Plymouth Community HealthCare CIC. Risk Assessment and Management Best Practice Guidance For Mental Health and Learning Disabilities. Version No 2.

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1 Plymouth Community HealthCare CIC Risk Assessment and Management Best Practice Guidance For Mental Health and Learning Disabilities Version No 2.0 Notice to staff using a paper copy of this guidance The policies and procedures page of Healthnet holds the most recent and procedural version of this guidance. Staff must ensure they are using the most recent guidance. Author: Professional Lead Asset Number: 717 Page 1 of 18

2 Reader Information and Asset Registration Title Information Asset 717 Register Number Rights of Access Public Type of Formal Guidance Policy Paper Category Corporate Format Word Document Language English Subject The guidance is to help support positive risk management principles and practice in a spirit of collaboration based on practitioner decision making and organisational support. To provide a practical guidance for practitioners in clinical risk management and to encourage a supportive cultural background. Document The policy guidance outlines the core principles of best practice in Purpose and managing risk, underpinned by the philosophy that care needs Description must be balanced against risk needs in the context of promoting recovery. It clearly emphasises that positive risk management is a part of a clearly constructed plan developed by all key stakeholders and requires comprehensive documentation to enhance open, democratic and transparent culture that embraces reflective practice. Author Professional Lead Ratification Date PRG July 2013 and Group Publication Date August 2013 Review Date and Frequency of Review Disposal Date Job Title of Person Responsible for Review Target Audience Two years after publication, or earlier if there is a change in evidence. The Policy Ratification Group will retain an e-signed copy for the database in accordance with the Retention and Disposal Schedule; all previous copies will be destroyed. Professional Lead / Clinical Risk Team in conjunction with Specialist Staff. For all Staff Circulation List Electronic: Plymouth Healthnet and PCH website Written: Upon request to the Policy Ratification Secretary on Please note if this document is needed in other formats or languages please ask the document author to arrange this. Consultation This policy was produced in consultation with the Mental Health Process and Learning Disability Services, Carer representatives, the Risk Page 2 of 18

3 Equality Analysis Checklist completed Management Team, Professional Leads, and specialist input from key services / professionals. Yes References/Source Best Practice in Managing Risk (2007) Department of Health Care Programme Approach Policy & Standards (2008) Best Practice in Managing Risk Implementation Tool Kit (2007), CSIP Threshold and Assessment Grid (TAG) New Ways of Working (2007), Department of Health Good Leadership and Management are key to avoid failings in patient safety (2008), Health Care Commission Serious Untoward Incident Protocol (Drug & Alcohol Services) (2006) Plymouth Community Healthcare Serious Incident Requiring Investigation Policy Latest Version Report to the NE SHA Independent Inquiry into the Health Care and Treatment of GT (2007), NHS North East Quarterly Partnership Review Meeting feedback minutes and recommendations from workshops held throughout MAPPA Guidance, version 2.0 (2007). Published by Home Office/National Probation Service. Available online at ance%202007%20v2.0.pdf Supersedes Document Associated Documentation Clinical Risk Assessment and Management Best Practice Guidance v1.3 Equality Impact Assessment Best Practice in Managing Risk (2007) DoH Care Programme Approach Policy and Standards (2006) Plymouth Community Healthcare s Risk Management Meeting Guidance Author Contact Details By post: Local Care Centre Mount Gould Hospital 200 Mount Gould Road Plymouth Devon PL4 7PY Publisher: (for externally produced information) Tel: Fax: (LCC Reception) N/A Document Review History Page 3 of 18

4 Version Type of Date Originator of Description of Change No. Change Change V:0:1 New 22 July 2008 Stephen Dinniss & New document. document Nigel Pluckrose V:0:2 Amendment 05 August 2008 Stephen Dinniss & New document Nigel Pluckrose V:0:3 Amendment 12 August 2008 Stephen Dinniss & New Document Nigel Pluckrose V:0:4 Amendment 26 August 2008 Stephen Dinniss & New Document Nigel Pluckrose V:0:5 Amendment 01 September Stephen Dinniss & New Document 2008 Nigel Pluckrose V:0:6 Amendment 08 September Stephen Dinniss & New Document 2008 Nigel Pluckrose V:0:7 Amendment 24 September Stephen Dinniss & New Document 2008 Nigel Pluckrose V:0:8 Amendment 26 September Stephen Dinniss & New Document 2008 Nigel Pluckrose V:0:9 Amendment 09 October Stephen Dinniss & New Document 2008 Nigel Pluckrose V1:0 Final 24/11/2008 S Edmunds Approved Document document v1:1 Update 08/11/2010 Author Reviewed, no changes made. V1:2 Review Dec 2012 PRG Review date extended, no other changes made. V1:3 Review Dec 2012 Author Review date extended, no other changes made. V2.0 Review Aug 2013 Professional Lead Final Changes made following consultation prior to ratification. Page 4 of 18

5 Contents of Clinical Risk Assessment and Management Best Practice Guidance 1 Introduction 2 Purpose 2.1 Core Principles of Best Practice in Managing Risk 3 Duties 4 Best Practice Guidance 4.1 Best Practice point Best Practice point Best Practice point Best Practice point Best Practice point Best Practice point Best Practice point Best Practice point 8 5 Structured Clinical Judgement Training Proposal 6 Monitoring Implementation of the Guidance in Practice Appendix A Risk Management Process Page Page 5 of 18

6 Risk Assessment and Management Best Practice Guidance 1 Introduction 1.1 The aim of this document is - 1) To provide practical on the ground guidance for clinicians in clinical risk management. 2) To encourage a positive and supportive cultural background within which the clinical practice occurs. 3) To outline Plymouth Community Healthcare s policy on clinical risk management. 1.2 The core principles of the document are based on the DoH document Best Practice in Managing Risk (June 2007) adapted here to be applicable to local services and service users. This document has the full endorsement and support of clinicians and managers at all levels throughout Plymouth Community Healthcare and is seen as the basis of good clinical practice in clinical risk management. The principles and guidance is applicable to all areas of mental health care and Learning Disabilities from high security through to community link working. 1.3 The philosophy underpinning this document is that care needs must be balanced against risk needs in the context of promoting recovery. It emphasises: - positive risk management - collaboration with the service user and others involved in care - coordinated working between clinicians, services, service users and teams - the organisation s role in risk management alongside individual clinicians 2. Purpose 2.1 Core Principles of Best Practice in Managing Risk Key best practice points: Overall 1) Best practice involves making decision based on knowledge about the individual service user and their social context, clinical judgement and research evidence. Page 6 of 18

7 Fundamental Principles 2) Positive risk management as part of a clearly constructed plan is a required competence of all mental health practitioners 3) Risk management should be conducted in a spirit of collaboration and based on a relationship between service user, their carers and clinical staff that is as trusting as possible. 4) Risk management requires an organisational strategy that promotes a positive culture around risk management and supports the efforts of individual practitioners. Core specifics for practice 5) Risk management tools should be used to complement structured clinical judgement rather than a replacement for it. 6) Risk management plans should be developed by multidisciplinary and multi-agency teams in an open, democratic and transparent culture that embraces reflective practice. 7) All staff involved in risk management must engage in regular training that meets their learning needs. This will be incorporated within the Care Programme Approach Training Programme which is reviewed annually, and links to other training programmes, such as, STORM and the minimum requirement will be for 3 yearly updates for staff, there are proposals to further develop Risk Training with new programmes being introduced. Training is already delivered by designated professional leads and experts in these fields of practice. 8) Comprehensive documentation is essential component of positive risk management and should be seen as enhancing clinical practice, not as a barrier to it. 3. Duties 3.1 Responsibility and Accountability clinical risk management in Plymouth Community Healthcare 3.2 Plymouth Community Healthcare has a responsibility to ensure that the organisation has structures in place to support the practice of clinical risk management and expects directly employed health professionals to work within them. 3.3 Responsibilities of the organisation Good clinical risk management is endorsed by the Executive Team of Plymouth Community Healthcare. Ensure that training is developed and put in place for all staff as needed (it is recommended that the Structured Clinical Judgement Training Package is implemented within Plymouth Community HealthCare) Page 7 of 18

8 Ensure that structures and systems are in place to facilitate the delivery of excellent clinical risk management practices. Monitor, evaluate and audit the practices as required to inform and update this guidance and training. Inform staff of the structures, organisation and systems in place for good evidence based clinical risk management by using information systems available in Plymouth Community Healthcare (e.g. PCH News and ). 3.5 Responsibilities of Managers Managers should ensure that all clinical staff to have access to any training identified as essential to a member of staff s role. 3.6 Responsibilities of Health Professionals All individuals are required to follow these best practice guidelines in relation to clinical risk management and planning risk management meetings That any training needs are identified within the approved Plymouth Community Healthcare routes of Line Management, Caseload Management and Individual Performance Review. 4 Best Practice Guidance 4.1 Best Practice point 1 Best Practice involves making decision based on knowledge about the individual service user and their social context, clinical judgement and research evidence. The practitioner, or team, is responsible for working with the individual to make decisions about risk by taking into account the needs of the individual service user, the safety of the wider community and the latest evidence about risk assessment. This evidence includes an understanding of risk factors, the effectiveness of interventions as well as evidence based risk management tools. Individuals needs, assessed from their clinical condition and social context, as well as their preferences, need to be taken into account. Plymouth Community Healthcare, in line with the DoH guidance, Best Practice in Managing Risk (2007), advocates the use of clinical knowledge and skills in combination with formal tools to guide risk management. Page 8 of 18

9 4.2 Best Practice point 2 Positive risk management as part of a clearly constructed plan is a required competence of all mental health practitioners and should be the basis for effective risk management on a daily basis. Positive risk management means being aware that, in the context of promoting recovery, risk can never be completely eliminated, and management plans inevitably have to include decisions that carry some risk. This should be explicit in the decision-making process and should be discussed openly with the service user and carer if appropriate. Positive risk management has been emphasised due to a recognition that risk averse practice has become more prevalent and can not only inhibit recovery, but can also take up additional resources, paradoxically increasing risk across the system. 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, both short and long term, 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 ie recovery, 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. Another way of thinking about good decision-making is to see it as supported decision-making. Independence, choice and risk has this to say: 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. MAPPA Guidance Page 9 of 18

10 Plymouth Community HealthCare has a clear and unanimous voice in supporting clinicians in implementing a positive approach to risk. It is an expectation that all staff embeds these principles into their every day practice and all staff can expect to be supported in doing so by all levels of the Plymouth Community Healthcare both clinical and managerial. 4.3 Best Practice in point 3 Risk management should be conducted in a spirit of collaboration and based on a relationship between service user, their carers and clinical staff that is as trusting as possible. Open involvement of the service user and carers in discussions around risk is a basic principle underlying quality practice. The emphasis should always be on a recovery approach building on recognition of the service user s strengths. The use of service user centred tools to encourage this can assist in this eg Service User Personal Safety Plan (available from local Risk Management Lead). The inclusion of any advance directives should be considered. Full engagement is sometimes not possible but the potential for it should always be considered. The development of the risk management plan should be carried out in an atmosphere of openness and transparency. If for some reason the service user is not involved this should be documented. 4.4 Best Practice point 4 Risk management requires an organisational strategy that promotes a positive culture around risk management and supports the efforts of individual practitioners. Risk management is not just the responsibility of individual practitioners but the responsibility of the wider organisation. The Plymouth Community Healthcare recognises that a balanced approach to safety and positive risk management is in the interests of individual service users, practitioners and the wider community. The Plymouth Community Healthcare has a responsibility to develop a culture in which positive risk management can flourish. Practitioners will be able to see that if risks have been managed and documented appropriately they will be supported if serious untoward incidents occur. This includes the need to learn from untoward incidents and build on good practice. These are integrated within the Serous Untoward Incident policy. Other relevant guidance has also arisen from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness which outlines recommendations for services. Plymouth Community Healthcare recognises the responsibility it shares for managing risk and all levels of clinical and managerial staff including the Plymouth Community Healthcare Board supports this current document. Page 10 of 18

11 4.5 Best Practice point 5 Risk management tools should be used to complement structured clinical judgement rather than a replacement for it. Actuarial risk assessment tools should be used to inform risk management plans. A basic risk assessment tool should be used for all patients being seen by mental health services. In more complex cases or where initial screening indicates significant risk a more in-depth risk assessment should be undertaken eg CPA risk assessment tool. In the most complex and high risk cases specialised tools to address specific areas of risk should be used eg STORM for suicide risk or HCR-20 for service users within forensic services. At all times these tools should be used in combination with a structured clinical Judgement of the service user and the service user s own view to inform the risk assessment and management plan. Involving structured clinical judgement as central to all risk assessment promotes flexibility and fluidity to the process as risk must be seen as changing and dynamic. (It is recommended the Structured Clinical Judgement Training package be available to PCH Staff) (See Section 5) Page 11 of 18

12 The flow diagram below describes the Plymouth Community Healthcare use of risk assessment tools: New referral Basic risk assessment tool (eg TAG or brief screening questions) as part of clinical assessment Clinical assessment and risk assessment indicates need for further risk assessment or for CPA CPA risk assessment tool completed Clinical picture and CPA risk assessment indicate further risk management/ assessment strategies needed Risk assessment meeting/ clinical discussion with colleagues (Please refer to Risk Management Meeting Guidance) (contained within this document) Consider specialist tools and processes eg MAPPA. The basic principle of proportionality should be applied- an appropriately proportioned risk management response is made to a clinical situation. This varies from informal processes of clinical discussions with service users, carers and clinicians through to more formal processes such as MAPPA and formal risk management meetings. Review dates should be made as an integral part of formal risk management plans. A flexible approach requires regular review and there is an expectation that risk assessment and management plans are reviewed at least every 6 months and at any time where there is a significant change in the clinical situation or following serious incidents involving risk. Page 12 of 18

13 4.6 Best Practice point 6 Risk management plans should be developed by multidisciplinary and multiagency teams in an open, democratic and transparent culture that embraces reflective practice. Working together is a critical part of risk management and can help ensure: That key information is shared to ensure safety That different perspectives can be brought together to make the best decisions That responsibility is appropriately shared between team s practitioners and service users. In low complexity, low risk cases practitioners working alone with service users can make effective risk management plans. However in many situations the best risk assessments and most effective management plans are developed by teams working in consultation with service users and carers. Clear channels of communication between practitioners and services are critical to effective risk management. Confidentiality remains central but where public protection concerns are raised MAPPA processes should be considered (see MAPPA guidance). The process for sharing information and involving teams and other services again must be proportionate to the risks being considered. Depending on the nature of the situation and risk, different means of collaborative working may be appropriate. When decisions need to be made urgently more formal meetings may not be possible but comprehensive documentation of consultations remains essential. The following are recommended ways of working with risk: Informal discussions with colleagues Discussion with practitioners from other teams Formal clinical supervision Discussion at full team meetings Formal risk management meetings Formal risk management meetings may include the multidisciplinary team, senior clinicians, other specialist teams eg home treatment, forensics etc., Plymouth Community Healthcare managers, risk managers and other services eg social services or police. These should lead to minutes or a clear documentation of the discussion and outcome. Involvement of the service user and carer in these processes is essential but the degree and how they are involved must be judged individually. Page 13 of 18

14 4.7 Best Practice point 7 All staff involved in risk management must engage in regular training that meets their learning needs. All practitioners involved in risk management should engage in relevant learning opportunities about risk and this should be updated every three years. The depth, complexity and focus of the training should be determined by the practitioners learning needs. Such training may include ongoing reflective practice, in depth team discussions about risk management, reading best practice guidance and literature, supervision focusing on risk management, internal and external courses. Training should include at least some problem based learning with peers or experienced practitioners. Needs for future training in risk management should be assessed annually as part of annual appraisals, as well as during induction to new posts. Training will be formally reviewed every three years with a brief record of recent training, analysis of training needs and a brief plan of how to achieve these. 4.8 Best Practice point 8 Comprehensive documentation is essential component of positive risk management and should be seen as enhancing clinical practice, not as a barrier to it. Risk management is part of the Care Programme Approach and all care plans. Risk management documentation includes a variety of formats: formal risk management meetings, completion of risk management tools and recording everyday clinical decisions about risk in clinical records. Comprehensive documentation is vital to ensure effective communication and the potential consequences of failures in this have been well catalogued following previous serious untoward incidents. Particular danger points where communication can fail are at discharge from hospital and referral to another care provider. It is expected that in general risk management documents should include an understanding of the specific risks, the triggers to these and contingency plans to manage these. In the majority of cases this will simply involve the development of a risk management plan as part of the care plan. If initial risk assessment indicates a higher degree of risk then appropriate and proportionate responses to managing this should be made. Initial discussion with other clinicians (especially more senior staff) should be undertaken and a decision to move to more formal processes of risk management meetings and the involvement of further services should be considered. All relevant risk related decisions should be recorded in suitable documentation. The service user and carer should be able to contribute to this documentation and should be provided with a copy of it. Where positive risk management is implemented, a clear rationale for the plan should be Page 14 of 18

15 documented. All clinical discussions and meetings relating to risk management should also be documented. The process of documentation should not be a bureaucratic end to itself and should not be aimed solely at self-protection but should contribute to effective risk management and assist the service in effectively supporting the service user. Risk management documents should, where appropriate, be communicated with the service user and all those providing their care. The local policy on information sharing governs this process. 5. Structured Clinical Judgement Training Proposal Development of a clinical risk assessment of violence programme for PCH staff. Objectives Develop risk assessment expertise within the PCH that is evidence based. Link risk assessments to risk management plans that are embedded in patient care plans and contribute to safety of patient, staff and public. Background A Large body of evidence indicates that clinical judgement of risk is not accurate and is not evidence based (Hart & Logan 2011, RCP 2008 & DOH 2007). Structured clinical judgement (SCJ) approaches are evidence based. They provide a probability of risk (of violence, sexual violence, suicide) and also provide information on frequency, severity, imminence and risk scenario planning. They also provide a framework for clinical risk decisions, management and interventions. SCJ approaches have been validated in forensic, correctional, in-patient, civil-psychiatric and community psychiatric settings (RMA 2008). Internationally mental health services, including the NHS have generally adopted a SCJ approach to risk often utilising the HCR-20 risk assessment tool. Benefits The development of an evidence based risk assessment/management assessment will improve clinical practice and patient pathways; particularly from secure services into the community. The process reliably improves patient, staff and public safety. It would also aid the Community Forensic Team (CFT) to refer clients on from their service to more appropriate teams. Assessment process For complex and or service users with a known forensic need it is recommended that a full HCR-20 risk assessment is completed, updated and monitored. For other service users that present with concerns or some risks, existing risk information (often contained in the ecpa and TAG) should be applied to the risk formulation matrix, which is part of the structured clinical judgement process. Training Implication Page 15 of 18

16 Two tiers of training would be offered, based on the two types of risk assessment. Full HCR-20 would be provided to a select group of suitably qualified staff who were willing and competent to provide a comprehensive and complex assessment. This training would take two initial days and a further two half days at three and nine months after initial training. The second tier of training would be for a larger pool of staff. This training would enable staff to take existing risk information and utilise the risk formulation matrix as part of the Structured Clinical Judgement process. It is suggested that this training would take one day The Royal College of Psychiatry (2008) emphasise that the person assessing the patient is more important than the risk assessment tool itself. Without training in risk assessment and management, risk assessment tools are useless. Risk assessment is an on-going process rather than a tick box tool kit. References Hart, S.D. & Logan, C.) in Sturmey, P. & McMurran, M. (Eds) (2011) Forensic case formulation. Chichester, UK. Wiley-Blackwell. Risk management authority (2008) Risk assessment tools evaluation directory. Rethinking risk to others in mental health services. Final report of a scoping group. June Royal College of Psychiatrists. Best Practice in Managing Risk is a recent Department of Health publication (2007) 6. Monitoring Implementation of the Guidance in Practice A local review of Clinical Risk Management practices should be used by individual teams to monitor compliance with this guidance. Additional review of compliance will occur as part of the annual Record Keeping Audit. Recommendations from Serious Incidents Requiring Investigation will also guide practice and these guidelines. Page 16 of 18

17 Risk Management Appendix A Risk Level Tools Processes Underlying principles MINIMAL MODERATE Basic eg TAG CPA risk Assessment Specific Tools eg STORM Specialist Tools Non-CPA care MDT discussion Risk Management Meeting MAPPA/ wider risk Management Meeting Positive risk management. Shared responsibility Service user engagement in risk management Structured Clinical Judgement Training (to be available for all staff) Plymouth Community HealthCare Risk Management Meeting Guidance EXTREME Page 17 of 18

18 All policies are required to be electronically signed by the Lead Director (the policy will not be accepted onto Healthnet until the e-signature is received). The proof of signature for all policies is stored in the policies database. The Lead Director approves this document and any attached appendices. Signed: Title: Date: Page 18 of 18