Ligature Risk Assessment Policy

Ligature Risk Assessment Policy Version Number: V3 Name of originator/author: Director of Estates and Facilities Name of responsible committee: Risk Committee Name of executive lead: Chief Operating Officer Date V1 issued: October 2012 Last Reviewed: August 2013 Next Review date: September 201 Scope: Trust wide MMHSCT Policy Code FE14 Page 1 of 16

Document Title / Ref: Document Control Sheet Ligature Risk Assessment Policy Lead Executive Chief Operating Officer Director Author and Contact Director of Estates and Facilities Number Type of Document Policy Broad Category Broad Document Purpose Manchester Mental Health and Social Care Trust acknowledges its responsibilities to identify all likely ligature points in inpatient wards, inpatient therapy areas, residential units and other premises where service users access a service within the trust. Scope Trust Wide Version number V3 Consultation Operational Management Team Matrons Head of Nursing Health and Safety Committee Length of Consultation: 2 weeks Approving Committee Risk Committee Approval Date 20 August 2013 Ratification Trust Board Date of Ratification October 2013 and Date V1 Valid from Date October 2012 Current version is valid from approval date Date of Last Review August 2013 Date of Next Review September 201 Procedural Documents to be read in conjunction with this document: Health and Safety Policy Risk Management Strategy Training Needs Analysis Impact There are no Training requirements for this procedural document Procedure for use of Ligature Knife Financial There are no Financial resource impacts Resource Impact Document Change History Changes to this document in different versions must be detailed below. Rationale for the change should also be given Version Number / Name of procedural document this supersedes Type of Change i.e. Review / Legislation / Claim / Complaint Date V2 Review August 2013 Details of Change and approving group or Executive Lead (if done outside of the formal revision process) Policy reviewed and updated accordingly. Formatted to Trust Procedural Documents standard External references used in the creation of this document: If these include monitoring duties upon the Trust for this policy the specific details should be recorded on the Monitoring and Compliance Requirements sheet Page 2 of 16

Privacy Impact N/a Any issues? Choose an item. Assessment submitted Fraud Proofing N/a Any issues? Choose an item. submitted If not relevant to this procedural document give rationale: Policy authors are asked to consider each of the nine protected characteristics under the Equality Act 2010. We expect you to demonstrate that throughout the policy process you have had regard to the aims of the Equality Duty: 1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Act; 2. Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and 3. Foster good relations between people who share a protected characteristic and people who do not share it. Please provide a brief account of how you have done this, further work to be completed and any support you have had in considering the aims and working in compliance with the Equality Duty. If you are unclear on how to do this or would like further advice and support then you may contact quality.admin@mhsc.nhs.uk. It is the responsibility of the approving group to ensure this statement reflects the Trusts objectives and position with compliance as set out within the NHS Equality Delivery System The policy is broad and the scope is Trust wide so complies with the Trust s Equality Delivery System In line with the Trust values we may publish this document on our External Website. Is there any reason you would prefer this is not done? No It is the Authors responsibility to ensure all procedural documents comply with the Trust values If you are unclear on any of the requirements in the document control sheet then please email quality.admin@mhsc.nhs.uk before proceeding Page 3 of 16

Monitoring and Compliance Requirements Sheet For audit, Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors, Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis. Procedural Document Title: Does this procedural document offer support or evidence for the Trusts registered activities and outcomes? Yes Primarily Choose an item. Additional Not Applicable Additional Choose an item. Is this an NHSLA Document? No Which Standard does this relate to? 1 Which Criterion Not Applicable Choose an item. Choose an item. If other Monitoring requirements are necessary i.e. Health & Safety Act and you should include them here and record them in the External References section Specify where the requirement originates Minimum Requirement / Standard / Indicator to be monitored & Section of document it appears Process for monitoring Audit Audit Audit Audit Responsible Individual / Group Additional Details i.e. Section number, Code of Practice Frequency of Monitoring Yearly Yearly Yearly Yearly Responsible Group for review of results / action plan approval / implementation Comments NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected timescales for completing the audit to quality.admin@mhsc.nhs.uk as soon as possible and no later than 4 weeks prior to the audit commencing. The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate. Page 4 of 16

Contents Page Section Title Page Number 1 Executive Summary 6 2 Introduction 6 3 Equality Impact Assessment 6 4 Privacy Impact Assessment 6 Definitions 6 6 Responsibilities 7 6.1 Chief Executive 7 6.2 Chief Operating Officer 7 6.3 Chief Nurse and Director of Quality Assurance 8 6.4 Medical Director 8 6. Senior Managers 8 6.6 Service Managers 8 6.7 Managers 9 6.8 All Staff 9 6.9 Nursing and Medical Staff 10 6.10 Head of Nursing 10 6.11 Matrons 10 6.12 Director of Estates 10 7 Systems, Policies and Procedures 10 7.1 Policies 11 7.2 Ligature Risk Assessments 11 7.3 Risk Rankings 11 8 Training 11 9 Action to be taken by staff first on the scene of a self 12 strangulation 10 Monitoring 12 11 Audits 12 12 Analysis of Adverse Events 12 13 Dissemination and Communication 12 Appendix Appx 1 Ligature Risk Assessment Form 13 Appx 2 Guidance on the completion of Risk Assessments 14 Have you considered using a flowchart in your document to provide easy reference for staff? If you need support in developing a flowchart contact quality.admin@mhsc.nhs.uk Page of 16

1 Executive Summary Ligature Risk Assessment Policy Manchester Mental Health Care Trust s Identification and Assessment of Ligature Risks Policy: Makes explicit the organisation s commitment to identify and manage all likely ligature points in inpatient wards, inpatient therapy areas, residential units and other premises where service users access a service within the trust. Explains the framework within which the policy has been developed. Contains descriptions of the responsibilities for ligature risk identification, assessment and management within the organisation This policy should be read in conjunction with the following documents:- Trust s Health and Safety Policy Trust s Risk Management Strategy. Procedure for Use of Ligature Knife 2 Introduction Hanging is the main method of suicide for mental health service users, whether they are in in-patient units or in the Community. Hanging may involve strangulation or asphyxiation caused by suspending the body from a high ligature point, or by using a ligature point below head height. A significant proportion of suicides are believed to occur through impulsive acts, using what may be seen as reasonably obvious ligature points. As a result of this data the National Suicide Prevention Strategy for England (2002) states that likely ligature points in mental health services environments should be removed or covered up. Due to human ingenuity and/or the lack of a suitable technical solution it is not possible for all potential ligature points to be removed. It is therefore necessary for a judgement to be made regarding the likelihood of an item being utilised as a ligature point, and the opportunity for a service user to utilise the potential ligature point. Manchester Mental Health and Social Care Trust acknowledges its responsibilities to identify all likely ligature points in inpatient wards, inpatient therapy areas, residential units and other premises where service users access a service within the trust. 3 Equality Impact Assessment An Equality Impact has been carried out against this policy. 4 Privacy Impact Assessment An initial Privacy Impact Assessment against this policy has been carried out. A full impact assessment is not required. Definitions For the purpose of this document the Board defines: Page 6 of 16

Employee Any member of staff who holds a contract directly with the Trust Worker Any person carrying out work on behalf of or for the Trust who does not hold a contract of employment directly with the Board. This includes selfemployed staff and those staff supplied and paid by contractors and agencies. Senior Managers Managers with the responsibility for managing key areas of the Trust, reporting to Executive or Non-Executive Directors, Department Managers Managers responsible for managing key sectors of service delivery, reporting to Senior Managers, Managers managers responsible for managing individual departments/teams/wards, reporting to Department Managers 6 Responsibilities 6.1 Chief Executive The overall and final responsibility for the identification, assessment and management of ligature risks within the Trust rests with the Chief executive, who is responsible for: Ensuring that there is a written Ligature Risk Assessment Policy which is regularly updated Ensuring the provision of sufficient resources to implement the Ligature Risk Assessment policy Ensuring that all employees are fully aware of their responsibilities under the Ligature Risk Assessment Policy and that these responsibilities are fulfilled The conduct of an annual audit of the ligature risks within the Trust and the implementation of any recommendations arising from such an audit Ensuring reports on statistics, trends and remedial measures implemented with regard to ligature risks/incidents are submitted to the Trust Board and appropriate Committees. The Chief Executive has delegated the responsibility for ensuring the satisfactory undertaking of the above to the Chief Operating Officer and the Director of Nursing and Therapies. The Chief Operating Officer has delegated the day to day management required to meet the above obligations to his Senior Management Team. 6.2 Chief Operating Officer The Chief Operating Officer must ensure that:- The Ligature Risk Assessment Policy, is implemented, corporately and within areas of his control. He delegates effectively the responsibility for Ligature identification, assessment and management within his areas of control He proactively supports his managers decisions and recommendations with regard to the provision of adequate resources to delivery the Trust s Ligature Risk Assessment Policy. Staff tasked with undertaking ligature assessments within areas of his control have adequate experience and training to safely undertake this duty Staff are aware of the procedures for responding to a ligature related incident Risk assessments are carried out as required to identify Ligature Risks, these assessments are recorded and reported, and that the results of these Page 7 of 16

assessments are communicated to employees before they are exposed to such risks Where emergency procedures are indicated by the risk assessment process, they are developed and resourced immediately. All incidents relating to ligature risks are recorded and investigated, and that all necessary reports are completed in accordance with the Trusts Incident Reporting System. 6.3 Chief Nurse and Director of Quality Assurance The Chief Nurse and Director of Quality Assurance Staff professionally accountable to him undertake and develop Clinical Risk Assessments and Care Plans as required, and that reasonable and appropriate consideration is given to potential ligature risks within the patient environment 6.4 Medical Director The Medical Director must ensure that: Staff professionally accountable to him undertake and develop Clincal Risk Assessments and Care Plans as required, and that reasonable and appropriate consideration is given to potential ligature risks within the patient environment 6. Senior Managers Senior Managers are responsible for ensuing that:- The Ligature Risk Assessment Policy, is implemented within their areas of control They effectively delegate the responsibility for Ligature identification, assessment and management within their areas of control They advise the Chief Operating Officer of any resources required to enable them to ensure that the Trust s Ligature Assessment Policy is implemented within their areas of control. Staff tasked with undertaking ligature assessments within areas of his control have adequate experience and training to safely undertake this duty Staff are aware of the procedures for responding to a ligature related incident Risk assessments are carried out as required to identify Health and Safety Risks, these assessments are recorded and reported, and that the results of these assessments are communicated to employees before they are exposed to such risks Where emergency procedures are indicated by the risk assessment process, they are immediately enacted. If such procedures cannot be enacted due to resource constraints they must advise their line mangers immediately. All incidents relating to ligature risks are recorded and investigated, and that all necessary reports are completed in accordance with the Trusts Incident Reporting System. 6.6 Service Managers Service Managers must ensure that:- Page 8 of 16

They undertake monitoring to ensure that the Ligature Risk Assessment Policy is implemented within their areas of control They delegate effectively the responsibility for ligature risk, assessment and management within their areas of control They advise their Line Manager of any resources required to enable them to ensure that the Trust s Ligature Risk Assessment Policy is implemented within their areas of control. Staff tasked with undertaking ligature assessments within areas of his control have adequate experience and training to safely undertake this duty Staff are aware of the procedures for responding to a ligature related incident Risk assessments are carried out as required to identify Health and Safety Risks, these assessments are recorded and reported, and that the results of these assessments are communicated to employees before they are exposed to such risks Where emergency procedures are indicated by the risk assessment process, they are immediately enacted. If such procedures cannot be enacted due to resource constraints they must advise their line mangers immediately. All incidents relating to ligature risks are recorded and investigated, and that all necessary reports are completed in accordance with the Trusts Incident Reporting System. 6.7 Managers Managers must ensure that:- They implement the Ligature Risk Assessment Policy in areas under their control They effectively delegate the responsibility for ligature riskand assessment within their areas of control Staff are aware of the procedures for responding to a ligature related incident They advise their Line Manager of any resources required to enable them to ensure that the Trust s Ligature Assessment Policy is implemented within their areas of control. Staff tasked with undertaking ligature assessments within areas of his control have adequate experience and training to safely undertake this duty Risk assessments are carried out as required to identify Health and Safety Risks, these assessments are recorded and reported, and that the results of these assessments are communicated to employees before they are exposed to such risks Where emergency procedures are indicated by the risk assessment process, they are immediately enacted. If such procedures cannot be enacted due to resource constraints they must advise their line mangers immediately. All incidents relating to ligature risks are recorded and investigated, and that all necessary reports are completed in accordance with the Trusts Incident Reporting System. 6.8 All Staff All staff are responsible for: Advising their line manager if they are aware of any potential ligature risk Notifying any incidents regarding ligature risks (including near misses) to their Page 9 of 16

Head of Department or immediate line manager Be aware of the procedures for responding to a ligature related incident Attending ligature risk assessment and management training courses provided by the organisation Taking part in ligature risk assessments. 6.9 Nursing and Medical Staff All nursing and medical staff are responsible for the following additional duties:- Undertake and develop Clinical Risk Assessments and Care Plans as required, and ensure that reasonable and appropriate consideration is given to potential ligature risks within the patient environment 6.10 Head of Nursing The Trust s Head of Nursing shall:- Provide specialist advice and support regarding the management of ligature risks Provide specialist advise regarding the identification and risk assessment of ligature risks Work with the Estates Department to ensure that development schemes, in as far as reasonable and practicable, incorporate anti-ligature designs and installations. Ensure that an annual ligature risk audits of all inpatient areas is undertaken, and develop with the Director of Estates, a planned ligature risk removal programme. Provide an annual report, jointly with the Director of Estates, detailing recommended actions to the Trust s Risk Committee. 6.11 Matrons Matrons shall:- Support ward managers to implement this policy Provide support and advise regarding ligature risks, and the undertaking of ligature risk assessments. Undertake an annual ligature risk audit 6.12 Director of Estates The Director of Estates shall:- Ensure that the agreed anti-ligature designs and installations are incorporated within development works undertaken by the Trust. Support the undertaking of an annual ligature risk audits of all inpatient areas is undertaken, and develop with the Head of Nursing, a planned ligature risk removal programme Provide an annual report, jointly with the Head of Nursing, detailing recommended actions to the Trust s Risk Committee. 7 Systems, Policies and Procedures 7.1 Policies Page 10 of 16

The Trust s Ligature Risk Assessment Policy is one of a suite of policies developed to support the Trust s Health and Safety Policy. The Trust s Ligature Risk Assessment Policy should be read in conjunction with the Trust s Health and Safety Policy, the Trusts Clinical Risk Management and Assessment Policy and Procedures, the Trusts Care and Support Planning Policy. 7.2 Ligature Risk Assessments Each ward and department must undertake an annual ligature risk assessment. The Ligature Risk Assessments are a working document and should be continuously reviewed and updated. Copies of the Risk Assessments, shall be kept in the ward and department, and all staff should be aware of their location and be able to assess them at all times. Appendix 1 to this Policy contains a Ligature Risk Assessment Form. This form should be used to record Ligature Risk Assessments. The results of Ligature Risk Assessments should be recorded on the ward/department risk register as required. It is essential that this is done, as it is this mechanism that will ensure that issues that cannot be controlled/resolved at ward and department levels are advised to Senior Management and Directors. 7.3 Risk Rankings The Risk Assessments risk ratings shall be allocated in accordance with the Trust s Risk Management Policy. As all potential ligature risks identified may result in death or serious injury the IMPACT of all identified ligature risks shall be considered to be ranked at LEVEL. The assessment of the likelihood of the identified ligature risk resulting in death or serious injury should be made following the consideration of the following factors:- Room Designation Height of identified ligature risk Type of potential risk Service accommodated within the rooms/areas Appendix 3 to this Policy contains guidance to assist those undertaking ligature risk assessments to access the likelihood of each identified ligature risk being used by a client to attempt suicide. The Governance Department provide training for staff and managers to enable them to correctly measure the risk ranking associated with identified risks. Training can be arranged via the Trusts Training and Development Team on 0161 882 1117. 8 Training Ward managers, supported by Matrons and Clinical Leads will ensure that this policy is disseminated and implemented within ward teams. Page 11 of 16

Ward Managers will ensure that this policy is included within local inductions and that, through on the job training, all staff understand their role in implementing this policy. Training to assist the completion of the ligature risk assessmenst can be obtained from the Trust s Health and Safety Advisor:- Tel: 0161 277 1214 Email: bernadette.bailey@mhsc.nhs.uk 9 Action to be taken by staff first on the scene of a self strangulation Refer to the Procedure for the use of Ligature Knife. 10 Monitoring Monitoring of the content and approach to the completion of ligature risk assessments will form part of the Trust s Clinical audit programme. 11 Audits A continuous rolling programme of Audit Visits will be undertaken to monitor compliance with the Trust s Ligature Risk Assessment Policy. Areas of non-compliance will be identified and reported to the Health and Safety Committee. 12 Analysis of Adverse Events All adverse events will be investigated in accordance with the Trusts policies. Learning from all adverse events is shared appropriately to improve care, services and working conditions. Further information can be found in the Policy for Management of Incidents including SIRI s Policy. 13 Dissemination and Communication The Policy will be made available to all staff on the Trust intranet and Trust Communications following approval. Page 12 of 16

Appendix 1 Ligature Risk Assessment Form DEPARTMENT/WARD: REVIEWED ON: Note: Likelihood is calculated by dividing the total column by 4 SITE : ASSESSED BY: ASSESSMENT DATE: Likelihood Assessment Current Risk Level Residual Risk Level Location Hazards Identified Persons at Risk Existing Control Measures in Place Locatio Height Type Service Total Likeliho od Impact Risk Additional Control Measures required Likeliho od Impact Risk Actions taken to implement additional control measures Page 13 of 16

Appendix 2 Guidance on the completion of Risk Assessments As stated in section.2 all potential ligature risks identified may result in death or serious injury. As a result the IMPACT of all identified ligature risks shall be considered to be ranked at LEVEL. In order to establish which level of likelihood should be applied to each identified ligature point the following should be considered: Location, ie. room/area Height of identified ligature risk Type of potential risk Service accommodated within the rooms/areas The overall likelihood score to be recorded on the risk assessment is calculated by adding together the individual likelihood scores attributed to each of the above categories and dividing by FOUR (the number of categories). Guidance on the allocation of likelihood scores for each of the categories is outlined below. Location The location of any ligature point should be considered with a view to establishing the level of supervision provided in the area that the ligature point is located within. Rooms with a greater level of supervision are considered to afford a lower level of opportunity to service users to locate and utilise ligature points. When assessing the potential likelihood of ligature points being utilised by service users ligature risk assessments teams should consider the location, and specifically the level of observation afforded to the area, and award a likelihood score in accordance with the following guidance:- Decreased observation of the room / area Likelihood Score 1 2 3 4 Page 14 of 16

Height of Identified Risk It is considered that those ligature points that are located over 1.6m from the floor level, afford a greater opportunity to service users to commit suicide. When assessing the potential likelihood of ligature points being utilised by service users ligature risk assessments teams should consider the height of the ligature point and award a likelihood score in accordance with the following guidance:- Height of ligature risk Likelihood Score At Floor Level Located below 1m from the floor level Located above 3m from the floor level Located between 1 1.6m from the floor level 1 2 3 4 Located between 1.6 3m from the floor level Type of Potential Risk It is considered that certain types of potential ligature risks are more readily identified by service users than others. When assessing the potential likelihood of ligature points being utilised by service users, the following should be considered:- 1. Is the identified ligature point considered to be an obvious potential point? 2. Is the ligature point easy to utilise Increased likelihood of ligature point being identified by service users Likelihood Score 1 2 3 4 Page 1 of 16

The following information is provided to assist with this assessment. Likelihood Score Potential Ligature Point 1 2 3 4 Radiators, Fire extinguisher brackets, Fire alarm sounders Panelling, Electrical outlets, Door closers Light fittings wall and ceiling types, Handrails, including grab rails Toilet seats, Tun dishes and overflows, Door handles, Toilet flushes, Suspended ceilings in corridors and day rooms Ceiling grilles, Taps, Shower units, Shower hoses, Suspended ceilings in shared bedrooms Suspended ceilings in WC s etc, Suspended ceilings in single rooms, Shower curtain rails, Curtain rails Service Accommodated in the rooms /areas It is recognised that the type of service accommodated within the area being audited, will impact upon the likelihood of ligature points being utilised by service users. The acuity of service users accommodated in the area must therefore be considered when undertaking a ligature risk assessment, and award a likelihood score in accordance with the following guidance:- Increase in Service User Acuity Likelihood Score 1 2 3 4 Scoring Matrix The scores allocated to each ligature point should be recorded on the risk assessment form, refer to Appendix 1. Page 16 of 16