g. postponed, then the service user should be informed as to the reason why and a discussion should be held to agree an alternative time. 12
15.3 On return from Leave On returning from periods of leave it is advised that the staff on duty speak with the patient and ascertain how the leave was spent and what occurred whilst the person was away from the ward. The patient should also be encouraged to highlight any worries, anxieties or concerns they may hold with regards to the leave. Whenever possible a short mental state examination should take place to assure the safety of the patient. All information gathered from the above must be recorded in the patient s notes 16 Summary 16.1 Risk Assessment must be viewed as a systematic and dynamic approach, which is an integrated part of routine care. Risk assessment and management is a supportive tool for staff, service users, relatives and carers and should be seen as a guide and a framework with which to aid in this process. 17 Monitoring of the Policy 17.1 The Learning and Development Department will keep records of attendance at all Risk Assessment and Management Training to monitor compliance with the Trust s training expectations. 17.2 Compliance with the Clinical Risk Assessment and Management Policy will be monitored through both the annual CPA audit and the Record Keeping audits as outlined within the Trusts Annual Audit Programme. This audit activity will be coordinated and monitored by the Governance Department. 17.3 Audit results and findings will be reported to the Clinical Audit and Effectiveness Committee with any remedial actions required cascaded through the Trust across both localities. Monitoring for compliance against such identified actions will also be undertaken through the Trusts Clinical Audit and Effectiveness Committee. NHSLA standard Duties Organisation s expectation in relation to staff training, as identified in the Training needs analysis Tools/processes authorised for use within the organisation Method of monitoring Responsibility Frequency Trust CPA It is the responsibility of the Clinical Governance Department for Yearly Audit ensuring that a clinical audit into CPA (Care Pathway Approach takes place within the Trust. It is the responsibility of the designated audit lead for ensuring that the audit is completed and recommendations made. The Trust CPA audit also includes Clinical Risk Assessments and will assess whether the key duties as defined in this policy have Monitored on an ongoing basis by the Trusts Training department Trust CPA Audit been carried out appropriately Training department It is the responsibility of the Clinical Governance Department for ensuring that a clinical audit into CPA (Care Pathway Approach takes place within the Trust. It is the responsibility of the designated audit lead for ensuring that the audit is completed and recommendations made. The Trust CPA audit also includes Clinical Risk Assessments Ongoing basis Yearly 13
18 References Department of Health (2007) - Best Practice in Managing Risk Department of Health (2001) The Mental Health Policy Implementation Guide Department of Health (2001) Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Morgan C (2001) Assessing and Managing Risk. The Sainsbury Centre for Mental Health Pavilion. National Health Service Litigation Authority (2005) Clinical Negligence Scheme for Trust Mental Health & Learning Disability Clinical Risk Management standards. O Rouke, M & Bird, L (2001). Risk Management in Mental Health. The Mental health Foundation. Vincent, c (2001), Clinical Risk Management. Enhancing Patient Safety. Walsall Multi Agency Adult Protection Procedures. Dudley Multi-Agency Policy and Procedures For The Protection Of Vulnerable Adults Safeguarding and Protection. 14