Document name:
Clinical Risk Assessment, Management
and Training Policy
Document type:
Policy and procedure
Staff group to whom it
applies:
All mental health and learning disability
practitioners within the Trust
Distribution:
All mental health and learning disability
clinical teams and services in the Trust
How to access:
Intranet
Issue date:
October 2012
Version:
4
Next review:
October 2014
Approved by:
Executive Management Team
Developed by:
Linda Hollingworth, senior portfolio
manager, risk
Updated by:
Phil Tordoff
CPA Lead
Director leads:
Director of Nursing, Clinical Governance
and Safety
Contact for advice:
Director of Nursing, Clinical Governance
and Safety
Julie Fleetwood
Assistant Director Nursing
Clinical Risk Assessment, Management and Training Polly Final. October 2012
1
Contents
1.0
Introduction
3
2.0
Purpose and scope of the document
4
3.0
3.1
3.2
4.0
Definitions
Generic risk definitions
Clinical risk definitions
Duties and responsibilities within the organisation
6
6
7
9
5.0
5.1
5.2
5.3
5.4
5.5
5.6
5.7
6.0
Principles
Decision making, MDT working and collective responsibility
Collaborative working with service users and others involved in care
Positive risk management and positive risk taking
Care co-ordination and the care Programme Approach
Diversity and equality
Reflective practice and learning from experience
Risk assessment procedural requirements
Equality Impact Assessment
11
7.0
7.1
7.2
7.3
Dissemination and Implementation of this document
Dissemination of the policy
Implementation of the policy
Risk assessment and management skills training
32
8.0
Process for monitoring compliance with this policy
35
9.0
Review and Revision arrangements
36
10.0
References
37
11.0
Associated documents
38
12.0
References
30
Appendices
A
B
C
D
E
F
Checklist for review and approval of procedural document
Version control document
Best practice in clinical risk management – key points
Positive risk management (from Best Practice in Managing Risk)
Sainsbury’s Risk Assessment Tool protocol - Use of the Sainsbury’s
risk assessment tool in the Trust
Flowchart re use of Sainsbury’s Risk Assessment tool in the Trust
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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43
44
45
46
51
2
1.0
Introduction
1.1
Clinical risk management is a whole systems approach to identifying, assessing,
evaluating, minimising and communicating risks associated with clinical activities in
order to maximise safety for all parties. Clinical risk is dynamic and multifactoral. It is an
integral part of clinical practice and is subject to rigorous audit. Clinical risk assessment
and management in practice provides a protective framework within which to promote
the principles of recovery. “Safety is at the centre of all good health care. This is
particularly important in mental health, but it is also more sensitive and challenging
Patient autonomy has to be considered alongside public safety. A good therapeutic
relationship must include both sympathetic support and objective assessment of
risk”. Best Practice in Managing Risk. Department of Health June2007.
1.2
The South West Yorkshire Partnership NHS Foundation Trust (the Trust)
recognises that thorough, evidence-based clinical risk assessment and management is
an essential and on-going element of good care planning, and effective and safe
mental health and learning disability practice. The key principle underpinning the policy
is that all service users accepted into Trust services will have a risk assessment
completed and documented, where necessary leading to the development of a
documented risk management plan.
It also recognises that positive risk taking is an essential element of this process.
1.3
Clinical risk management involves developing flexible strategies aimed at
preventing the negative event from occurring or, if not possible, minimising the harm
caused. (Best Practice in Managing Risk 2007)
1.4
The philosophy underpinning this policy is one that balances care needs against
risk needs:
The following core values and principles are embedded within the policy
 Value of communication
.
The giving and receiving of information supporting clinical risk assessment and
management
 Risk management
Identification and positive management of risks which maximises the Management
of risk proactively and effectively.

Safeguarding
The protection and preservation of individuals where issues relating to personal
safety and the safety of others.

Promotion of effective clinical outcomes

Promote best care management of people and their carers across service
boundaries

Collaboration with the service user and others involved in care;

The importance of recognising and building on the service user’s strengths;
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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2.0
Purpose and scope of the policy
2.1
The Trust has a responsibility to ensure all employees have an understanding of
the principles of Clinical Risk Assessment and Management. This policy will set the
standards required in clinical practice and will reflect the requirements of the National
Health Service Litigation Authority, Care Quality Commission Standards and the
requirements of Better Health, and the Best Practice in Clinical Risk Management
(2007),
2.2
Set a clear standard for a systematic approach to positive clinical risk
assessment and management including positive risk-taking in clinical practice across all
Business Delivery Units in the organisation.
 Describe how risk assessment and management is undertaken as an integral
part of the care planning and care coordination process, including the Care
Programme Approach (CPA) in mental health services.
 How this will be implemented and monitored, through training, supervision and
audit processes
2.3
This policy is intended to guide practitioners who work with service users to
manage the risk of harm. It sets out the principles and standards required that should
underpin best practice across all health settings, and describes the tools
that are used to structure the often complex clinical risk management process. In
addition the policy describes the governance process for the agreement of the
introduction of clinical risk assessment and management tools
2.4






2.5
This Policy will :
Clarify the scope and methods of clinical risk assessment
Outline the systems by which clinical risk models and clinical risk assessment
tools used in services are authorised by the Trust
Clarify the standards of clinical risk assessment and management practice.
Set standards for the documentation and communication of Clinical Risk
Assessment and Intervention/care plans.
Describe the training requirements for employees.
Set out practice within the framework of personal accountability and
responsibility of clinicians.
Rationale for development of the policy
Safety is at the centre of all good health care. This is particularly important in mental
health but it is also more sensitive and challenging. Patient autonomy has to be
considered alongside public safety. A good therapeutic relationship must include both
sympathetic support and objective assessment of risk.
Professor Louis Appleby, National Director for Mental Health
Risk assessment and management, including positive risk taking, is an essential part of
providing a service to people. Clinicians are involved in making judgments of risk every
working day.
People who use Trust services will have varying support needs. Assessing the risk a
person poses, to him or herself or to others, can be a very difficult, uncertain and
complex task. It is important that a thorough risk assessment is undertaken and a clear
reasoned judgment developed and documented, which demonstrates that the best
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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possible practice has been followed. This includes documenting decisions to carry
some risk or where risk has not been fully eliminated, and the reasons for this (positive
risk management).
For each person the risks will be unique but the common factor is that without the right
support the person may put themselves and/or other people at serious risk. Providing
care to service users who have a history of serious aggressive or risk-taking behaviour
presents special problems and requires very thorough and careful assessment.
Although there are no research instruments and no risk assessment scales or scores
that will enable anyone to say with complete accuracy the level of risk or that one
service user is at risk and another is not, there is a considerable body of evidence that
indicates factors associated with risk and how prediction of risk can be made on the
basis of assessment information.
There may also be a number of agencies involved in each person’s care. It is crucial for
Trust staff to know what their responsibilities are around risk and for the policy and
procedure to be agreed with key partner agencies.
2.6
Development of this document
2.6.1 Approval of the document
This policy has been approved by the Executive Management Team in accordance with
the Trust’s policy for the development, approval and dissemination of policy and
procedural documents. Prior to approval the checklist for the review and approval of
procedural documents has been completed
2.6.2 Consultation and communication with stakeholders
In developing this policy a range of stakeholders were identified and consulted
including a range of clinical staff, professional leads and relevant specialist advisers.
Stakeholder
Executive directors
Assistant directors and senior managers
HR – training
Clinical staff
Professional leads
Specialist advisers
Clinical governance team
Professional leads
Mental Health Act group
CPA Leads
Health and safety group
Partner agencies: joint integration boards
Level of involvement
Consultation and dissemination
Consultation and dissemination
Consultation and dissemination
Consultation and dissemination
Consultation and dissemination
Consultation and dissemination
Consultation and dissemination
Consultation
Consultation
Consultation
Consultation
Consultation and dissemination
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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3.0
Definitions
The definitions below have been separated into:
 Generic risk definitions - broader risk assessment and management terms.
 Clinical risk definitions - terms relating to risk assessment and management in
providing care to individual service users
3.1
Generic risk definitions - broader risk assessment and management
processes
3.1.1 Risk - How likely it is that the harm from one or more hazards (or danger) will
happen and the consequences or impact that it would have.
3.1.2 Hazard - a danger – something with the potential to cause harm
3.1.3 Accident - An unplanned and unwanted event that actually results in a loss of
some kind.
3.1.4 Risk Assessment
A systematic way of:
1. Identifying hazards and risks
2. Deciding what harm could result, to who or what and how
3. Reviewing if these hazards/risks are adequately managed.
4. Taking action to manage, control or limit the hazards or risks
5. Identifying whether there are any benefits that justify the level of risk
6. Reviewing the effectiveness of the assessment and action plan
7. Recording this process
3.1.5 Risk assessment tools
Risk assessment tools are forms or formats specifically designed to inform systematic
risk management decision making and practice. Some are actuarial and others provide
structure for risk decisions.
3.1.6 Actuarial risk assessment tools
A tool designed to predict outcome measures (such as harm) based on scores from
predictor variables, such as previous history, gender and age. Statistical techniques are
used to examine which combination of variables produces the highest correlation with
the outcome measure, to increase the reliability of prediction. An actuarial approach is
used in motor insurance; an applicant answers questions about type of car, age,
geographical area, etc. This information is then entered into a statistical formula to
provide a risk score to determine the cost of insurance for that individual).
3.1.7 Risk management
Systematically applying policies, procedures and practice to:
1. Risk assessment based on identifying and evaluating hazards
2. Implementing measures to control or manage the risk
3. Regular monitoring and review
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3.1.8 Adverse incident - an unintended and/or unexpected event. A circumstance
that led to (or could have led to) harm, loss or damage to a service user, member of
staff, visitor, contractor, or property.
3.1.9 Serious incident (SI)
A serious incident where a patient, member of staff, or member of the public has
suffered serious injury, major permanent harm, or unexpected death either on Trust
premises or in some way connected to the services provided by the Trust.
3.2
Clinical risk definitions - risk assessment and management in providing
care to individual service users
3.2.1 Clinical Risk
The risk of a negative event occurring i.e. violence, self-harm/suicide, self-neglect or
harm from others, and covers a number of aspects:
 How likely it is that the event will occur
 How soon it is expected to occur
 How severe the outcome will be if it does occur
3.2.2 Clinical risk assessment
Clinical risk assessment follows a similar process to other risk assessments as
described. In addition clinical risk assessment involves working with the service user
(and/or their carers if appropriate) to help to estimate each of the aspects of risk (i.e.
violence, self-harm/suicide or self-neglect) occurring, how likely it is, how soon and how
severe it would be if it did. The assessment process will be evidence based and will
include information about the service user’s history of violence, self-harm or selfneglect, their relationships, their strengths, any recent difficulties, losses or problems,
employment, housing issues, their family and the support that’s available and any other
issues that could be relevant. It will also involve identifying whether the clinical benefit
justifies the level of risk, and the appropriateness of positive risk taking.
3.2.3Clinical risk assessment tool
Forms or formats specifically designed to inform systematic clinical risk management
decision making and practice. Tools can contribute one part of an overall view of the
risk presented by a particular individual at a particular time. Some are actuarial (see
general risk definition) and others provide structure for clinical judgements. Some tools
have built-in prompts for thinking about the management of any risks that are identified
while others do not. Tools should only ever be used as part of a general clinical
assessment conducted with a service user and combined with other information on
many aspects of the service user’s life and current situation.
The Trust has approved some tools for use by staff which includes the Sainsbury’s Risk
Assessment, Level 1 and Level 2 tools (adult and older people’s services),Sainsbury,s
clinical risk assessment and management tools and the HCR – 20 Assessing Risk for
Violence, Version 2 (Historical Clinical & Risk Management) (forensic services) and the
Learning Disabilities Initial and Comprehensive Risk Assessment tools.
The additional use of specific tools can be used in addition to the identified tool above
through agreement through the Governance council.
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3.2.4 Clinical risk formulation
Analysis and evaluation of the full risk assessment information and risk evidence base,
which will inform the development of the risk management plan. This formulation will
include an understanding of what the potential risks are, how likely they are, when they
might be present, what triggers, what indicators, how often and how serious they are.
3.2.5 Clinical risk management
Developing flexible strategies aimed at preventing any negative event from occurring
or, if this is not possible, minimising the harm caused. Risk management is a core
component of mental and learning disability healthcare and will often include elements
of positive risk-taking. In mental health risk management is a core component of the
Care Programme Approach and will include a set of action plans and a date for review.
Each aspect of the plan is allocated to an identified mental health practitioner.
3.2.6 Clinical risk management plan
A documented plan that includes a set of action plans to manage the risk of harm and
a date for review. The plan should include a summary of all risks identified, formulations
of the situations in which identified risks may occur, and actions to be taken by
practitioners and the service user in response to crisis. It will document where positive
risk-taking is being included as part of the plan, the rationale for this and how this
aspect of the plan will be managed.
Each aspect of the plan is allocated to an identified person, profession or team. The
plan describes how the service user’s strengths contribute to the management of risk,
and any signals of an increase in risk to others or self. There will be good and clear
communication of risk assessment and management plans.
3.2.7 Positive risk management
Being aware that risk can never be completely eliminated and that risk and care
management plans may include informed decisions regarding carrying some risk which
is assessed/considered to be tolerable. Carrying some risk (exposing the patient and
others to risk) may be an important element of the care plan to achieve a positive
outcome for the service user. These decisions should be explicit in the decision-making
process and should be discussed openly with the service user (and carer/others if
appropriate).
3.2.8 Positive risk taking
Taking an informed decision to carry some risk, with the aim of achieving a positive
outcome for the service user. This should be explicit in the decision-making process
and should be discussed openly with the service user (and carer if appropriate).
3.2.9 Levels of risk
How high or low the level of risk is considered to be based on a risk assessment. This
may be defined by an assessment tool or by the individual team or service.
3.2.10 Mental health or learning disability practitioner
Any mental health or learning disability staff working within Trust services (including
Social Services and Trust integrated teams) involved in providing direct care to service
users. Some clinical professions working in the Trust do not undertake mental health
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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assessments as a core part of their role and are therefore exempt. These professional
groups include dietitians, speech and language therapists, physiotherapists, and some
art and occupational therapists.
3.2.11 Recovery
Recovery is a personal process of tackling the adverse impact of experiencing health
problems, despite their continuing or long-term presence. Recovery involves personal
development and change, including acceptance there are problems to face, a sense of
involvement and control over one's life, the cultivation of hope and using the support
from others, including collaborating in solution-focused work with informal carers and
professional workers. (Rethink: Recovery Report)
4.0
Duties
4.1
Responsibilities of the Trust board
The Chief Executive and Directors of the Trust are responsible for managing all aspects
of Health, Safety and Welfare and to do all that is reasonably practicable to eliminate or
reduce to acceptable levels the risks and thereby promote the Health and Safety of all
employees, self employed persons, contractors, members of the public in general and
those whom are specifically in our care. The Trust therefore needs to have systems in
place to identify and manage risk.
4.2
Director of Nursing, Clinical Governance and Safety
The Director of Nursing, Clinical Governance and Safety is responsible for



The development of this policy
Monitoring adherence to this policy
identifying any potential barriers to the implementation of this policy
4.3
Medical Director (Mental Health)
It is the Medical Directors responsibility to ensure that all Doctors (including Doctors in
training) are aware of and work to the standards contained in this policy
.
4.4
Professional leads
Professional leads are responsible for ensuring that the policy and the implementation
of the policy is consistent with the expectations of the professional regulatory bodies
and does not put staff at risk of breaching their professional Code of Conduct.
4.5
Business Delivery Units (BDU’s)
Responsibility for the implementation of the policy in clinical services is delegated
from the responsible director through the BDU’s management and clinical leadership
structures. This includes ensuring:


Policy dissemination and implementation; all relevant mental health and
learning disabilities practitioners are aware of the policy and how it is
implemented at local/team level
Staff roles in relation to risk assessment and management are clearly
identified within the team
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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








That new staff are inducted into the risk assessment processes as
appropriate, including the tools used at local level, and are supported in this
until they have attended the necessary training
Training needs are identified through the supervision, KSF and training
needs analysis processes
Staff are alerted to and attend risk training in accordance with the policy, a
minimum of every 3 years or as identified at appraisal/performance reviews
Training records are maintained
Supervision processes include a review of risk assessment and management
skills and practice
Support is available to staff in taking informed, measured and managed risks
with service users
Systems are in place to review and monitor risk management practice
Wherever relevant , risk assessment and risk management decision-making
is made within the multi-disciplinary and/or multi-agency setting
Systems and processes to review and consider risks are put in place eg to
discuss high risk issues, agree levels of risk, explore scenarios, good
practice and adverse incidents and near misses.
4.6
All mental health and learning disability practitioners are responsible for:
 Working in accordance with this policy
 Considering clinical risk assessment and management issues in all contacts
with service users.
 Working collaboratively with service users, carers and colleagues (including
multi-disciplinary and multi-agency working) as necessary to provide a high
standard of care.
 Ensuring that the information on which they base their decisions is as up-todate, accurate and complete as possible.
 Considering diversity in risk assessing individual service users to ensure
responsiveness to individual need
4.7
In addition all professionally qualified mental health and learning disability
practitioners are responsible for:
 Ensuring that an initial risk assessment is undertaken as part of the first
assessment for all service users and that further risk assessment is
undertaken according to need
 Formally considering risk assessment and management as part of all care
plan reviews and that these are undertaken in collaboration with service
users and/or if appropriate their carers, wherever possible.
 Communicating and clearly recording all risk assessment and management
processes and decisions in the individual service user’s case notes and care
plan (electronic and/or paper records).
 Ensuring attendance at clinical risk training sessions at least every 3 years.
 Keeping up-to-date with developments in clinical risk assessment and
management pertinent to their area of work and client group.
 As a new member of staff, seeking supervision from staff more experienced
in risk assessment, and the use of the relevant risk assessment tool.
 Ensuring that their personal practice and knowledge is up to a recognised
standard, that this is applied and there is evidence that it has been applied.
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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4.8
Key worker and care coordinators including CPA care coordinators are
responsible for consultation and communication with stakeholders and ensuring
that risk assessments and management plans are:
 Undertaken regularly and in accordance with this policy.
 Integrated into the care planning process
 Documented
 Communicated (on a need-to-know basis)
 Implemented and any concerns identified and reviewed
 Reviewed regularly
 Reviewed at any other key stages such as crisis or change in circumstances.
4.9
Clinical and managerial supervisors
Supervision processes (clinical and managerial) for mental health and learning
disability practitioners will include clinical risk assessment practice in accordance
with this policy. (See Trust supervision Policy.)
5.0
Principles
5.1
Decision making, multi-disciplinary working and collective responsibility

All service users accepted into Trust services to have a risk assessment
completed and documented in the main case file held on Rio (the Trust
electronic service user record system) or Systmone where applicable. The
exceptions to this are where Trust services are currently implementing or have
planned implementation dates for RiO, therefore some clinical groups or teams
will still be using paper based records. It is important that a thorough clinical risk
assessment is undertaken and a clear reasoned judgment developed and
documented, which demonstrates that the best practice has been followed.

Decision making, wherever possible, should be made within a multi-disciplinary
or multi agency setting. It is important that all professionals involved in the
decision making process have access to the relevant risk information.

It is essential that the most difficult decisions around managing serious risk are
made on the basis of collaborative information-sharing, discussion and
agreement between the relevant mental health and learning disability
practitioners and agencies.

The decision-making process and outcome should be clearly documented and
all people involved in the collaborative discussions and decisions clearly
identified.

Sometimes there may be dissent from the decision made which has to be
accepted and clearly recorded in the electronic and/or paper case notes, where
possible in the risk assessment and management planning documentation.

Positive clinical risk management as part of a carefully constructed plan is a
required competence for all mental health practitioners
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
Clinical risk management plans should be developed by multidisciplinary and
multi-agency teams operating in an open, democratic and transparent culture
that embraces reflective practice. Where a clinical risk assessment has been
conducted in isolation by a member of staff , the rationale for decision making
should be communicated to the service user and people supporting the Service
User and reviewed by the wider team as soon as is practical. A clinical risk
management plan is only as good as the time and effort put into communicating
its findings to others.

Clinical risk management requires an organisational strategy as well as efforts
by the individual practitioner to mitigate presenting factors to the lowest possible
risk

Clinical risk management involves developing flexible strategies aimed at
preventing any negative event from occurring or, if this is not possible,
minimising the harm caused

Knowledge and understanding of mental health legislation is an important
component of clinical risk management. A working knowledge of the Mental
Capacity Act is essential

Where clinical risk assessment tools are used to inform management strategies
it is recognised that the tool can not substitute carefully considered
multidisciplinary professional judgement. Clinical risk assessment and
management is an aide to decision making but any decisions taken must be
clinically and legally defensible.
5.2
Collaborative working with service user and others involved in care

The principles of engagement and developing trusting therapeutic relations with
service users and carers are central in providing mental health and learning
disability services.

When it is safe to do so service users will be consulted about risk-related issues,
and involved in risk assessment and management decision-making processes,
in order to make risk management plans as realistic as possible.

Carers may be able to provide valuable information about the service user,
including their strengths and vulnerabilities, and can also be an important source
of support. Where appropriate, carers will also be involved in this process.

In relation to service users who are detained under the Mental Health Act, the
Mental Health Act 1983 (as amended by the Mental Health Act 2007) introduces
the new Participation Principle:
‘Patients must be given the opportunity to be involved, as far as practicable in the
circumstances, in planning, developing and reviewing their own treatment and care to
help ensure that it is delivered in a way that is as appropriate and effective for them as
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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possible. The involvement of carers, family members and other people who have an
interest in the patient’s welfare should be encouraged (unless there are particular
reasons to the contrary) and their views taken seriously’,
Mental Health Act Code of Practice 1.5

Clinical risk management should be conducted in a spirit of collaboration and
based on a relationship between the service user and their carers that is as
trusting as possible. It is acknowledged that on occasion this may not be
possible due to the nature of risks and the duty of all professionals to work within
the law (Obligations under Public Disclosure supplement to NHS Code of
Confidentiality 2010)

Clinical risk assessment and management must be built on recognition of the
service user’s strengths and also their individual responsibility where the person
has the requisite mental capacity.
5.3
Positive risk management and positive risk taking (See also Appendix D)
5.3.1 Sometimes a decision may be made to carry some risk – either because it is not
possible to eliminate all risks and/or because there are positive benefits for the
service user. A positive risk management approach and plan, based on the
expressed personal wishes of the service user, offers the best starting point for a
collaborative working relationship.
5.3.2 Positive risk taking should be seen as the first choice focus of clinical
interventions and has to be about:
 Identifying and targeting resources
 Agreed decisions between all people involved in the network of care and
support, inclusive of the service user and carer(s)
 A fully agreed and recorded collaborative action plan which is closely
linked to the overall care planning process
 Recording any risks which are being carried and any dissenting views
 Reviewing the care plan, listening, agreeing and responding to the views
of others relating to decisions been taken on positive risk taking.
5.4


Care coordination and the Care Programme Approach (CPA)
CPA will be considered for mental health service users where there are
concerns about high levels of risk of harm to self or others.
The CPA process supports the following key principles through the care
coordinator’s responsibilities:
 Regular review of clinical risk assessment and management.
 Action to meet/manage identified needs and risks.
 Steps to take in a crisis.
 Contingency arrangements if the agreed plan cannot be implemented.
 Signs and symptoms of relapse and steps to be taken to manage this.
 Action to take if there is a failure to attend agreed appointments.
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
Arrangement for follow up within seven days of discharge from hospital
for those on CPA.
CPA is not currently used across all learning disability and Children’s services in the
Trust .although case management processes and systems are in place as.
5.5
Diversity and equality
The Trust is committed to being responsive and supporting the needs of the
diverse population which it serves and has developed an approach to diversity
through the Equality and Diversity Strategy and Race Equality Scheme. This
includes providing equal access and equitable services for all service users,
which are respectful and effective while addressing the diverse needs of
individuals.
5.6
Reflective practice and learning from experience
The Trust seeks to operate as a learning organisation and work within a just and
open culture. Staff are encouraged to report all adverse incidents including near
misses in the knowledge that they will be treated fairly, and that a root cause
analysis approach will be used to investigate incidents.

Reflective practice in clinical risk assessment and management is supported and
encouraged by the Trust, as in other aspects of practice through:

Regular team discussions about clinical risk to clarify and develop consistency in
decision-making processes and definitions of types and levels of risk

Scenario-planning as a useful way of exploring what might happen in relation to
potential risks, and how these can be managed.

Learning from experience such as good practice, incident and near-miss review
processes

Individual and team supervision

Training
5.7
Risk assessment procedural requirements

Risk assessment involves working with the service user (and/or their carers as
appropriate) to estimate each aspect of risk occurring (harm to others, self harm,
self neglect):
 how likely it is to happen
 how soon it could happen
 how severe the outcome would be if it did happen
5.7.1 The assessment will be fully informed by:
 Complete, accurate and up-to-date information.
 The potential risks and the factors that impact on any identified risks
(described more fully below).
 All relevant factors that may contribute to, increase or decrease levels of risk
Clinical Risk Assessment, Management and Training Polly Final. October 2012
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


Known risk history and put into the context of the up-to-date factual
knowledge of the individual current situation and circumstances
Information gathering of any additional information
Evidence-based information about risk assessment
5.7.2 When will service users be risk assessed?
All service users will be risk assessed in order to identify any current risks and develop
a risk management plan:
i. on admission to the service
ii. at key turning points during their care, such as a change of circumstances
iii. CPA/Standard Care Reviews/Non-CPA reviews
5.7.3 What risks will be considered?
Consider the full range of risks in the context of his or her environment and
circumstances (social, family and welfare circumstances), including those associated
with being a user of mental health and learning disability services eg social inclusion
and mental health promotion.
a) Risk to self
 Self harm
 Self neglect
b) Risk to others
 Violence to others
 Risk to children may also need to be considered (see Section 7.0 )
c) Other potential risks and risk factors
 Risk of abuse, exploitation, physical ill health, poor living conditions, the
effects of poverty, discrimination, homelessness, isolation, social
exclusion and the need for mental health promotion.
 Risks associated with particular interventions, such as physical
interventions, percutaneous endoscopic gastrostomy (PEG) placement
feeding, medications
 Risk pertaining to medicines prescribed or self administered including
substances of abuse, drug interactions and complex prescribing
regimens
d) Temporal aspects of risk assessment.
Understanding the risk and the potential impact over time. Is the risk
acute, immediate, short term, medium term, long term?
5.7.4 Risk factors to consider
a) Static risk factors – historical risk factors generally not subject to change, such
as things that have happened in the past. (Although static these can have
dynamic components, such as anniversaries and triggers.)
b) Dynamic risk factors – more volatile risk factors that are subject to change,
such as alcohol abuse, medication concordance, mental state, current
relationship issues.
c) Factors that influence risk, which include:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Historical risk information
How recent and severe any risk has been.
Any known patterns or triggers to risk behaviour
Any current plans or intent related to risk behaviour
Any risk or relapse indicators
Unwanted side effects from treatment
Difficulties treating with medicines(treatment resistance) – prescribing
high dose/unlicensed treatment.
Polyprescribing including risk of drug interaction
Compliance and engagement issues, which may relate to the
acceptability of treatment or care proposals
Effects of poor diet
Effects of physical health problems
Poor social networks
Being a carer as well as suffering mental health problems
Stigma
Local community issues (e.g. difficult neighbours)
Offending behaviours and patterns, including recidivism (habitually
returning to crime)
5.7.5 Identifying service user strengths and recovery
Service users will have (or may be able to develop) strengths, skills and
resources that are important protective factors that can be used in recovery and
risk management plans. This may include both personal strengths and any
support networks. It can also include identifying where skills and strengths could
be developed, or how unhelpful or maladaptive behaviours could be reduced.
Carers can have an important contribution to make to this process.
5.7.6 Risk assessment tools used in the Trust
Assessing and managing clinical risk in mental health and learning disability
services is complex and needs to include a number of different approaches.
There is a considerable body of evidence that indicates which factors are
associated with risk and how prediction of risk can be made on the basis of
assessment information.
Although some concerns have been expressed about employing risk
assessment tools and ‘tick box’ forms, risk assessment tools can bring a
systematic approach to assessing and recording risk by:
 Prompting staff to comprehensively consider and record relevant risk factors
and information
 Providing a clear record and evidence of the risk assessment process.
In the light of this the Trust has formally approved a number of risk assessment
tools for use in the individual care areas, as part of the electronic clinical
information system (RiO). (Paper record where RiO to be implemented)
Risk assessment tools are one aspect of risk assessment. A tool can only
contribute one part of an overall view of the risk presented by a particular
individual at a point in time. Good risk assessment and formulation is supported
and strengthened through the clinical experience of clinicians thinking
incrementally and continuously. The results of the tool-based assessment must
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always be combined with other information on many aspects of the service
user’s life and current situation. Where these evidence-based risk assessment
tools have been identified for use in the Trust they will be used consistently to
inform and support a comprehensive assessment and care planning process
and development of a risk management plan.
Staff using these risk assessment tools will be appropriately trained in their use.
The risk assessment tools formally approved for use in the Trust are as follows:
5.7.7 Adults of Working Age Services and Older Peoples Services (exception of
Barnsley)
Sainsbury’s risk assessment tools
 Level 1 Tool(Initial risk assessment) for all referred into service
 Level 2 Tool (Comprehensive Multi-disciplinary assessment) for those
individuals assessed as requiring CPA
The Sainsbury’s initial risk assessment tool (level 1, is identified as good
practice in the Best Practice in Managing Risk, Department of Health 2007. and
is used in adult and older people’s services It is recognised that professional
groups also have their own initial risk assessment tools designed for this
purpose.
All service users of working aged adult and older people’s services will have a
risk assessment. The Sainsbury’s Risk Assessment Tools have been approved
for use in the trust the level of assessment will depend on whether the service
user is on Standard Care (Non CPA) or Care Programme Approach pathway
When a service user transfers from one mental health team or service to another
an up to date Mental Health Clustering Tool, Sainsbury Risk Assessment (Level
1 and where necessary Level 2, and a comprehensive Health and Social care
assessment should accompany the referral or be sent at the time of transfer of
care. A further assessment may still need to be completed by the service taking
over care. Further procedural guidance and good practice standards is available
in the Trust’s Discharge and Clinical handover Of Care Policy.
5.7.8 Barnsley Services
The above principles and guidance are delivered through the following
processes in the Barnsley BDU.
Completion of:

Risk assessment utilising Sainsbury risk assessment tool and other secondary
assessments (as agreed through the clinical governance process)

Clinical Risk Summary sheet
As part of the of risk assessment and management within the Trust we will be
reviewing systems and processes.
5.7.9 Forensic Services - medium secure
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HCR – 20 Assessing Risk for Violence: Version 2 (Historical Clinical and Risk
Management). Historical, clinical and risk management items are included in the
content of this assessment tool.
5.7.10 Forensic services – low secure
Sainsbury’s risk assessment tools and HCR 20 (Historical Clinical and Risk
Management)
The Low secure service have established a specific combined Risk Assessment
and Management Plan Tool (RAMP) relevant to all service users in the Bretton
Centre.
5.7.11 Learning Disability Services
Generally risk assessment takes place using the three Local Authority Care
Management assessment processes, which incorporate risk assessment.
Currently there are a range of risk assessment tools in use in the Trust specific
to Learning Disability services. A risk assessment tool has now been developed
for Learning Disability Services and is held on RiO, the Trust’s electronic record.
This covers an initial and a comprehensive risk assessment and is being
implemented across level 2 services (Inpatient and Community Assessment
&Treatment)
In addition to these risk assessment tools care teams may identify additional or
specialist risk assessment tools to support clinical practice. The choice of a
particular additional tool by a care team must take into account the evidence
base of the tool, the competence and skills in its use of the practitioners in the
team and it’s relevance to the circumstance in which it is being used.
5.7.12 Child and adolescent mental health services (CAMHS)
Barnsley
CAMH Services in Barnsley use the DICES Risk Assessment and Risk
Management System developed by APT (The Association for Psychological
Therapies).
DICES relate to the % stages of this Risk Management system which are;
1. Describe the Risk. In this section you should describe all significant risks the
person presents to him or her-self, or to others. You should also describe the
evidence for what you write, taken from the DICES™ guides.
2. Identify the Options. Here you list the options for managing the risks. Include
even the options you may reject: others want to know why you reject them.
Good options will (a) minimise the risks posed and (b) help the person
concerned and those around him or her.
3. Choose your preferred option(s). This is your risk management plan and will
be one or more of the above. You may expand your chosen option(s), give
details, name who will undertake the tasks involved, etc. You may also specify
“if X then Y” plans.
4. Explain your choice. Include in particular why you rejected your non-preferred
options.
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5. Share your thinking. The point of sharing is (a) so others can disagree and (b)
so others know their part in the plan. Your thinking (as on this form) should
therefore be shared verbally and in writing. State here (a) who you will talk to,
(b) who this form will be copied to and (c) where this form will be filed
(somewhere accessible to those who need to know).
Staff undertake a 3 day training facilitated by APT which focuses on the main
areas of risk identified in CAMHS.
Wakefield CAMHS.
Wakefield CAMHS currently utilise risk assessments which relate to specific care
pathways and Sainsbury’s screening tool which leads to formulation of specific risk care
plans, co-produced with children, young people and carers.
They are currently reviewing their risk assessment tools which will, on completion of the
review, go through the appropriate process for approval by the Trust.
5.7.13 Risk Formulation
Risk formulation is the process of analysing and evaluating the risk assessment
information and evidence base to inform the risk management plan. It involves
developing an understanding of the risk profile of the individual service user and the
level of risk presented, including:
- What the potential risks are (What are the risks? Who are the risks to?)
- How likely is it to happen?
- If it happens how serious could it be?
- When is the risk likely to be present?
- What might (or does) trigger the risk of harm?
- How often is the risk present?
- What indicators might there be of the risk?
- Any history of offending?
Formulation will then lead on to developing a risk management plan, which forms a
core component of mental healthcare and the Care Programme Approach. Formulating
risk can be helped by considering potential scenarios (possible futures, posing the
question, ‘if…’).
5.7.14 Risk management planning and positive risk taking
The clinical risk management plan is a documented plan, clearly based on the findings
and formulation of a risk assessment that includes clearly identified action plans to
manage the risk of harm, and may include positive risk-taking (see appendix D).
Clinical risk management planning involves:





Developing flexible strategies, aimed at preventing any negative event from
occurring or, if this is not possible, minimising the harm caused.
Considering what will limit or control the risks most effectively
Matching the clinical intervention to the service user’s needs, with the
expectation of reducing risk as well as reducing distress and despair.
Including the service user’s strengths.
Include informed decisions to take positive risks.
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
Taking account of how critical risk factors need to be managed over time (a
risk assessment is undertaken at a point in time).
Wherever possible, decision-making should be agreed made within a multi-disciplinary
setting and involve the service user and carers.
The risk management plan will be clearly documented and will include:
 A summary of all identified risks
 Formulations of the situations in which identified risks may occur
 How these risks will be managed
 How the service user’s strengths contribute to the management of risk
 How the service user’s strengths will be promoted through the development of
important life skills eg problem-solving, stress management.
 How unhelpful or maladaptive behaviours will be reduced.
 Each aspect of the plan allocated to an identified person, profession or team.
 An identified lead practitioner (eg care coordinator or case manager) who will:
o work with the service user to improve effective risk management
o ensure the plan is recorded and communicated
o ensure the plan is appropriately reviewed and updated
 Any known triggers of an increase in risk to self or others
 Any known signals or indicators of an increase in risk to others or self.
 Awareness of the potential for service user’s disengagement with care and
whether that might signal an increase in risk to others or self.
 Actions to be taken by the service user (and/or carer if appropriate) and by
practitioners in response to crisis
 A date for review
 Guidance on the reasons for earlier review
5.7.15 Recording risk assessment and risk management plans
Good and clear documentation serves a number of essential purposes, including
communication with others, a record of the care provided at a point of time and the
reasons for this and potentially as a source of evidence in the face of scrutiny eg an
investigation if something goes wrong.
Risk assessment and management are not static; attention should be paid constantly to
risk and the recording of it.
All considerations and decisions relating to risk will be clearly recorded in the service
user’s main case records (with copies to others as necessary). This will usually be in
the electronic service user record, RiO.(paper records where implementation of RiO is
awaited These records will include:
1. Level of user, carer and professional involvement in the risk
assessment and management process including:
o Service user consent to information sharing and involvement
o Actual involvement
o Reasons for non-involvement or refusal to engage in the
process
o Any dissenting views or disagreements
2. Risk assessment information
o Completion of a risk assessment tool or
– Presenting risks and risk factors
– Historical risk information
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o
More detailed risk assessment records - such as the Level 2
Sainsbury risk assessment tool
3. Risk formulation
o Formulations
o Decision-making processes and outcomes
o Records of who was involved,
o Any dissenting views.
o The views of service users and, where appropriate, their
carers
o Any lack of collaboration (or obstacles to collaboration) by
service users or carers. This will also be documented in the
care plan where appropriate.
4. The risk management plan and actions
o The plan (as described above)
o Positive risk taking
o Accessibility of the information to others eg the service user,
carer, other agencies
5. Progress notes
5.7.16 Information sharing and transferring information between services
A risk management plan is only as good as the time and effort put into communicating
its findings to others. (Best practice point 16 - A risk management plan is only as good
as the time and effort put into communicating its findings to others)
i. General principles
Sharing information with other individuals, teams and services (on a need to know
basis, taking account of confidentiality and consent) is an essential element of risk
management and supports safe, seamless and effective care. This will clearly identify
the main areas of risk (e.g. violence or suicide), management concerns, clear
statements about the most relevant risk and protective factors, and a management plan
with responsibilities agreed.
Wherever possible the risk assessment and risk management planning process will
have been undertaken in collaboration with the service user and will be shared openly
with him or her. Carers may also be actively involved in this process and have access
to this information either with the service users consent, or if the service user does not
have capacity to consent, by considered agreement with the care team on the basis of
the service users best interests.
Information sharing around individual service users, between Trust services and teams,
with Local Authority services and sometimes other multi agency teams, is essential to
providing coordinated care and effectively managing risk. Standardised risk
assessment formats across services will enable risk information to be more easily
transferred and understood between services.
The following standards will apply to information sharing between Trust services and
teams:

Where a person is transferred between services or teams (eg between
community and inpatient services) the new team/service will usually receive a
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

copy of the most up-to-date risk assessment (as part of the relevant
documentation) at referral and/or transfer.
Where a service user is cared for by more than one service or team the same
risk management plan should be used and shared to support a consistent
approach to care.
Information sharing arrangements should be documented in the service users
main care record, usually as part of the CPA or care planning process. This will
include reasons for not involving service users or carers, or for not sharing
information from others with them.
ii. Confidentiality and information-sharing
There are very clear legal restrictions on sharing service user information. Any
information-sharing will be in line with the Trust’s Information Governance policies and
procedures, including the Confidentiality Policy, to ensure that practice is in keeping
with national legislation and good practice. National guidance is available in the NHS
Code of Practice: Confidentiality.
Sharing information between health professionals and teams (including health and
social services integrated teams) should be on a need-to-know basis and only for the
purpose of providing care. The service user should be made aware that the
information-sharing is to take place and unless he/she objects can be assumed to have
consented.
The service user’s agreement should be sought before sharing information with
external services and agencies and in any circumstances where the information is not
directly related to the service user’s care. There are situations when it may be
necessary to breach the confidentiality of service users, such as when there is a clear
risk to themselves or others. In this instance advice should be sought from the Trust’s
Caldicott Guardian. This decision and the reasons for it should be clearly documented
in the service user’s main records. This may need to be justified at a later date.
Services may also receive information from a third party (individual or organisation),
which is subject to the same information sharing principles and restrictions. Before
sharing this information the service should clarify whether that information can be
shared with the service user and/or carer. Providers of third party information should
be made aware that the information could potentially become available to the service
user due to a court order in the future.
5.7.17 Extracts are from Trust Documents
It is recommended that you access these documents for further information/clarification
i. Code of Conduct: Confidentiality
Guidance to all staff based on the NHS Code of Practice : Confidentiality
Breaking Confidentiality
If a health care professional chooses to break confidentiality, the decision must be
carefully considered as it will need to be justified. In such a case, the health care
professional should consult their manager, who may then seek advice from the
Caldicott Guardian. Such decisions should be clearly recorded in the patient’s
records, and on the form in Appendix E of the confidentiality and data protection
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policy. The service user should be informed of the information sharing unless the
reason not to do so can be justified
Occasions for Disclosure
Disclosure of confidential information should only occur if the individual gives
consent, except in very limited circumstances (see section 4.8.5).
Protecting the Public
There may be instances when staff working for, or on behalf of the Trust consider
there is a serious risk to the public, an individual or the service user themselves,
which can be averted by sharing information. They may also become aware of
information which would help prevent or detect a serious crime. This type of
disclosure should be made in consultation with the Caldicott Guardian, unless
specifically allowed within one of the Trust policies.
Sharing Information
The six Caldicott Principles should be adhered to in all cases where the sharing of person
identifiable information is being considered. (Appendix B)
ii.Information sharing, Confidentiality and Data Protection Policy
Information Sharing
In providing safe and effective care it will at times be necessary and appropriate
to share information. There are a range of reasons for sharing information for the
benefit of the service user, some of which may relate to risk management and
safeguarding issues. Consent should be sought when the service user is well to
share information for the service users benefit and for risk management and
safeguarding reasons when they are unwell. The advantages of planned
information sharing should always be explained. Where consent is withheld, the
service users wishes should be respected. There are only limited occasions
when the service users consent would not be sought or their refusal to consent
would be over ridden (section 7.2). The service users decisions on information
sharing should be clearly documented in the consent to share form on RiO and if
appropriate the care plan.
5.7.18 Reviewing risk assessment and management plans
Risk assessments and risk management plans will be reviewed and updated to ensure
the plan is still relevant. For people on CPA/Standard Care this will be at least annually.
The care coordinator is responsible for ensuring that a risk review is undertaken at
relevant times and is documented. The key worker will hold this responsibility in
situations or services where there is no identified care coordinator.
Reviews will be undertaken regularly and a review date identified. Clinical judgement
will dictate when additional review is necessary, such as:
 Deteriorating or improving symptoms.
 A serious untoward incident.
 A change in circumstances (eg non availability of usual support mechanisms).
 Transfer or discharge.
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
CPA/Standard Care review.
Service user records will clearly show risk review dates and the most recent risk
assessment and management plan.
5.7.19 Other issues to consider
Following any incident or allegation an incident report form must be completed and the
incident investigated at an appropriate level, in accordance with the Trust policies and
procedures. Issues should also be recorded in the individual service user’s records
including decisions and decision-making processes.
i. Assessing risks to children - see sections 5.7.20 – 5.7.23
ii. Vulnerable adults
The Trust requires all staff who observe abuse of a service user, or have a concern in
relation to the vulnerability of a service user, to report those issues as soon as possible
to their line manager. (If they suspect that the manager is implicated, they must report
to a more senior manager as soon as possible.) A monitoring form should be
completed and forwarded to the Trust’s Specialist Adviser for Vulnerable Adults
Definitions of abuse, vulnerability and adult protection principles are identified within the
local area (Calderdale, Kirklees and Wakefield) multi-agency Adult Protection policies
and procedures policy, which can be found on the Trust intranet or via access to the
appropriate local authority website. The Trust Protocol for the Prevention of Abuse of
Vulnerable Adults is in place to join up Trust Vulnerable Adults procedures with these
local area policies.
If an issue appears to involve a crime the Police must be contacted as soon as possible
- it is not necessary to wait for an adult protection strategy meeting or the go-ahead
from a lead person. Advice can be sought from the Trusts Specialist Adviser for
Vulnerable Adults.
iii. Domestic violence
Domestic violence has been identified as a major public health issue. It includes any
incident of threatening behaviour, violence or abuse (psychological, physical, sexual,
financial or emotional) between adults who are or have been intimate partners or family
members, regardless of gender or sexuality. Staff undertaking risk assessments need
to be aware that service users may be the victims or perpetrators of domestic violence.
– Women are more likely to experience repeat incidents of abuse.
– Abuse against women also affects their children; about 750,000 children witness
domestic violence each year. Staff need to be aware of their responsibility to
acknowledge the risk to any children within households where abuse may be
taking place (see section 7.0).
– Domestic abuse can also affect:
o Men
o Older age adults
o People in same sex relationships.
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Staff can seek advice from their manager, the Named Nurse for Safeguarding Children
or the Specialist Adviser for Vulnerable Adults and should follow Child Protection or
Vulnerable Adult procedures if abuse of a child or a vulnerable adult is suspected.
iv. Missing service users
If there is a possibility that a service user may go missing, or actually does go missing
the risks in relation to this situation need to be assessed and appropriate actions taken.
The risks and actions may relate to the vulnerability of the service user or the risks this
may present to others. The Trust Missing Mental Health Service User/ Patients Policy &
Procedure which is a joint protocol with the South and West Yorkshire Police should be
followed.
v. Harm reduction - managing risky behaviour
Some services and units within the Trust manage high levels of risky behaviour, such
as self-harming. In some situations these services may wish to explore and agree the
use of a harm reduction model, rather than a zero tolerance model. (There is evidence
that a harm reduction model is more likely to work over the long-term than the latter.)
These decisions need to be made in a multi-disciplinary forum as part of the care
planning process and wherever possible in collaboration with the service user and/or
carer. The Vulnerable Adults specialist adviser may also need to be consulted.
.
Advance decisions and the mental capacity act
vi. Service users can be offered the opportunity to provide advance communications or
less formal statements covering how he or she would like to be managed when they
are acutely mentally ill (lacking capacity) or in distress. These can be used with
service users who sometimes lack the capacity to inform practitioners what they
need or want by way of risk management at such times
Local partnership agreements
Locally agreed determinants supporting decision making
Advanced Decisions have legal force and are covered under sections 24 – 26
of the Mental Capacity Act 2005. Advanced Decisions offer the opportunity for
the service user to provide advance communications of treatments which he or
she would not consent to.
Advanced Statements can be created covering how the service user would like
to be managed when they are acutely mentally ill (lacking capacity) or in
distress. These take effect when the service user lacks the capacity to inform
practitioners what he would need or want by way of risk management at such
times.
Mental capacity act 2005
In co-production of risk assessments consideration should always be given to
the Mental Capacity Act 2005 and an assessment of decision making capacities
– referring to the M.C.A Policy or code of conduct to guide practice
The Mental Health Act 1983 (as amended by the Mental Health Act 2007) supporting
Code of Practice advises that service users should be encouraged to set out their
wishes in advance (17.14) and that these should be “included in care plans and other
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documentation which will help ensure that the patient’s views are remembered and
considered in situations where they are relevant in the future” (17.18).
Both Advanced Decisions and Advanced Statements are currently being developed to
allow recording on RiO (Electronic Record) and are going through a final legal check
before they become active
vii.
Service users detained under the Mental Health Act
Mental health practitioners involved in risk assessment and management planning also
need to have a good understanding of the Mental Health Act and its associated Code of
Practice and Memorandum. Assessment under the Mental Health Act is a form of risk
assessment and management.
Being detained under the Mental Health Act does not limit the need to collaborate with
service users and, if appropriate, their carers - service users detained under the Mental
Health Act in an inpatient setting will still be consulted about risk assessment and risk
management planning wherever possible.
viii. Environmental risks
Clinical risk assessment and management is supported by assessment and
management of environmental risks, such as ligature points (see Health and Safety
policy and procedures).
ix. Victim safety planning
It is important that any issues regarding victims or potential victims are identified at the
point of referral and risk assessment, and at any other point in the care and treatment
of an individual. Risk management plans will be based on the individual case and the
following factors will need to be considered in developing a risk management plan:
– Risks may vary depending on the service user’s mental state at a given time, or
may be a consistent risk.
– Whether the identified risk is general or specific to a known potential victim eg an
ex-partner)
– The service user’s volition in terms of seeking that person out and how this can
be managed.
– Managing the balance between risk and protective factors eg in an inpatient unit
the risk management plan may need to include plans for if the service user goes
missing from the unit, as well as for leave and discharge arrangements.
– Include liaison with the person/s at risk, the probation service and police.
– See also the Trust policies on missing patients, the Multi Agency Public
Protection Arrangements (MAPPA), and Trust policies and procedures for
managing violence and aggression (see section 12.0).
– MARAC –Multi Agency Risk Assessment committee (Domestic violence)
x. Risk of harm to staff
There may be occasions when individual staff members are identified to be at risk from
a service user e.g. there are specific or general threats against staff members. These
situations should always be taken seriously, reported to a senior manager and a
process followed to assess and manage the risk appropriately. As with victim safety
planning the management plan will be based on the individual case, but may involve
liaison with the police. See also other Trust policies relating to the management of
violence and aggression and the Policy for Personal Safety from Violence and
Aggression (see section 12).
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xi. Links with and support from specialist forensic services
Practitioners from the Trust’s low secure forensic services offer support and advice on
risk management to practitioners in other services on request. Referrals can also be
made to the low secure services for a forensic risk assessment.
The Trust’s Regional Medium Secure, Newton Lodge, offers:
- Pre admission assessments
- Risk management advice to Trust services with difficult to manage service users
Assessment and management of risk in relation to
children and service users
5.7.20
In assessing and managing any risks where children may be affected staff should also
refer to the Trust’s Child Protection Manual and the Area Child Protection Committee
procedures. The Trust’s named nurse for Safeguarding Children can provide advice
related to assessing and managing risks in relation to children and child protection,
including information-sharing with other agencies.
Assessment and consideration of risks in relation to children needs to consider:
i. Children who are a service user in their own right
ii. Children who have a familial or other relationship with a service user, (including
children who are carers) who may be identified as at risk of harm, or have
identified needs
iii. A service user who may be identified as a risk to children
The definition of a child, as laid out in Working together 2006, is:
“A child is anyone who has not reached their 18 th birthday. The fact that a child has
reached 16 years of age, is living independently or is in further education, is a member
of the armed forces, is in hospital, in prison or in a young offenders’ institution, does not
change his or hers status or entitlement to services or protection under the Children Act
1989
5.7.21 Children who are a service user
Staff working with services users who are children will undertake appropriate risk
assessments and develop risk management plans in accordance with this policy taking
into account all other considerations in relation to the particular risks and risk
management processes specific to children.
See the following section for information on risk assessment and management specific
to children. These are fully described in the Trust’s Child Protection Manual and the
Area Child Protection Committee procedures.
5.7.22 Children who have a family relationship or substantial contact with a
service user (including children who are carers), who may be identified as at risk
of harm, or have identified needs
When assessing and providing services to an adult with mental health problems,
mental health professionals must be alert to and inquire about the needs of any
children in the family, even if there appears to be no immediate concern of significant
harm. This will include any child or children:
Clinical Risk Assessment, Management and Training Polly Final. October 2012
27
•
•
•
for whom the adult is the parent and/or has parental responsibility
in the service users more extended family
with whom the service user has substantial contact
During all assessment, monitoring, review and discharge planning staff should consider
if the individual is likely to have or resume contact with their own children or other
children in their network or family friends, even when the children are not living with the
person:
 If the person has or may resume contact with children, this should trigger an
assessment of whether there are any actual or potential risks to the children.

Staff should pay particular attention to expressed delusional ideas towards children
and/or if suicide plans may result in the harm of a child.

A consultant psychiatrist should be involved with all complex cases, and this
includes direct involvement in all clinical decision making for all persons involved in
services who may pose a risk to children. (medical staff may wish to seek advice
from their own MDO in cases where they feel there may be an issue relating to the
best interests of their own patient and the paramount interests of the child)
Mental health professionals must consider the needs of both the adult and the child but
the welfare of the child is always paramount. The illness of a parent does not
necessarily have an adverse impact on a child but it may:



Restrict their education, and social activities;
Give them inappropriate caring responsibilities;
Cause them to be at risk of severe injury or profound emotional neglect;
Initial assessment will include and record the following:
• Is the service user the parent of any children and/or or living in the same
household as any children?
• Number, age and sex of all children living with the service user
• Does the service user have regular and substantial contact with any children?
• Number, age and sex of any children closely associated with the service user
• Is a child or are children acting as a carer for the service user
• Record details of any other professionals or services involved with the care of
the children
• How the service user sees his/her caring responsibility?
• How the service user is managing child care responsibilities and how these
impact on the service user
• How the service user thinks their illness is impacting on the child(ren)
Care planning including the Care Programme Approach (CPA)
Child protection work is multi-agency in its nature. All care planning processes
(including CPA) where children are affected will include:



Inviting all allocated child care workers or ‘duty’ child care workers;
Ensuring that care plans include referral of children who are vulnerable/at risk to
relevant statutory and/or voluntary agencies as appropriate;
Identifying the need for ongoing liaison between the CMHT and relevant child care
agencies.
Clinical Risk Assessment, Management and Training Polly Final. October 2012
28
The welfare and safety of children in the service users family and/or for whom the
service has parental responsibility should always be discussed in the care planning
meeting and included in the care plan.
There may be other meetings relating to the child or the family concerned e.g. looked
after children’s reviews, child protection conferences or other planning or strategy
meetings. The mental health worker should ensure attendance at such meetings and
in the event of not being able to attend should prepare a report and inform the
named/designated professional.
Assessing risk: Child Protection and significant harm:
Child Protection risks to children will be given separate consideration relating to
responsibilities under specific legislation and procedures, which are described in the
Trust’s Child Protection Manual and the Area Child Protection Committee procedures.
Mental health and learning disability practitioners have a duty to share any concerns
relating to child protection with appropriate agencies and to prioritise attendance at
multi-agency child protection case conferences and strategy meetings.




Mental health professionals must recognise and act upon indicators that a child’s
(including unborn and older children) safety and/or welfare could be at risk of
significant harm;
Significant harm is the threshold for compulsory intervention in family life in the best
interest of children;
Professionals must refer concern about significant harm without delay to the
Department of Social Services.
Mental health and learning disability practitioners may want to seek advice from the
named nurse for Child Protection, prior to making a referral.
Where there are concerns about possible harm to a child, or where the child appears to
be a child in need and could benefit from an assessment of need by Social Services,
the mental health or learning disability practitioner is responsible for referring the child
to the appropriate local authority Social Services:
Referring a child to the appropriate local authority Social Services
Referrals should be made where there are concerns about possible harm to a child or
where the child appears to be a child in need and could benefit from an assessment of
need by Social Services. This will be discussed with the appropriate mental health
team leader and named/designated child protection professionals).
-
Parental consent is required for a child referred in need
Parental consent is not required for a child referred for child protection - but it
is good practice to advise the parent(s) a referral is being made. This should
only be done when it will not increase the risk of significant harm and the
welfare of the child or other children will not be compromised.
Mental health professionals should offer support and services, which will support the
family as a whole and take into account and enhance the adults parenting capacity;
Clinical Risk Assessment, Management and Training Polly Final. October 2012
29
Information sharing
Child protection work is multi-agency in its nature and mental health and learning
disability practitioners have a duty to share any concerns and relevant information
relating to child protection with appropriate agencies.
However if a service user becomes involved in any legal proceedings regarding their
children (e.g. care proceedings, contact/residency disputes) mental health workers will
not share information with any legal personnel without first seeking advice from the
Caldecott Guardian either directly or through the named nurse or doctor for
Safeguarding Children or the Portfolio Manager, Information Governance.
5.7.23 Service users identified as a risk to children
Some service users may be identified as posing a risk to children more generally. The
risk assessment and management plan will take account of this in the context of the
legal framework, to ensure that staff working with the person are aware of the potential
risks and the risk management plan, and know what actions to take and when. Advice
should be sought as necessary from the lead nurse for child protection.
Service users subject to Hospital Orders, or who are otherwise considered to pose a
potential risk to the public may meet the criteria for Multi Agency Public Protection
Arrangements (MAPPA) registration. Where this is the case, or is suspected, the matter
should be made known to the area MAPPA nominated officer
5.7.24 Risks related to medicines
 Where service users are prescribed medicines that are unlicensed for the use the
are prescribed the risks of these need to considered for the service user and
consent obtained.
 When doses of medicines are higher than those identified in BNF they become
unlicensed.
 At times service users are prescribed medicines in a way that does not meet NICE
guidance, the BNF and Trust prescribing guidelines and there is minimal data to
support there use. Under these circumstances the risk and benefits must be
assessed by peer and expert review via the clinical queries mechanism managed
by D&T.
 The tool to manage the above practices is contained in section 17 of the medicines
code
 Unlicensed use of medicines and clinical queries.
6.0
Equality Impact Assessment
Equality
Impact Evidence based Answers & Actions:
Assessment Questions:
1
Clinical Risk Assessment, Management and
Name of the policy that you Training Policy
are Equality Impact Assessing
2
To deliver best practice in Clinical Risk
Describe the overall aim of Assessment and Management
your policy and context?
Clinical Risk Assessment, Management and Training Polly Final. October 2012
30
Who will benefit from this Service users, Trust Staff and partnership
policy?
agencies
3
Director of nursing, clinical governance and
Who is the overall lead for this safety
assessment?
4
5
6
9
Who else was involved in Julie Fleetwood – Assistant Director
conducting this assessment? Phil Tordoff – Care Programme Approach
Lead
The Policy has been reviewed to incorporate
Have
you
involved
and best practice and training requirements of
consulted
service
users, Clinical Risk Assessment and Management
carers, and staff in developing and to incorporate the The Trusts Care
this policy?
Programme Approach and Care Coordination policy.
What did you find out and how This is not a new function.
have
you
used
this The core values and principles of the Policy
information?
promote involvement, engagement and
choice wherever possible.Therefore good
practice will promote equality of opportunity
across all equality groups, taking into
account and address people’s ethnicity,
disability, gender, sexual orientation, religion
and belief needs.
CPA audit and training audit will look at
What equality data have you capturing equality data
used to inform this equality
impact assessment?
Taking into account
information gathered.
the
Does this policy affect one
group
less
or
more
favourably than another on
the basis of:
10a
Race
Evidence based
Answers
&
Where Negative impact Actions
has been identified Policy underpinned
please explain what by the key values
action you will take to
of
Personalised
mitigate this.
and
Client
Centred
If no action is to be
taken please explain approaches to care
and
support
your reasoning.
therefore it will
have a positive
impact
on
all
equality groups
YES
NO
“
10b Disability
NO
“
10c
NO
“
10d Age
NO
“
10e
Sexual Orientation
NO
“
10f
Religion or Belief
NO
“
Gender
Clinical Risk Assessment, Management and Training Polly Final. October 2012
31
10g Transgender
“
NO
Monitoring:
11
13
What measures are you
implementing or already have
in place to ensure that this
policy:
 promotes equality of
opportunity,
 promotes
good
relations
between
different
equality
groups,
 eliminates harassment
and discrimination
Have you developed an Action
Plan
arising
from
this
assessment?
CPA audit
Training audit
service user and carer feedback
Community and In-Patient Service User
Survey 2009/2010
Dialogue groups
To review the CPA audit
monitoring requirements.
to
capture
If yes, then please attach any
plans at the back of this
template
14
7.0
Director of
Who
will
approve
this innovation
assessment and when will you
publish this assessment.
nursing
compliance
and
Dissemination, Implementation and Training
7.1
Dissemination of the policy
This policy will be disseminated according to the Trust’s policy for the development,
approval and dissemination of policy and procedural documents. It will be made
available to staff through the Trust intranet system. Clinical staff will be alerted to the
policy through the Trust’s Management Briefing process and through the Business
Delivery Units management and communication systems. Amendments to the policy
will be disseminated through the same process.
7.2
Implementation of the policy
Implementation of this policy is supported by:
a) The most up-to-date version of this policy will be available on the Trust
intranet.
b) Key risk assessments and tools are incorporated into the Trust-wide
electronic service user record system, RiO. These will be updated to include
any relevant changes or amendments.
Clinical Risk Assessment, Management and Training Polly Final. October 2012
32
c) Clinical risk management training programmes specific to the care group are
in place, which are consistent with the policy and will be amended to reflect
any policy changes.
d) Staff supervision processes will assess competency, provide support and
identify training needs in risk assessment and management
7.3
Risk assessment and management skills training.
7.3.1 Clinical risk assessment and management skills are an essential competence for
all mental health practitioners. These skills sit alongside other risk assessment
and management skills, such as managing violence and aggression, moving and
handling and environmental risk assessment. The Trust provides staff with
training for a range of risk assessment and management situations. This training
is specified for each care group.
7.3.2 Identifying training needs
Training needs will be identified via the appraisal system in response to policy
and guidance, which is then recorded on the Trust wide Training Needs
Analysis.
Clinical risk training includes a programme to train staff in positive clinical risk
assessment and management skills, and aims to provide update training at least
every three years. This training programme includes the use of the Sainsbury
risk assessment tool and is aimed at staff working in working aged adult and
older people’s services. In forensic services training is provided on tools such as
the HCR-20 (Historical Clinical and Risk Management - Version 2).
All professionally qualified mental health and learning disabilities
practitioners are expected to keep up-to-date with developments in clinical risk
assessment and management pertinent to their area of work and client group,
and to attend formal training as necessary. Learning Disability staff receive
training in the use of the risk tools specific to Learning Disability services
Non-professionally qualified staff will attend the risk training as need is identified
by the manager and/or supervisor, according to the needs of the staff member’s
role in the service where they work.
Staff members are encouraged to complete further training where a need to
improve competency is identified through such processes as appraisal, clinical
supervision, and personal development planning or learning from adverse
events
New starters should aim to complete the training as soon as possible but will be
provided with an overview of local clinical risk assessment practice and
procedures at induction. When undertaking risk assessments in between starting
in post and completing training, new staff should seek direction from staff more
experienced in risk assessment, and the use of the relevant risk assessment
tool.
Responsibility for identifying training needs and ensuring training has been
completed lies with the individual member of staff and their manager. Effective
Clinical Risk Assessment, Management and Training Polly Final. October 2012
33
assessment and management of clinical risk is an integral part of
clinical/professional supervision.
7.3.3 KSF mapping:
Risk assessment and management has been mapped through the Knowledge
and Skills Framework (KSF) and will be monitored through the management
supervision and appraisal process.
Risk assessment
• Core 3 - health, safety and security
• Core 4 - service improvement
• Core 5 - quality
Health and well being
• HWB2 - assessment and care planning to meet health and well-being
needs
• HWB3 - protection of health and well-being
Risk management
• Core 3
• Core 5
• HWB 3
• HWB 5 - provision of care to meet health and well being needs
• HWB 6 - assessment and treatment planning
• HWB 7 - interventions and treatment
7.3.4 The content of training
The content of training in the use of risk assessment and management tools will
include the following key points:












Use of the risk assessment tool as part of a comprehensive risk
assessment and management plan.
Indicators of risk
High risk periods
Positive risk taking
Managing non compliance
Managing loss of contact
Communication
Formulation and understanding
Care Programme Approach
Diversity and equality including the need to be vigilant about possible
inequalities discrimination and bias
RiO (Electronic Clinical Record) , documentation processes supporting
risk assessment and management
Mental Health Clustering Tool
7.3.5 Systems to monitor training
Each Business Delivery Unit will identify who needs to attend this training
through the training needs analysis, KSF, staff appraisal and development. A
central database (Oracle Learning Management System (OLM)) is kept of those
who are trained in the use of evidence-based clinical risk assessment tools.
Through the central database the Trust operates a system where staff members
who do not attend courses are sent letters to ensure that action is taken to
Clinical Risk Assessment, Management and Training Polly Final. October 2012
34
ensure training needs are met. The staff member’s manager is also sent a letter
informing them of the non attendance.
7.3.6 Related training
A range of related risk management training is provided including:
 Safeguarding children and child protection
 Adverse incident management and root cause analysis (RCA)
 Mental Health Act
 Diversity
7.3.7 Links with educational establishments
In addition to internal training courses, links exist between the Trust and local
universities or colleges. The Trust has a process in place to support staff to
undertake long courses. Clinical risk assessment is one of the subjects on which
advanced learning is available. Staff who undertake long courses sometimes
include a clinical risk assessment module in their studies.
8.0
Process for monitoring compliance with this policy
The processes for monitoring compliance and effectiveness with this policy
include:
1. The provision of appropriate training
2. Monitoring attendance at training
3. Assessing competency through supervision
4. Case note audit and review
5. Serious untoward incident investigation processes
8.1
Monitoring training
o Training needs will be identified through supervision and management
processes including the KSF and training needs analysis
o Attendance at training will be recorded and monitored by both the
training department and managers
o The content of Trust risk training will be regularly reviewed and updated
o In forensic services there are arrangements for “training the trainers” for
HCR 20 to ensure that the required number of staff are trained in it’s use
and kept up to date,
o In Learning Disability Services there are arrangements for training in the
Learning Disability risk assessment tools. Records are kept to ensure
that the required number of staff are trained in it’s use and kept up to
date,
8.2
Assessing competency in risk assessment and management
The key processes for assessing competency in risk assessment and
management is through case note review and audit, supervision and use
of the Knowledge Skills Framework (KSF).
Assessing competency in risk assessment and management is based on:
Clinical Risk Assessment, Management and Training Polly Final. October 2012
35
a. Attendance at training
b. Identifying training needs
c. Case note review and audit to evidence that:
 The level of risk assessment completed is consistent with the
guidance provided by the Trust
 Risk assessment tools are used in accordance with Trust policy
 The process is appropriately multi-disciplinary and/or multi-agency
 Reasoned risk-related decisions are recorded in the risk management
plan
 There is evidence of timely reviews
 The documentation is defensible:
– Risk information and decisions are clearly recorded
– Information is clear, concise and unambiguous
– Information is up-to-date, dated and timed
8.3 Audit
Clinical risk assessment practice within the Trust will be reviewed and formally
audited through the electronic case note system, RiO.
An annual CPA audit will be undertaken which will include audit elements related
to clinical risk assessment for service users on CPA.
This will be led by the CPA TAG, supported by The Clinical Governance Support
Team.
Exception reporting to the Clinical Governance and Clinical Safety Committee.
Forensic services will:
o Monitor the maintenance of the HCR 20 process which has recently been
updated.
o Undertake regular audits of clinical records to ensure that all patients have
an up to date HCR 20 risk assessment.
9.0
Review and Revision arrangements
This document will be reviewed in line with the Trust’s policy for the
development, approval and dissemination of policy and procedural documents. It
will be reviewed at least every 2 years, to ensure that it is up-to-date and reflects
recognised best practice, and re-issued on or before the review date identified
on the front cover. It may be amended more frequently than this to reflect any
major changes in external or Trust policies and procedures. All amendments will
be approved by the Executive Management Team.
Clinical Risk Assessment, Management and Training Polly Final. October 2012
36
10.0 References
In addition to Trust policies and procedures there are a range of other documents
national guidance and reports relevant to clinical risk assessment. These include:

Best Practice in Managing Risk
o Best practice in managing risk: principles and guidance for best practice in
the assessment and management of risk to self and others in mental health
services : Department of Health - Publications (DofH) June 2007)
o Best Practice in Managing Risk - Implementation toolkit (DofH Oct 2007)

Care Programme Approach
o


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsP
olicyAndGuidance/DH_083647 Refocusing the Care Programme Approach,
Policy and Positive Practice. (DofH 2008). London
Capabilities education and training
o
Acute Inpatient Mental Health Care: Education, Training and Continuing
Professional Development for All. Clarke S (2004) London NIMHE/SCMH
o
Mental Health Policy Implementation Guide: Developing Positive Practice to
Support the Safe and Therapeutic Management Of Aggression and Violence
in Mental Health In-Patient Settings. DofH (2004). London:
o
The Ten Essential Shared Capabilities London: DofH (2004).
o
Essential Shared Capabilities.
DofH
www.skillsforhealth.org.uk/mentalhealth/esc.php
(2006)
Available
at:
Children
o The Children Act 2004;
o Working together to safeguard children: a guide to inter-agency working
to safeguard and promote the welfare of children : Department of Health Publications (DoH 1999)
o Framework for the assessment of children in need and their families pack : Department of Health - Publications (DoH 2000)
o Pushed into the Shadows – young peoples experience of adult mental
health facilities. (January 2007). Office of the Children’s Commissioner.
London: Available at: www.childrenscommissioner.org

Learning from experience
o
An organisation with a memory report of an expert group on learning from
adverse events in the NHS : Department of Health - Publications Department
of Health. (2000). London:
o
Seven Steps to Patient Safety. National Patient Safety Agency. (2004).
London: Available at: www.npsa.nhs.uk/
o
Safety First: Five-year report of the National Confidential Inquiry into Suicide
and Homicide by People with Mental Illness : Department of Health Publications London: DofH (2001).
o
Inquiry publications 2006 (Centre for Suicide Prevention - University of
Manchester) Avoidable Deaths Five year report of the national confidential
Clinical Risk Assessment, Management and Training Polly Final. October 2012
37
inquiry into suicide and homicide by people with mental illness. University of
Manchester (2006). www.medicine.manchester.ac.uk/suicideprevention/nci/
o
Review of Homicides by Patients with Severe Mental Illness. Maden, T.
(2006). Available at: CSIP: Our Work: Risk management programme

NHS Code of Practice: Confidentiality

National Institute for Health and Clinical Excellence - www.nice.org.uk
o
2005/003 NICE issues guidance on the short-term management of
disturbed/violent behaviour In In-Patient Psychiatric Settings And Emergency
Departments. National Institute for Clinical Excellence. (2005). Clinical
Guideline 25
o
Self-harm: The Short Term Physical and Psychological Management and
Secondary Prevention of Self Harm in Primary and Secondary Care.
National Institute for Clinical Excellence (2004) London

Policy
o
The national service framework for mental health - five years on :
Department of Health - Publications DofH London (2004).
o
Mental health policy implementation guide: Adult acute inpatient care
provision : Department of Health - Publications DofH London (2002),
o
Mental health policy implementation guide: a learning and development
toolkit for the whole of the mental health workforce across both health and
social care : Department of Health - Publications London DofH (2007).
o
Mental health: New ways of working for everyone : Department of Health Publications DofH (2007). London:

Professions
o
From values to action: The Chief Nursing Officer's review of mental health
nursing : Department of Health - Publications: DofH (2006).
Guidance on new ways of working for psychiatrists in a multi-disciplinary and multiagency context: Department of Health - Publications DofH (2004).

Rethink Recovery Report
11.0 Associated documents
Clinical risk assessment and management is complex and this policy should be used in
conjunction with other Trust and multi-agency procedural documents available on the
Trust intranet. Key documents include:
Care Programme Approach and care coordination policy and procedural
guidance
Children - Risk to children policy and procedural documents
 Trust’s Child Protection Manual and Policy
 Area Child Protection Committee inter-agency child protection procedures;
Clinical Risk Assessment, Management and Training Polly Final. October 2012
38
Claims Policy
Clinical policy and procedural documents
– Discharge policy
Complaints Policy
Consent to treatment policy
Discharge and Transfer of Service Users(including leave of absence for informal
service users)
Domestic Violence guidelines
Equality and Diversity Strategy and Race Equality Scheme
Health and safety policy and procedural documents - including environmental risk
assessment
Information governance policy and procedural documents
Incident management policy and procedural documents
InPAC (Integrated Packages of Care)
Management of Violence and Aggression policy and procedural documents
Training policies and procedures
Mental Health Act policy and procedural documents
Mental Capacity Act policy and procedural documents
Missing Patients Policy
Multi Agency Public Protection Arrangements (MAPPA) policy
Non compliance with treatment policy
Policy and procedural documents - development, approval and dissemination of
Supervision Policy
Vulnerable adults procedural documents including Local Authority area (Calderdale,
Kirklees and Wakefield) multi-agency Adult Protection policies and procedures and the
Trust Protocol for the Prevention of Abuse of Vulnerable Adults
Whistle Blowing Policy
Clinical Risk Assessment, Management and Training Polly Final. October 2012
39
Clinical Risk Assessment, Management and Training Polly Final. October 2012
40
Appendix A
Checklist for the Review and Approval of Procedural Document
Clinical Risk Assessment Management and Training Policy completed 07/08/08
Clinical Risk Assessment, Management
and Training Policy
1.
2.
4.
5.
6.
7.
Comments
Title
Is the title clear and unambiguous?
Yes
Is it clear whether the document is a guideline, policy,
protocol or standard?
Yes
Rationale
Are reasons for development of the document stated?
3.
Yes/No/
Unsure
Yes
Development Process
Is the method described in brief?
Yes
Are people involved in the development identified?
Yes
Do you feel a reasonable attempt has been made to
ensure relevant expertise has been used?
Yes
Is there evidence of consultation with stakeholders and
users?
Yes
Content
Is the objective of the document clear?
Yes
Is the target population clear and unambiguous?
Yes
Are the intended outcomes described?
Yes
Are the statements clear and unambiguous?
Yes
Evidence Base
Is the type of evidence to support the document identified
explicitly?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are supporting documents referenced?
Yes
Approval
Does the document identify which committee/group will
approve it?
Yes
If appropriate have the joint Human Resources/staff side
committee (or equivalent) approved the document?
N/A
Dissemination and Implementation
Is there an outline/plan to identify how this will be done?
Yes
Does the plan include the necessary training/support to
Yes
Clinical Risk Assessment, Management and Training Polly Final. October 2012
41
Clinical Risk Assessment, Management
and Training Policy
Yes/No/
Unsure
Comments
ensure compliance?
8.
9.
10.
Document Control
Does the document identify where it will be held?
See Trust policy
Have archiving arrangements for superseded documents
been addressed?
See Trust policy
Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the
monitoring of compliance with and effectiveness of the
document?
Yes
Is there a plan to review or audit compliance with the
document?
Yes
Review Date
Is the review date identified?
Is the frequency of review identified?
acceptable?
11.
Yes
If so is it
Yes
Is it clear who will be responsible implementation and
review of the document?
Yes
Overall Responsibility for the Document
Clinical Risk Assessment, Management and Training Polly Final. October 2012
42
Appendix B
Version Control Sheet for:
Clinical Risk Assessment, Management and Training Policy
This sheet should provide a history of previous versions of the policy and changes made
Version Date
Author
Status
Comment / changes
1
Feb
2006
Hazel O’Hara
Archived
New policy
2
October
2008
Linda Hollingworth
Final - for
review
August 2010
Reviewed and updated to reflect:
 Best Practice in Managing Risk
 new CPA guidance and InPAC
 NHSLA RMS 2008
3
October
2010
Phil Tordoff
Final
–for
review
August 2012
Reviewed and updated to reflect:
 Best Practice in Managing Risk

CPA guidance and Care Coordination
NHSLA RMS 2010
Management structures
4
October
2012
Phil Tordoff
Julie Fleetwood
Final
Trust wide
Clinical Risk Assessment, Management and Training Polly Final. October 2012
43
Appendix C
Best practice in clinical risk management – key points
‘Best Practice in Managing Risks; principles and evidence for best practice in the
assessment and management of risk to self and others in mental health’ (DofH
2007) identified 16 key best practice points for effective clinical risk management, which
apply at an organisational and individual practitioner level. This policy reflects these
points, which are listed below:
1. Best practice in clinical risk assessment involves making decisions based on
knowledge of the research evidence, knowledge of the individual service user
and their social context, knowledge of the service user’s own experience, and
clinical judgement
2. Positive risk management as part of a carefully constructed plan is required
competence for all mental health practitioners
3. Risk management should be conducted in a spirit of collaboration and based on
a relationship between the service user and their carers that is as trusting as
possible
4. Risk management must be built on a recognition of the service users strengths
and should emphasise recovery
5. Risk management requires organisational strategy as well as efforts by the
individual practitioner
6. Risk management involves developing flexible strategies aimed at preventing
any negative event from occurring or, if this is not possible, minimising the harm
caused
7. Risk management should take into account that risk can be both general and
specific and that good management can reduce and prevent harm
8. Knowledge and understanding of mental health legislation is an important
component of risk management
9. The risk management plan will include a summary of all risks identified,
formulations of the situations in which identified risks may occur and actions to
be taken by practitioners and the service user in response to crisis
10. Where suitable tools are available risk management should be based on
assessment using the structured clinical or professional judgement approach
11. Risk assessment is integral to deciding on the most appropriate level of risk
management and the right kind of intervention for a service user
12. All staff involved in risk management must be capable of demonstrating
sensitivity and competence in relation to diversity in race, faith, gender, disability,
and sexual orientation
13. Risk assessment and management must always be based on awareness that
the service user’s risk level can change over time and that each service user
requires a consistent and individualised approach
14. Risk management plans should be multidisciplinary and multi-agency teams
operating in an open democratic and transparent culture that embraces reflective
practice
15. All staff involved in risk assessment and management should receive training
which should be updated at least every 3 years.
16. A risk management plan is only as good as the time and effort put into
communicating its findings to others
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Appendix D
Positive risk management
(from Best Practice in Managing Risk)
“The governing principle behind good approaches to choice and risk is that
people have the right to live their lives to the full as long as that does not stop
others from doing the same. Fear of supporting people to take reasonable risks
in their daily lives can prevent them from doing the things that most people take
for granted. What needs to be considered is the consequence of an action and
the likelihood of any harm from it. By taking account of the benefits in terms of
independence, well-being and choice, it should be possible for a person to have
a support plan which enables them to manage identified risks and to live their
lives in ways which best suit them.”
Department of Health, Independence, choice and risk: a guide to best practice in
supported decision making, DH, London, May 2007
Positive risk management means being aware that risk can never be completely
eliminated and that risk management plans inevitably have to include decisions that
carry some risk.
This should be explicit in the decision-making process and wherever possible openly
discussed with the service user. Another way of thinking about good decision-making is
to see it as supported decision-making.
Positive risk management includes:
 working with the service user to identify what is likely to work;
 paying attention to the views of carers and others around the service user when
deciding a plan of action;
 weighing up the potential benefits and harms of choosing one action over another;
 being willing to take a decision that involves an element of risk because the potential
positive benefits outweigh the risk;
 being clear to all involved about the potential benefits and the potential risks;
 developing plans and actions that support the positive potentials and priorities
stated by the service user, and minimise the risks to the service user or others;
 ensuring that the service user, carer and others who might be affected are fully
informed of the decision, the reasons for it and the associated plans;

using available resources and support to achieve a balance between a focus on
achieving the desired outcomes and minimising the potential harmful outcome.
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Appendix E
Sainsbury’s Risk Assessment Tool protocol
Use of the Sainsbury’s risk assessment tool in the Trust
1. Introduction
The Sainsbury’s risk assessment tool is the tool formally identified by the Trust for use
to support risk assessment, risk management and care planning in Working Aged Adult
Services and Older Peoples Services. The tool provides the process and record of
formal risk assessment and management under the Care Programme Approach and
Standard Care journey in these services.
All service users who are in receipt of or assessed by either Trust working age adult or
older peoples mental health services will follow one of the two service delivery
pathways (as described in ‘Refocusing the Care Programme Approach, Policy and
Positive Practice Guidance’, DoH, March 2008):
o Standard Care
o The Care Programme Approach (CPA)
Within South West Yorkshire Mental health Trust (the Trust) these pathways are
incorporated into the Care Programme Approach and care coordination policies and
procedures, RIO (the Trusts electronic service user records system), InPAC (Integrated
Packages of Care) and the Single Assessment Process for older people.
The Sainsbury’s risk assessment tool has two levels – screening (level1) and
comprehensive (level 2). Both are accessible on the RiO system for completion as part
of the service users electronic case notes as.
i. The Sainsbury’s Level 1 Tool (screening)
ii. The Sainsbury’s Level 2 Tool (comprehensive)
This risk assessment tool is recognised in Best Practice in Managing Risk (DoH 2007).
Although some concerns have been expressed about employing risk assessment tools
and ‘tick box’ forms, this risk assessment tool constitutes a format for eliciting and
recording relevant information to assess and formulate risk. It prompts staff to
comprehensively consider risk factor and also provides a clear record and evidence of
the risk assessment process and emphasises positive risk management
.
Comprehensive advice for completion of both levels of this risk assessment is provided
in the Sainsbury Centre Clinical Risk Management, A Clinical Tool and Practitioner
Manual (Chapter 6).
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2. The Sainsbury’s Level 1 (screening)
This first part of the Sainsbury’s risk assessment – the Level 1 (screening tool )
includes formulation of an initial risk management plan, which will form the initial risk
management plan for those service users who receive Standard Care.
Minimum standards required by the Trust (see also attached flowchart)
These are the minimum Trust requirements regarding risk assessment using the
Sainsbury’s Initial Risk Assessment Tool. Where these standards cannot be met, it is
important to clearly document the reasons.
The Sainsbury’s Level 1 Assessment Tool will be:
o Completed for every person who is assessed for/by either Working Aged Adult
or Older Peoples Services (except where an alternative initial risk assessment
tool or process has been approved for use by the professional involved).
o Completed at the first face-to-face contact with the individual service user, as
part of their initial assessment:
 For in-patient or residential units, where 24 hour staffing is available, it is
expected that an Initial Risk Assessment and management plan will be
completed within the first 24 hours of admission. (Where an Initial Risk
Assessment has been completed by community staff immediately prior to
admission, within 7 days.)
 For most areas of community services, an Initial Risk Assessment/
Management Plan will be completed within 24 working hours of the first
planned contact with the service user.
o Used to form the initial risk management plan for those service users who
receive Standard Care.
o Reviewed according to need
o Provided to the new team/service when a service user transfers from one mental
health team or service to another, together with an up to date Mental Health
Clustering Tool– it should accompany the referral or be sent at the time of
transfer of care. A further assessment may still need to be completed by the
service taking over care.
The first risk assessment completed may have to rely only on information from the
referral and past notes, or it may rely on a very brief face-to-face contact. Subsequent
timed and dated copies can be compiled as new information becomes available.
In addition other risk assessment and management tools may be identified and used.
Other uses for the Level 1 Risk Assessment Tool
Even where the need for more detailed Multi Disciplinary Risk Assessment is indicated
the Initial Risk Assessment and Management Plan is also for use:
i. As a tool to assess and record where risks are rapidly changing by the use of
multiple timed and dated copies or daily completion eg during the first week of
an in-patient admission or crisis team intervention. This will usually be for short
periods and for and will be for a minority of people seen.
ii. Prior to leave and discharge
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Completing the Level 1 Risk Assessment Tool
The most important aspect of risk assessment is that it forms an integral part of initially
engaging the service user. Usually, the brief assessment and formulation of an initial
management plan will be quickly documented on the Initial Risk Assessment/
Management Plan format after the contact.
It is not an interview format. The structure gives a guide to broad areas of risk that may
be considered within the individual circumstances and context of the person being
assessed. It acts as a format for documenting broad assessments of risk information
derived from your professional judgements and views expressed by others, verbally or
in writing.
Most of the broad categories on the Initial Risk Assessment/Management Plan could
apply in circumstances encountered by any sector across the services e.g. ‘wandering
and falls’ often associated with older peoples or disability services could apply in some
cases in adult mental health.
The examples in brackets after most broad categories of risk are indicators of what may
be interpreted in each category. These are not exhaustive or prescriptive lists eg ‘risk
from others’ may also include ‘violence’. Use your discretion and if necessary briefly
explain your use of the relevant categories.

“Network of Support’ – your assessment and plan are only as good as the quality of
information you had available to you. Document the sources available on the first
page using the add button on the list of others involved, and possibly the further
information needed (which should be indicated in your initial management plan).

Ticking the ‘don’t know/unknown’ box indicates information you need to check out
further - it is not a negative reflection on your assessment skills.

“Other (specify)” is a way of keeping the number of tick boxes to a minimum while
still reflecting needs across a diverse range of service sectors - a catch-all for the
individual factors you identify to be relevant for one individual, which have not been
sufficiently covered in the list.

‘Comments’ at the end of each checklist offers a small but flexible opportunity to
clarify any of the ticked areas, that you feel need some further comment.

Where you determine no risk to be present, based on the information you have
available, circle ‘No’. You must up-date the assessment immediately information
becomes available to indicate a ‘No’ could be a ‘Yes’ or ‘Unknown/uncertain’. (You
are not accountable for the information you did not have, providing reasonable
steps have been taken to gather information, and you are making a brief
assessment of the ‘here and now’.)

‘Summary of Assessment’ is your (usually collective, occasionally individual)
formulation of the complex risks experienced and/or posed by the individual at this
time. It should capture the most significant factors from the previous checklists, and
add something of the context in which you assess the risks may take place. It
should introduce new information, where relevant, about any environmental or
organisational factors that may contribute to the risks e.g. influence of service
settings, impact of delayed service responses, early warning signs needing quick
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responses, gut reactions (where you feel able to defend the feelings, if challenged).
If a continuation sheet is needed it should be securely attached, and referred to at
the bottom of this page.

‘‘Initial management plan” - may be as simple as an urgent need to gather specific
information, urgent need to complete the Multi Disciplinary Risk Assessment, need
for referral on to a specific service, notifying other relevant services of the outcome
of assessment (eg the referrer), expressing concerns about a person who has
absconded and (if possible) indicating how the service user or carers are involved
in managing the identified risks.

‘Is a more detailed assessment needed?’ is one area where specific sectors of the
service can indicate references to their own specialised needs e.g. forensic
assessments, Beck’s Depression Inventory or Suicide Scale, or other tools used by
services to assess risk.

It is important to have a brief statement of how involved and/or in agreement the
service user and any relevant carers were in the process of this assessment and
management plan (use the ‘Comments’ box to describe the quality of
involvement/agreement).

The ‘review date’ is a professional judgement at your discretion (in consultation
with others). It could be a matter of hours, days, or at the point of the next formal
review of care e.g. next outpatient’s appointment. Individual teams or services may
wish to set standard intervals over and above this, e.g. before discharge or
transfer.
3. Sainsbury’s Level 2 Risk Assessment Tool (comprehensive)
This second part of the tool is used to document more detailed risk assessments, and
more detailed risk management plans which have been discussed and agreed in
review. It links some of the current knowledge of the research into clinical risk factors
with a broader range of risk factors reflecting practice experiences of practitioners
across mental health. It remains strongly based in individual and collective professional
judgements. The format combines the use of checklists, as an aide memoir to a broad
range of potential areas of risk, with a more flexible narrative style of capturing the
individuality of an assessment and management plan.
Generally, this assessment tool will be used with service users who have complex
needs, who are vulnerable to a host of potentially negative risks, and who may require
co-ordination of a range of services to meet their needs. For the majority of people at
multi disciplinary assessment, risk assessment and management will have been
identified through an existing history of service contacts and incidences of risks. Some
may have brief or first time contact, but indicate a significant potential for risk.
The Level 2 Risk Assessment Tool will serve as an on-going risk assessment and will
be attached to the CPA process. It will be reviewed as part of the CPA review process
and at times of change for the service user.
When a service user transfers from one mental health team or service to another an up
to date Mental Health Clustering Tool and Level 2 Risk Assessment should accompany
the referral or be sent at the time of transfer of care. A further assessment may still
need to be completed by the service taking over care.
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Minimum standards required by the Trust (see also attached flowchart)
The Level 2 Risk Assessment Tool will be:
 Completed for all service users registered on CPA following the initial
assessment, when the need for CPA has been identified (the initial risk
assessment tool will have been completed as part of the initial assessment).
This assessment period may take up to 4 weeks.
 Reviewed as part of the CPA review process and at least annually.
 Reviewed at times of change for the service user.
 Completed for service users on Standard Care, if the care coordinator or
other professional involved identifies the need.
Where these standards cannot be met, it is important to clearly document the reasons.
Completing the Level 2 Risk Assessment Tool
o Service user’s and carer’s personal assessments of risk should be elicited and
documented wherever possible; particularly where they conflict with the
service view.
o Events occurring during the last 6 months will usually be seen as ‘current’, with
those occurring further back than 6 months being ‘past’. However, professional
judgement will determine individual occasions where significant changes over
the last month may change this rule e.g. something that happened 3 weeks
ago as being a ‘past’ event, and something arising in the last 2 weeks as the
‘current’ situation. Professional judgement, in consultation with others, should
also apply to determinations of what current emphasis is placed on an event
that happened 20 years ago, for example. ‘Context’ of risk is the important
consideration.
o The box at the head of the sheet “Categories of Risk Identified” gives
indications from the Initial Risk Assessment/Management Plan of what may be
considered in compiling a risk management plan. Carefully considered risktaking, with identified positive outcomes, should be documented, where
relevant. The people responsible for carrying out the actions across the plan
should also be clearly identified.
o The service users and carer’s involvement and/or agreements with this plan
should be documented.
o The signing for ‘collective responsibility’ recognises that one person may have
been responsible for documenting the information, but it is a result of the
discussions and decisions of more than one person (indicated by the ‘network
of support’ list on page 1, or the associated broader care plan documentation).
o The level 2 risk assessment should be completed and signed off with in a
maximum of 28 days from the commencement of the assessment. For inpatient services this should be reviewed/initiated to support discharge planning
services to support safe discharge.. Where an admission to hospital is of a
very short duration, the level 2 risk assessment tool must be considered to
inform risk assessment and risk management
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Appendix F
Flowchart: Use of Level 1 and Level 2 risk assessment tools in
Working Aged Adult and Older People’s Services in the Trust
Person referred to Working Aged Adult
or Older Peoples Services
Sainsbury Level 1 Assessment and Management Plan completed at
first face-to-face contact as part of initial assessment.
Community services – within 24 (working) hrs of 1st planned contact with
service user
In-patient or residential units (where 24 hr staffing) within 1st 24 hrs of
admission
Decision about care pathway
Standard Care
Care Programme
Approach (CPA)
Sainsbury Initial Risk
Assessment Tool forms risk
management plan (recorded on
RiO and copied to care team)
Sainsbury Level 2 Assessment
Tool completed integral to CPA
assessment process (recorded
on RiO and copied to care team)
Reviewed according to need
Reviewed at least annually
Level 2 Assessment Tool can
be completed if professional
involved identifies the need
Multiple timed and dated copies
of Level 1 Assessment and
Management Plan can be used as
tool to assess and record
fluctuating risk
When service user transfers from one mental health team/service to another
up-to-date Mental Health Clustering Tool and Level1/ Level 2 Risk Assessment
to accompany referral or transfer of care (a further assessment may still need
to be completed by the team/service taking over care)
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