The Assessment and Management of Clinical Risk Policy

SH CP 27 The Assessment and Management of Clinical Risk Policy Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: This policy describes the processes Southern Health NHS Foundation Trust (SHFT) uses to ensure risks relating to the clinical presentation of patients and their care and support are assessed and managed. It should be read in conjunction with the Practice Guidance for Managing Clinical Risk Document (SH CP 28) which supports the implementation of this policy. Risk assessment, risk, clinical risk, assessment. All clinical staff. Next Review Date: March 2019 Approved & Ratified by: AMH Performance & Assurance Board Date of meeting: 17 Date issued: Author: Tim Coupland, Head of Nursing, AHP and Quality Mental Health Liz Durrant, Area Manager AMH Sponsor: Dr Lesley Stevens, Director of Mental Health & Learning Disability Services 1

Version Control Change Record Date Author Version Page Reason for Change April 2014 Sept 2014 Sept 2014 July 2015 Aug 2015 Oct 2015 Dec 2015 Tim Coupland Version 2 Full revision of policy Tim Coupland Version Further refinements to policy to reflect developments and 2 training ambitions Tim Coupland Version Change to title of policy to reflect comments from Consumer 2 Advisor Louise Hartland 15 Updated TNA (appendix 2) and contents page Liz Durrant Version 3 Review date extended from Aug to Nov 2015 Review date extended to Further refinements to policy to reflect changes in national guidance and practice Reviewers/contributors Name Position Version Reviewed & Date Risk Assessment Task & Finish Group Version 2 Feb Risk Assessment Task & Finish Group Comments returned from Dr Lesley Stevens Version 2 Sept Mental Health/Learning Disabilities staff Various Version 2 Sept Lesley Herbert Consumer Advisor Version 2 Sept Liz Durrant Area Manager - AMH Version 3 Dec 2

CONTENTS Page 1. Introduction 4 2. Scope 5 3. Duties/ responsibilities 6 4. Risk Assessment 8 5. Review of risk assessment 9 6. Recording of risk assessment 10 7. Use of Structured Risk Assessment Tools for Risk of Violence 10 8. Management of Identified Risk 11 9. Management of People with Higher Risks 11 10. Transition Points 12 11. Communicating Risk Information 13 12. Recording Risk Incidents 13 13. Training Requirements 13 14. Monitoring Compliance with the Contents of this Policy 14 Appendices A1 Risk Planning Cycle 15 A2 TNA 16 A3 Equality Impact Assessment (EqIA) 17 3

1. Introduction 1.1 Risk assessment should be a core component of any mental health, physical health and learning disability assessment, in any setting. The Department of Health Guidance, Best Practice in Managing Risk (DOH 2007) provides a framework based on the principle that modern risk assessment should be focused on positive risk taking, structured, evidence-based and as consistent as possible across settings and across service providers. The assessment of Clinical Risk and subsequent management of the identified risk is integral to Care Planning and in particular, the management of patient safety in Southern Health NHS Foundation Trust. 1.2 The need for clarity and transparency in the assessment of risk and sharing this information with other relevant clinicians, teams and agencies, has been highlighted in a number of critical incident reviews and independent inquiries. Consideration of risk is required during an assessment and at key points in care. For quick reference appendix 1 covers the safety planning cycle. 1.3 Each Division will have its own methodology for learning from incidents and will be expected to ensure that any learning is shared widely. Recurring themes from reviews and inquiries have included the need for clinical information to be communicated and shared so that it follows the patient throughout their treatment. Learning has also established the need to ensure that where risks are identified the assessment, care plan and progress notes all convey consistent information. 1.4 The Department of Health Guidance, Best Practice in Managing Risk (DOH 2007), states that a consistent approach to risk assessment will enable better communication between agencies and professionals and will contribute to improved collaborative care with service users and carers. Therefore our procedure Practice Guidance for Managing Clinical Risk Document (SHCP 28) advocates the use of the structured clinical judgement approach as recommended for all types of risk practice. The purpose of this is to decide on the most appropriate level of risk management and the right kind of intervention for the service user It also advocates Practical Ways of Working with Risk Who s risk is it anyway (2102) - a guidance document written from collaborative work with Steve Morgan which identifies components of positive risk taking practice in everything we do. 1.6 The Trust has a range of polices/ guidance relating to specific clinical risk and care and support issues which provide in-depth guidance and should be referred to where relevant risks are identified. These include but are not limited to; Practice Guidance for Managing Clinical Risk Document (SHCP 28) Practical Ways of Working with Risk Who s risk is it anyway (2012) Risk Training- Shifting from centralized workshops to team-based training reflection and practice development (January 2014) Management of Violence and Aggression Procedure (currently under review) Observation and Engagement Policy and Procedure Patients Missing or Absent Without Leave Policy Safeguarding children and adults policies and procedures 4

Moving and Handling Policy Incident Reporting Policy Slips, Trips and Falls Policy Physical health monitoring policy Search Policy Care Planning Policy Infection Prevention and Control policy 1.7 The key components to working with risk are to regularly assess the risks, to put into place plans with the person which help to minimise and manage the risk and thus improve safety and to keep such plans under regular review. 2. Scope 2.1 The principles in this policy apply to all Divisions within the Trust who provide a service directly to individuals, or arrange a service to be provided by another provider where contact is maintained with a person. 2.2 The following principles are adapted from Justifying Risk Decisions by Dr David Carson & Rethinking Risk to Others (RCPsych, 2008) and apply to this Policy: By definition, it is inevitable that harm will sometimes occur from risk taking, even with the highest quality decisions. When judging a risk decision both the assessment of the risk and the management of its implementation should be considered. The quality of risk decisions made by all staff in SHFT will not be measured by whether harm does or does not result. Risk assessment is an assessment of a current situation, not itself a predictor of a particular event. Although accurate prediction is never possible in individual patients, some negative outcomes can be reduced in frequency by sensible contingency planning. Mental health, learning disability and Adult Services (Social Services) professionals in SHFT must ensure that they have the necessary competencies to make risk decisions; including using approved relevant structured tools. Management strategies across the mental health and learning disability divisions will also ensure frontline clinical teams have the collective competence to make risk decisions Organisational contributions to poor quality risk decisions will always be considered along with the contribution of individual decision makers. 2.3 The Trust aims to use the best practice points for effective risk management identified in Best Practice in Managing Risk Department of Health. June 2007 and Practical Ways of Working with Risk Who s risk is it anyway (2012) It wishes to promote positive risk taking procedures where risk assessment and management: Promotes collaborative partnerships with explicitly involve service users and carers around important risk decisions; Emphasises strengths as part of overall management strategies; Focuses on Recovery; Is flexible, individualised and responsive to the nature of the risk i.e. whether it is a short or medium/long term risk; Is integrated into CPA/Care Planning practice; Managed and supported at an organisational as well as clinical level 5

Improving risk management practice through continuous learning Guidance from the ImROC briefing Risk, Safety and Recover, Jed Boardman and Glenn Roberts, June 2014, proposes a move to developing co-produced Safety Plans which use a person-centred approach to using risk information to help maintain safety through agreed actions which work for the person. This practice is commonplace on some of our AMH inpatient wards. The guidance also emphasises: It needs to be understood that over-defensive, risk-avoidant practice is bad practice and is associated with avoidable harms to both the people who use services and to practitioners It is important that Primary risk is always considered i.e. risks and safety issues relating to the service user. Secondary risks are often common i.e. the anxiety evoked relating to the risk. Southern Health wishes to promote a way of working, supported through training, which minimises elements of secondary risk through effective learning systems and support. 2.3 The risks covered by this policy and the associated guidance can be grouped into one of four over-arching categories: 1) Risk of harm to the person accessing services including deliberate self-harm, self-neglect, health/infection, social isolation or the potential for abuse by others, including, physical abuse, the potential for actively or passively leaving the unit/department/scheme/care home without the knowledge and agreement of staff or exploitation of any kind, including financial, drug, politically (or otherwise) motivated abuse such as terrorist exploitation 2) Risk of harm to others including physical violence or harm, abuse including physical, emotional, sexual, domestic abuse, verbal or psychological abuse, harassment, potential harm to others through passive or active unsafe actions including fire setting or other dangerous acts 3) Risk of damage to property including damage to fabric or structure of buildings or objects, including as a result of passive or active fire setting. 4) Iatrogenic risk- the potential to create harm by staff/ services involvement in the risk itself 3. Duties / Responsibilities 3.1 Chief Executive - The Chief Executive has overall responsibility for the management of clinical risk. 3.2 Medical Director (quality) is responsible for: Ensuring that the Managing Clinical Risk Policy, Guidance and Training are regularly reviewed and are in line with best practice. Ensuring that the Quality Improvement & Development Group (QID) considers reports regarding clinical risk assessment and management practices and initiates appropriate actions to address concerns. Ensuring that the policy and related guidance is audited across the Trust and the results are acted upon Ensuring that reports regarding risk management are provided to the Quality & Safety Committee and the Board as required 6

3.3 The Director of Operations (Mental Health, Learning Disabilities & Social Care) Disability and Associate Director of Nursing are responsible for: Ensuring that staff receive the necessary training to enable them to carry out risk assessments and manage risk as per the policy. Ensuring that staff receive clinical supervision and support to enable them to be competent at following the policy in their practice. Ensuring that the clinical risk management audit is undertaken. This tool will be set against practice standards identified within this policy. That good practice is celebrated. That action plans are developed and implemented to improve practice where required and that lessons are shared. 3.4 Ward and Team Managers are responsible for: Ensuring that staff receive consistent training to enable them to carry out risk assessments and manage risk as per the policy including adult and children safeguarding training Ensuring that staff receive clinical supervision and support to enable them to be competent at following the policy in their practice. Ensuring that the clinical risk management audit is undertaken. That good practice is celebrated. That action plans are developed and implemented to improve practice where required and that lessons are shared. 3.5 Care Co-ordinator/Consultant/Responsible Clinician (Depending on the location of the patient) are responsible for: Ensuring that a Risk Assessment has been carried out in line with this Policy and Divisional procedures for all patients under their care. Ensuring that the Risk Assessment is reviewed in line with this Policy and Divisional procedures, for all patients under their care. Ensuring that the Risk Assessment is recorded in line with Divisional procedures. Ensuring that all potential risk areas have been considered including safeguarding 3.6 Individual Clinical Staff - Are responsible for: Reading the policy and guidance documents and following the procedures for undertaking risk assessments and managing risk. Recording all risk assessments and risk management activities in line with the policy and related guidance document. Accessing agreed training and supervision to ensure their competence is current. Ensuring that they have read the current Care Plan and Risk Assessment & Management Plan Ensuring that actions are taken in a timely way to mitigate the risks identified and escalation through appropriate line management process as per policy 3.7 The Audit Department are responsible for: Leading on the compliance and monitoring of the policy with support from respective Divisional compliance leads 3.8 Other Sources of Information for Risk Assessments - the process of collecting information at all points should be collaborative, pulling from a wide range of sources and include multidisciplinary decision making following a clear formulation of evident 7

risks. When staff are assessing a person for the first time, they are responsible for ensuring that they access all available sources of information to formulate the risk assessment. The assessment should be done in collaboration with the person being assessed, and the following additional sources of information should be accessed: Relatives and carers Advocates Previous contacts with other mental health, physical health and learning disability services (whether internally within the Trust or externally to the Trust) Primary Care Records Other health professionals involved Other health or social services involved. Criminal Justice Service agencies, including Police and Probation. The information sources used should be recorded in the electronic patient record. 4. Risk Assessment 4.1 Risk Assessment should be a holistic measurement of risk encompassing core components of any Mental &Physical Health Assessment in any setting. The Practice Guidance Notes for Managing Clinical Risk and the Department of Health Best Practice Guidance both emphasise that Risk Assessment should be structured and evidence based. 4.2 Risk assessment tools will vary and be agreed based on the area of risk to be reviewed e.g. RIO risk assessment tool. 4.3 Other specialist/ empirically tested Risk Assessment tools can be used, this includes SVR 20 in the Learning Disability directorate and HCR-20 and SAVRY tools in the Specialised Services. Specialised tools such as these will only be used where they have been agreed by the relevant Divisional Service Group and they should only be completed by those with appropriate training and practice. 4.4 A new Risk Assessment must be completed in the following situations: As part of the initial assessment by any Clinical Team in all Service Divisions. At the beginning of each new episode of care. Within four weeks of transition, e.g. between Community Teams. (MH/LD specific) During the first assessment of the patient s condition Following admission to hospital. (Within 4 hours) Annually (as a minimum), as part of CPA/Care Plan Reviews, if a new Risk Assessment has not been completed in the previous 6 months. 4.5 Risk Assessments should be completed after multi-disciplinary discussion, but if there is an urgent need to complete the Risk Assessment, this should be done by a qualified Professional and agreed with the Multi-Disciplinary Team at the next opportunity. For detained patients risk assessments must be explicitly agreed by the person s RC or deputy. 4.6 Whilst Risk Assessment is a multidisciplinary activity a lead professional is important to ensure it is initiated and undertaken in consistent manner. The Clinician responsible for ensuring that a Risk Assessment has been carried out will be; 8

In the case of community patients, the Care Co-ordinator/ Key worker In the case of inpatients, patients on Community Treatment Orders or patients on Section 17 Leave or patients requiring leave, the Multidisciplinary Team led by the admitting nurse (in conjunction with the admitting doctor) Where patients have more than one professional involved looking after a range of needs, e.g. in Learning Disabilities, it is important that the risk assessment is undertaken in a coordinated manner by all those involved in the patient s care to reflect the range of risks. 4.7 For patients seen in the community by medical professionals whilst on call: If the patient is known to the community team the care coordinator/key worker is responsible for updating the risk assessment in the next working day. If the patient is admitted the inpatient service is responsible for completing the risk assessment as above. If the patient is not known to services and referred to community teams the community team is responsible for completing the risk assessment as part of their initial documentation, however it is important the doctor appropriately documents any risks as part of their progress notes. If the patient is not known to services and referred back to primary care only for follow up the risk assessment does not need completing but it is important that any risks are captured within the medical practitioner s progress note and/or letter to primary care. 5. Review of Risk Assessment 5.1 Community Patients For all community patients, the current Risk Assessment should be reviewed as part of a review of dynamic/acute factors with reference to historical factors that are static. Particular points include: At each CPA/Care Plan Review. If there is evidence of a change in the presentation, as shown in the following areas; o Behaviour, especially known risk behaviours o Mental state o Physical condition If there is information from a third party, including, carers, family members or other informants which suggests that the patients risk has changed. Significant change in life events. Following a Serious Incident which Requires Investigation (SIRI) If there is evidence either from the patient s history or from a third party (e.g. family member or other) that a vulnerable other person such as a spouse (in domestic abuse) or child or other (vulnerable) person are at potential risk from the patient, thus raising safeguarding concerns If there is evidence that the patient may be at risk of exploitation from others As part of the clinical assessment of suitability for transfer to another team. Within 7 days of discharge from an inpatient service or on the same day if the patient had been assessed as a high risk of suicide at any point during the admission (MH specific) If a new risk incident occurs 9

5.2 Inpatients For all inpatients, the current Risk Assessment should be reviewed as part of a review of dynamic factors with reference to historical factors that are static. Particular points include: At each Multi-Disciplinary Ward Review/CPA/Care Plan Review. Prior to decisions about change in the leave status of the patient (whether informal or detained under the MHA). Before each episode of leave. By the Responsible Clinician (for detained patients) or the inpatient Multi- Disciplinary team, prior to discharge planning. This must include due consideration to the risk to any actual or potential victims in the community. It should also take into account the heightened risk of suicide in the first three months after discharge. Prior to transfer between inpatient wards or inpatient units. Evidence of change in the presentation of the patient as shown by their; o Behaviour, especially known risk behaviours. o Mental state Significant change in life events. Following a Serious Incident which Requires Investigation (SIRI) Evidence from information from a third party, including, carers, family members or other informants, which suggests that risk has changed. Where any safeguarding concerns are raised on the ward (institutional, from other patients) On the day of discharge from an inpatient ward If a new risk incident occurs Within 24 hours of being accepted onto the Acute Mental health Team caseload 6. Recording of Risk Assessment 6.1 Completion of the RiO Risk Assessment Tool or other agreed tools will be recorded directly into the patients RiO record and validated. 6.2 The fact that a new Risk Assessment has been completed will be noted in the patient s progress notes and recorded as a risk related progress note. All reviews of Risk Assessment must be recorded in the progress notes, even if there has not been a change to the risk assessment. This should be recorded as a risk related progress note. Further information is within the appropriate RIO guide 7. Use of Structured Risk Assessment Tools for Risk of Violence 7.1 If the standard Risk Assessment Checklist (RIO)- where used, and subsequent analysis of risk factors indicates a high risk to others, Practitioners could consider referring the patient to the Forensic Psychiatry Services for a detailed Risk Assessment, which could include the use of a structured Risk Assessment Tool instead like the HCR20. 7.2 The Protocol for referrals to the SHFT Adult Secure Services makes clear that one of the reasons for referrals states; 10

For advice, including Risk Assessment, on the management of patients who are either in the community or in other mental health services. 7.3 Referral to the SHFT Adult Secure Services should also be considered for patients who have previously been under the care of either the Trust s Forensic Psychiatry Services or Forensic Psychiatry Services of other Trusts, who have been readmitted to hospital or are being considered for discharge from inpatient care. 7.4 Structured Risk Assessment Tools such as the HCR-20 must only be completed by clinical staff who have received appropriate training in their completion. 8. Management of Identified Risk; Safety Planning 8.1 Effective management of risk requires appropriate plans to reduce the level of risk. The Practice Guidance Notes for Managing Clinical Risk (SH CP 28) contains detailed advice on Risk Management. Risk Assessment should be used to inform the person-centred safety plan which is co-created with service user and their lead professional and should help inform the planning of how best to support the person s needs. 8.2 If the standard RiO Risk Assessment Tool indicates a significant risk of harm to self or others, then reference must be made to the Risk Assessment Section of the Practice Guidance Notes for Managing Clinical Risk, in particular, the Risk Factors for violence and for suicide which are listed in that section. Practitioners should identify the Dynamic Risk Factors i.e. changeable or acute factors and use those to draw up the Risk Management Plan. 9. Management of People with Higher Risks 9.1 People with a significant level of risk will need to be considered within the Care Programme Approach Policies and Procedures. Therefore the Person Centred Safety Plan must be integrated and form an essential part of the patient s Care Plan/CPA Care Plan. The care coordinator (community) or MDT led by lead clinician and named nurse would take responsibility for this. 9.2 People who have been assessed as being at high risk of suicide during an inpatient admission may present a higher risk to themselves immediately following discharge from an inpatient unit. 9.3 Inpatients who have shown the following higher risk behaviours to others, either prior to their admission to hospital or during their current admission to hospital, are likely to present a high risk to others. Assault to others, including sexual assault. Use of weapons. Fire setting, where there is a risk to others. Focused animosity, including threats to kill, to identified potential victims. 9.4 All patients discharged from inpatient mental health and LD services, including those who are high risk, are contacted within 7 days of discharge. As a minimum, the purpose of the visit is to ensure a positive and person centred engagement that covers: Brief mental state and clinical presentation Social circumstances and occupation 11

Concordance with treatment Review of risk Plan for further contact or otherwise 9.5 Where high risk concerns are identified carers and primary care / other agencies should also contacted / communicated with in an appropriate and timely way- this should be part of the outcome of an MDT discussion at the point of assessment or review. 10. Transition Points 10.1 It is generally accepted that transition points in an individual s care can be times of increased risk. For example, when a patient is discharged from inpatient care to the community, there will be a decrease in the protective factors associated with being in hospital and an increase in the potential risk factors associated with a move to less supervised accommodation in the community. 10.2 Transitions are often challenging and important points in peoples lives. It can be potentially distressing for individuals and family members. All transitions must be managed sensitively to ensure effective collaboration and communication with the person concerned and the immediate teams/colleagues. Transition points may include but are not limited to Discharge from inpatient setting to the community. Transfer from one level of security to another (e.g. from PICU ward to Acute Inpatient ward). Transfer from one Team to another. Transfer from a Forensic Psychiatry Service to General Adult Psychiatry Service. Release from Prison to the community. Transfer from hospital to prison CAMHS to AMH AMH to OPMH Transfer between wards in a unit Transfer between similar units in trust Where children are involved, communication with family units will be essential and risk assessed prior to the patient returning home 10.3 Risk Assessment, Safety Planning and Care Planning, must be considered at any of these transition points, to ensure that continuity of care is maintained and information is shared with Teams and Services who may be involved in providing care to the patient following transition. 10.4 It is best practice for the patient s current Risk Assessment and Safety Plan to be reviewed within four weeks of the point of transition to consider the impact of the transition on the previously identified risks and to put in place Risk Management Plans. 10.5 The Risk Assessment and Safety Plan must be reviewed in conjunction with the Team who will be responsible for the patient s care following the transition. This is to ensure that both Teams are clear about the potential risks, management strategies, contingency plans and their clinical responsibilities. A Transfer CPA Meeting must be held and this will form an essential part of the transition planning process. It will allow clinical teams to consider and review the Risk Assessment, Risk Management 12

Plans and Contingency Plans and ensure that the patient is clear about the transition plans. 11. Communicating Risk Information 11.1 The Practice Guidance Notes for Managing Clinical Risk (SH CP 28) contains further advice on communicating risk information. This makes clear that once a Safety Plan has been developed or reviewed, it must become a live document and be communicated and shared with the person, family and all those involved in providing their care. 11.2 Communication of risk information is essential for the following reasons; To assist in effective team working. Because of the fact that all Practitioners have a duty of care to the wider public, especially to carers/family members of patients. 11.3 Staff must make reference to the SHFT Policy on Information Sharing. 11.4 The Practice Guidance Notes also gives information on Multi Agency Public Protection Arrangements (MAPPA) 12. Recording Risk Incidents 12.1 Whenever a member of SHFT staff becomes aware that a person has been harmed (including when they have caused harm to themselves) or caused harm to others, the details should be recorded in the electronic record. The entry should clearly be identified as Risk Information. The entry should include the following: The source of the information, whether it was witnessed by Trust staff. An accurate account of the circumstances of what happened, including the events leading up to it and a description of the patient s behaviour. The outcome of the incident, including, if harm resulted to the patient or any other person as a result of it. The consequences of the incident, including any legal proceedings. An assessment of how this relates to the individual s mental illness. 12.2 This should enable a history of risk incidents to be built up to help inform the risk assessments and management plans. In addition, an incident form should be raised in line with the Trust Incident Reporting Policy. 12.3 Where there are environments with frequent changeable risk behaviours it is acceptable to document in the progress notes when there are new risk behaviours. Significant changes to patterns in risk behaviour should be added to the risk history. 13. Training Requirements 13.1 As part of the Trust risk management process a Trust training needs analysis is completed annually to identify the staff that are required to complete training in clinical risk assessment/management. All staff that are required to complete training are identified on the Training Needs Analysis (Appendix 2). 13

13.2 Training within Divisions will be agreed on a bespoke basis e.g. the implementation of the Team-Based Risk Assessment and Management Practice Development Initiative in Mental Health Teams. This involves shifting from centralised to team based training. 14. Monitoring Compliance with the Contents of this Policy 14.1 A set of generic practice standards are in place to support audit and review 14.2 The following table sets out how the Trust will monitor compliance with key elements of this policy Practice Standards Consideration of risk is during an assessment. Risk Assessment is undertaken at the beginning of each new episode of care. All staff undertaking risk assessments and management plans are trained Risk reviews are conducted in a timely way and are current Risk assessments for detained patients are reviewed and explicitly agreed by the RC or deputy The Risk Management Plan must be integrated and form an essential part of the patient s Care Plan/CPA Care Plan and reflected in the progress notes Transitions are managed sensitively and collaboratively All audits will be conducted annually and be led by the Divisional Professional Lead. 14

Appendix 1 - Risk Planning Cycle Undertake Review With Multi-Disciplinary Team Regularly as part of Care Planning At times of crisis If evidence of change in presentation of patient Before and after transition Include relevant agencies Review crisis management plan Assess Risk in collaboration with the service user Review Risk Information from all sources Ask person about the risks Discuss Risk Assessment with Multi-Disciplinary Team Identify Risk Factors using Practice Guidance Notes Identify any children involved and anyone the patient may be a carer for Take account of any Substance Misuse problems Record using appropriate toole.g. RiO Risk Assessment Tool Document in Patient Record Draw up Safety Plan in collaboration with the service user Use Dynamic/Acute Risk Factors to inform Safety Plan Include a Crisis Management Plan and actions to be taken when warning signs are apparent Integrate with Care Plan Evaluate Outcome of Safety Plan in collaboration Review effectiveness of Risk Management Plan Take account of both positive and negative outcomes for the patient Ensure Safety Plan is Carried Out Provide effective treatment, including for Substance Misuse problems. Ensure monitoring of risk Ensure effective supervision Refer to relevant policies & procedures Consider use of Mental Health Act when required Liaise with child or adult social services as appropriate Communicate Safety Plan Discuss with the patient Include in Care Plan With other agencies if appropriate Consider issues of Privacy and Dignity Consider any Safeguarding issues. Communicate with the Trust Safeguarding Teams child and/or adult as per safeguarding policies 15

Appendix 2 Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process. Training Programme Assessment and Positive Risk Frequency Course Length Delivery Method Facilitators Every 3 years 3 hours Face to face LEaD clinical trainers Recording Attendance LEaD Strategic & Operational Responsibility Strategically Head of Nursing, AHP and Quality for MH. Operationally Team Managers/Modern Matrons Directorate Service Target Audience MH/LD/TQ21 Adult Mental Health Specialised Services Learning Disabilities TQtwentyone All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners who work in the following services; East ECT; Hawthorns ward, PICU and MOD unit; South Outpatients, Saxon ward, Hamtun Ward, Trinity ward, South Fast Stream Rehab (Forest Lodge), South OT, Abbey ward. Mother & Baby Unit; Kinsley ward, Melbury OT. All art therapists that work in North Psychological Therapies. All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners, support workers, technical instructors/technicians who work in the following services; CQUIN Psychiatric Liaison; Liaison Psychiatry; AMH Management; Division Bed Management; West Medical Expansion; New Forest Teaching CTR; Homeless Team; Liaison & Diversion and the Perinatal Community Team. All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners who work in the following services; Leigh House; Ravenswood House (Ashurst, Lyndhurst, Malcolm Faulk, Mary Graham, Meon Valley wards and RSU community), RSU Therapies, RSU Psychology, Clinical Risk & Security and RSU Management); Southfield, Southfield OT & Southfield Psychology; Bluebird House (Bluebird Nursing & Security, Bluebird House OT and Bluebird House Psychology, Hill, Moss & Stewart wards) and Personality Disordered Offender team. Cypress and Ashford. All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners who work in the following services; Willow ward;; Evenlode; House 2 Step Down; Ridgeway centre. All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners, support workers, technical instructors/technicians who work in the following services; Community Learning Disability Teams including management; Psychology teams; Autistic Spectrum Disorder team.. Not Applicable ISD s Older Persons Mental Health All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners who work in the following in-patient services; Gosport War Memorial Hospital (Dryad & Daedalus wards); Melbury Lodge (Stefano Olivieri ward); Parklands Hospital (Beechwood, Elmwood wards & North Inpatient Therapies ); Western Community Hospital (Beaulieu, Berrywood & Minstead wards & Western Inpatient Therapies) All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners, support workers, technical instructors/technicians who work in the following community services; Community mental health teams (CMHT); Western/West Psychology; Western Management; Dementia Advisors; OPMH-Sift; ECT & Clinics; Aerodrome; East Management; St. Waleric and Newtown House. ISD s Adults Not Applicable ISD s Childrens Services Not Applicable Corporate All Not Applicable 16

Appendix 2 Training Programme Team Based Reflective Practice: Risk Training Frequency Course Length Delivery Method Facilitators E-assessment once only E-verificationannually Staff are required to complete the Positive Risk Taking e- assessment and participate in a minimum of 2 team based reflective practice sessions (1 hour minimum duration per session) e-assessment and team based facilitated sessions (minimum of one hour duration) A central register of facilitators will be maintained by the Head of Nursing, AHP and Quality- Mental Health Recording Attendance e-assessment via LEaD Staff will e-verify compliance with team based reflective practice risk training requirements via the LEaD website. Directorate Service Target Audience MH/LD/TQ21 Adult Mental Health Specialised Services Learning Disabilities TQtwentyone Strategic & Operational Responsibility Strategically Head of Nursing, AHP and Quality for MH. Operationally Team Managers/Modern Matrons All qualified practitioners, assistant/associate practitioners, therapists and trainee practitioners, support workers, technical instructors/technicians who work in the following services; Eating Disorders Service, Hampshire IAPT, all community treatment teams (CTT s), access and assessment teams, early intervention in psychosis teams (EIP), crisis and hospital at home teams, assertive outreach teams, psychology teams, enablement team, Elmleigh (inpatients & PICU) and Hollybank. (Exception art therapists). Not Applicable Not Applicable Not Applicable ISD s Older Persons Not Applicable Mental Health ISD s Adults Not Applicable ISD s Childrens Services Not Applicable Corporate All Not Applicable 17

Appendix 3 Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team Name of policy/service/project/plan: The Assessment and Management of Clinical Risk Policy Policy Number: SH CP 27 Department: Lead officer for assessment: Mental Health Division Liz Durrant Date Assessment Carried Out: December 2015 1. Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes This policy describes the processes Southern Health NHS Foundation Trust (SHFT) uses to ensure risks relating to the clinical presentation of patients and their care and support are assessed and managed. Intended policy outcomes: support clinicians in the assessment and management of clinical risk ensure that the Trust has an agreed process for clinical risk assessment and management ensure that the Trust can demonstrate that it complies with all national and commissioner guidance on clinical risk management. 18

2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions 2.1 What is the equalities profile of the team delivering the service/policy? Data, research and information that you can refer to The Equality and Diversity team will report on Workforce data on an annual basis. 2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment 2.3 What is the equalities profile of service users? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? The Trust is preparing to implement the Equality Delivery System which will allow a robust examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 19

1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations 20

In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this: Age Disability Positive impact (including examples of what the policy/service has done to promote equality) Use of Interpreters or other appropriate communication services such as sign language, may be required to ensure full involvement of service users in clinical risk assessment. Negative Impact As people grow older, they are more likely to be diagnosed with conditions such as cancer, heart disease and arthritis. A patient s relative need for a range of health interventions, including surgical treatment, therefore increases with age. People with severe and enduring mental health problems are more likely to have coexisting physical health problems, have poor social functioning and be stigmatised. National Institute for Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date 21

Gender Reassignment Throughout the process of gender reassignment all treatments, procedures, access criteria, associated risks and expectations should be clarified with the patient. An individualised programme of information provision, services, treatment, and surgery as appropriate to the person's individual needs and situation should be discussed and agreed. Clinical Excellence (2003). Schizophrenia: Full National Clinical Guideline on Core Interventions in Primary and Secondary Care, London: Gaskell & the British Psychological Society. Marriage and Civil Partnership Pregnancy and Maternity No negative impacts identified at this stage of screening No negative impacts identified at this stage 22

of screening Race Use of Interpreters or other appropriate communication services such as sign language, may be required to ensure full involvement of service users in clinical risk assessment. Interpreting and translation provider Religion or Belief Sex Sexual Orientation No negative impacts identified at this stage of screening No negative impacts identified at this stage of screening 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, 23

suicidal ideation, substance misuse, and DSH than heterosexual people 24

Sign Off and Publishing Once you have completed this form, it needs to be approved by your Divisional Director or their nominated officer. Following this sign off, send a copy to the Equality and Diversity Team who will publish it on the Trust website. Keep a copy for your own records. Name: Designation: Signature: Date: 25