Policy Number: Issue/Version No.

CLIN/0017/v5 V5

Clinical Risk Assessment and Management Policy

Current Status:

Ratified

Compliance All members of Tees, Esk and Wear Valleys NHS Foundation Trust employees will adhere to the parameters of trust policies. The consequences of noncompliance may include disciplinary action and/or legal action.

DOCUMENT CONTROL Application This policy pertains to all areas, departments and services of Tees, Esk and Wear Valleys NHS Foundation Trust N/A 6 June 2012 1 June 2015 Clinical Risk Assessment and Management Policy CLIN/0017/ 4 Stephen Scorer Deputy Director Nursing and Patient Safety

Associated policy reference and title Date of Ratification Date of Review Replacing

Lead

Policy Review Contributions From Kevin Stubbings MHSOP Teesside Denise Colmer Suicide Prevention Paul Stephenson CPA/Risk Karen Conlon CPA Manager Michael Sykes: Patient Safety Manager Carlie Johnston Modern Matron AMH Cath Crawford Modern Matron MHSOP N Yorks This policy has been agreed and accepted by: (Director) Name Designation Director of Nursing, & Governance Signature Date

Chris Stanbury

6 June 2012

This policy has been ratified by: Trust Board or Trust Board Sub Committee Date of Trust Board or Sub Committee 6 June 2012 Date of EqIA 31st March 2012

Executive Management Team This policy has gone through an equality analysis (EA)

4 October 2011 Review date extended to 31 March 2012 6 June 2012 Amended to incorporate North Yorkshire requirements

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CONTENTS
1 2 3 Introduction Scope of Policy and Objectives Definition/Glossary 3.1 Practitioner 3.2 Clinical Risk Assessment 3.3 Clinical Risk Management 3.4 Risk Behaviour 3.5 The Care Plan 3.6 The Intervention Plan 3.7 Contemporaneous records 3.8 Risk Formulation Responsibilities Key Themes 5.1 Safety and Security 5.2 Therapeutic Engagement and Collaborative Working 5.3 Record Keeping and Documentation 5.4 Clinical Risk Assessment Models and Tools 5.5 Equality and Diversity 5.6 Communication 5.7 Service user, Family and Carer Involvement 5.8 Engagement and Observation 5.9 Management of Behaviour that Challenges 5.10 Suicide Prevention and Risk 5.11 Supervision Process/Procedure 6.1 Responsibilities 6.2 Clinical Risk Assessment and Clinical Risk Management 6.3 Discharge from Hospital Implementation 7.1 Policy Awareness 7.2 Training 7.3 Policy Monitoring & Review Audit Related Documents 4 4 5 5 6 6 7 7 7 7 7 8 8 8 9 9 9 10 10 10 11 11 11 11 11 12 13 13 13 13 14 14 14 16 28

4 5

8 9

10. Appendices Appendix 1 Protocol for Engagement & Observation of patients in inpatient and residential services Appendix 2 Gaining Approval For The Clinical Risk Assessment Tool (CRAT) Register 11 12 Bibliography/References Author

15 15

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KEY POLICY ISSUES This policy applies to all staff that provide or contribute to the clinical care of service users and carers All aspects of Clinical Risk Assessment, Formulation and Care Planning including specific risks to children and vulnerable adults Engagement and Observation Record keeping, communication and staff support.

Clinical Risk Assessment and Management Policy Summary The policy describes all aspects of Clinical Risk Assessment and Management including the procedure for engagement and observation practices. Key Points The policy describes the scope, objectives and clinical practice issues in clinical risk assessment formulation and management. It defines risk behaviours. There is a description of the process required to complete risk assessment and formulation of those risks into meaningful interventions which manage the risks posed by and to the individual. The engagement and observation protocol describes the three levels of observation and engagement as: general, enhanced within arms length, and enhanced within eyesight. The following are described in the policy: o record keeping practice to support clinical risk assessment, formulation and management o requirements for best practice in recording engagement and observation practice. o The decision- making process for increasing and decreasing patients levels of engagement and observation. The Governance process for the management of directorate specific risk tools is described with the requirements for their management.

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1.

INTRODUCTION This policy when implemented must give due regard to equality, diversity and human rights and reflect Trust values. This policy will outline the principles of Clinical Risk Assessment and Clinical Risk Management that will apply to all services provided by Tees, Esk and Wear Valleys NHS Foundation Trust and the training that employees will undertake to ensure safe and effective Clinical Risk Assessment and Management. Clinical Risk Assessment and Clinical Risk Management are fundamental to the care of individuals in receipt of mental health and learning disability services. Care is delivered within the Care Programme Approach (Refocusing the Care Programme Approach; Policy and Positive Practice Guidance March 2008) and care planning within CPA should demonstrate needs formulation based on principles of clinical risk assessment. Clinical Risk Assessment involves working with service users in the identification and further investigation of factors associated with an increased probability of specified risk behaviours occurring. The systematic collection of information to determine the degree to which risk is present, or is likely to pose problems at some point in the future for the patient or the general public. 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) Tees, Esk and Wear Valleys NHS Foundation Trust is committed to working with service users, their families and carers and fully acknowledge the pivotal role of all of those individuals in the identification and management of clinical risk. Tees, Esk and Wear Valleys NHS Foundation Trust have a responsibility to ensure all employees have an understanding of the principles of Clinical Risk Assessment and Management. This policy will set the standards for the practice and training and will reflect the requirements of National Health Service Litigation Authority, CQC Essential Standards, and the Best Practice in Risk Management (2007)

2.

SCOPE OF POLICY AND OBJECTIVES This policy applies to all employees where competency in practice of clinical risk assessment, formulation and management is required to fit their role. There are mandatory training requirements for this group of employees. Other employees who have regular contact with service users, their families and carers will have an awareness of clinical risk issues and the important role in the care of service users. Other practitioners who work with service users, their families and carers through partnership agreements, interagency integrated working arrangements, service level agreements, honorary contracts and educational placements will adhere to the

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principles and standards in this policy and will have access to the Trust training programme if they identify that need. This Policy will aim to: Clarify the scope and methods of clinical risk assessment Outline the systems by which clinical risk models and clinical risk assessments tools used in services are authorised and registered by the Trust Clarify the standards of Clinical Risk Assessment and Clinical Risk Management practice expected of TEWV employees, Set standards for the documentation and communication of Clinical Risk Assessment and Intervention/care plans that are in keeping with the Trust Minimum Standards for Record Keeping Policy Highlight the training requirements for employees as set out in appendix 1 of the Learning and Development policy, ensuring that wherever possible training and staff development provision reflects national capability frameworks, competencies and local standards. 3. 3.1 DEFINITIONS/GLOSSARY Practitioner Practitioner is the term used to describe any member of the multi-disciplinary team who may be involved in engagement and observation practices. Any activity that is solely the duty of a registered practitioner will be highlighted as such. 3.2 Clinical Risk Assessment Morgan (2000) defines risk as: The likelihood of an event happening with potentially harmful or beneficial outcomes for self and others There are a number of key features of this definition 1. Risk is fundamentally about uncertainty 2. It is also about weighing up the likelihood of the different outcomes arising. 3. Risk refers to the possibility of benefits as well as harm when assessing risk there is a tendency to focus only on harmful outcomes, which will produce an imbalanced risk assessment. So, risk assessment is about weighing up both the possible beneficial and harmful outcomes and stating their likelihood. To improve its predictive value, risk assessment should also take place within a stated timescale. It is easier to predict outcomes in the short term than in the longer term. Clinical Risk Assessment involves working with the service user to help estimate each of these aspects: information about the service users history of violence, selfharm or self-neglect, their relationships, any recent losses, problems, adverse
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effects of hospitalisation, employment and any recent difficulties, housing issues, their family and the support that is available, and their more general social contacts, could all be relevant. (Best Practice in Managing Risk, 2007) Clinical Risk Assessment is a dynamic and ongoing process that should be reviewed on a regular basis, especially after significant events and prior to changes in the service users care arrangements. (Morgan, 1998) 3.3 Clinical Risk Management Clinical Risk Management involves developing one or more flexible strategies aimed at preventing the negative event from occurring or, if this is not possible, minimising the harm caused. Risk Management must include a set of action plans, the allocation of each aspect of the plan to and identified profession and a data review. (Best Practice in Managing Risk, 2007) Clinical Risk Management is the process within the care planning framework that ensures the risks and vulnerabilities of the service user are formulated, and appropriate and timely interventions are planned to manage the outcomes of the clinical risk assessment. The need for positive, supportive and therapeutic risk taking is essential to effective care delivery and a key element of risk management which interfaces with the CPA/Standard Care process 3.4 Risk Behaviour Risk behaviour is defined as behaviours that increase the likelihood of adverse psychological, social or physical consequences. (Resnick M.D., 1997) The policy applies to the full spectrum of risk behaviours liable to present to clinicians. This definition would apply to the following types of behaviour - however this list is not exhaustive: Risk of harm to others, violence, sexual violence, abuse, arson and hostage taking. Risk of harm to self deliberate self-harm, suicide, and through environmental and social risks. Level of vulnerability e.g. to abuse, relapse, exploitation, falls, wandering, absconding, predatory behaviour, or disinhibition. Risk of self-neglect through lack of self-care and/or lack of compliance or nonengagement with required treatment. Risk of self-abuse e.g. alcohol or illicit substance misuse. Risk of adverse effects of hospitalisation.
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Risks to physical health through neglect, abuse, disease, or disability or falls. 3.5
The Care Plan The care plan will include the summary of the total care package that is to be provided across all disciplinary/agency boundaries 3.6 The Intervention Plan The intervention plan is used by individual professionals to detail professional and or service interventions. It is the responsibility of the relevant professional leading on a particular aspect of the service users` assessment/care/treatment. This should be done working with the service user and relate to the CPA/ Standard Care care plan once this is in place. The intervention plan should also be used as an initial care plan until the CPA/standard care plan is agreed.

3.7

Contemporaneous Records The update of progress and clinical interventions documented in the current paper or electronic clinical record in use, as set out further in section 5.3

3.8

Risk Formulation Risk formulation should, as far as possible, specify factors likely to increase risk or dangerous behaviour, and those likely to decrease it. 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. A risk formulation should account for the role of protective factors as well as risk factors. Using a risk formulation of the evidence will provide the crucial link between assessment and management by informing the planning and implementation of interventions while concisely summarizing and communicating an individuals risk status

4. 4.1

RESPONSIBILITIES The Chief Executive is responsible for assuring that this policy is implemented within the Trust. The Director for Nursing and Governance is responsible for: The development, monitoring and review of this policy and practice standards The provision of appropriate mandatory foundation training and education to support the policy standards. (Specific training in risk assessment tools is the responsibility of clinical services) Operational Director Heads Of are responsible for: Implementation and monitoring of this policy in their areas of responsibility

4.2

4.3

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Ensuring that systems and processes are in place and monitored to meet the requirements outlined in this policy The provision of appropriate specialist training and education to support the policy standards including the use of agreed assessment tools. 4.4 Team leaders, Departmental Heads, Ward and Unit Managers are responsible for: Ensuring that all appropriate employees attend the relevant training within 3 months of appointment and with updates as outlined within section 7.2 of this policy. Implementation of the systems and processes that are in place to monitor compliance with the policy. All employees where competency in clinical risk assessment formulation and management is required in their role are responsible for: Ensuring personal awareness of the content of this policy Implementing the policy standards and procedures Maintaining their individual competence in Clinical Risk Assessment and Clinical Risk Management and attending training as required by their roles. The Policy Lead is responsible for: Co-ordinating the Register for Approved Risk Assessment and Management Models and Tools Developing the curriculae and co-ordinating the delivery of the foundation training programmes in Clinical Risk Assessment and Management.

4.5

4.6

5. 5.1

KEY THEMES Safety and Security The safety and security of service users, their carers and relatives, employees and the general public is the fundamental principle guiding Clinical Risk Assessment and Clinical Risk Management practice.

5.2

Therapeutic Engagement and Collaborative working Therapeutic engagement involves healthcare professionals spending quality time with patients and aims to empower the patient to actively participate in their care. Therapeutic engagement and collaborative working are fundamental practices in Clinical Risk Assessment and Management. When they feel able, and when appropriate, service users, their families and carers should participate in the Clinical Risk Assessment and Management process. Every practitioner will be skilled in therapeutic engagement and collaborative working. Staff have a professional responsibility to ensure their knowledge base and skills are adequate to carry out risk assessment and develop risk management plans. This will be monitored through audits, PDP, supervision, preceptorship, observations etc.

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5.3

Record Keeping and Documentation All practitioners will record clinical risk assessment findings and formulation findings with intervention/care planning outcomes on their service specialist local clinical risk assessment and management documentation. This will be held within the service users clinical electronic record. This will be recorded within the Trust identified time scales for Record Keeping. All service users will have their individual risks identified and formulated into intervention/care plans. All other record keeping will use the Trust core clinical documentation and electronic clinical record, other than where a formal data input agreement exists, e.g. with a local authority. Intervention/Care Plans will clearly identify which practitioner or service, relative or carer where appropriate is responsible for which agreed intervention, including how and when the intervention will be delivered, and reviewed. A summary of the Clinical Risk Assessment and Intervention/care plan will be recorded on the Trusts Corporate Electronic Recording systems as part of the local Care Programme Approach systems. This will ensure access to contemporary Clinical Risk Assessment and intervention/care plans for all on-call and out of hours employees. The use of documentation and record keeping processes will be audited against , Professional Codes and Trust Record Management Policy.

5.4

Clinical Risk Assessment Models and Tools This policy recognises that the use of Clinical Risk Assessment models and tools are part of the process to aid recognition and rating of clinical risk to the service users, their families and carers, employees and the general public. There will be a system managed through the Directorate Quality Assurance Groups (QUAGs) to ensure all Clinical Risk Assessment models and tools used in the clinical services are registered for use and their implementation is monitored. There are a number of models and tools that have been approved by the Trust for use and only these should be used. If a clinical service or professional group does identify an alternative Clinical Risk Assessment and Management model and/or tool the process for gaining Trust approval for its use and registration on the trust database is outlined in Appendix 3

5.5

Equality and Diversity This policy when implemented must give due regard to equality, diversity and human rights and reflect Trust values. Trust staff and any person who has an association with the Trust must take into account any needs arising from: Race and ethnicity Sex (gender) Disability

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Sexual orientation Religion or belief Age Gender reassignment Pregnancy and maternity Marriage and civil partnership 5.6 Communication Communication of risk is a fundamental core principle for all clinical practitioners in the Clinical Risk Assessment and Management process and communication skills are core skills for all clinical practitioners. Communication and sharing of outcomes of clinical risk assessment, formulation and management plans, with all clinical practitioners involved in the care of the service user, is essential. Patients must be informed, in general terms, how their information may be used, who will have access to it and the organisations it may be disclosed to. That is, they must be made aware that the information they give may be recorded or shared in order to provide them with care, and may be used to support local clinical audit and other work to monitor the quality of care provided. (TEWV Information Governance Policy) Full guidance regarding confidentiality and sharing of information can be found in the Trust Confidentiality Code of Practice Policy. 5.7 Service user, Family and Carer Involvement Best practice would be that service users, their families and carers are involved in all stages of the Clinical Risk Assessment and Management process and are fully informed of outcomes and changes to care provision and all discussions in relation to this is documented. This may not be possible in all cases and it will be reviewed on an individual basis by the multi-disciplinary team, considering the wishes of the service user. 5.8 Engagement and Observation Key interventions in the assessment and management of clinical risk in in-patient and residential services are the therapeutic engagement with service users and the clinical observation of service users by clinical practitioners. Part of the Clinical Risk Assessment and Management process in in-patient and residential, services will include the identification of engagement and observation interventions. The NICE Clinical Guideline 25 Violence: the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments (2005) defined specific levels of enhanced observation that are used when clinical risk levels are high. The minimum level of clinical observation for all service users in in-patient and residential services is general observation. The specific recommendations for the recording of contact and review of clinical risk assessment in the in-patient and residential services are outlined within the Engagement and Observation Protocol (Appendix 2 of this Policy)
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5.9

Management of Behaviour that Challenges A significant clinical risk in mental health and learning disability services is the potential for violent, aggressive and/or behaviour that challenges (NICE, 2005). All clinical practitioners should ensure they are familiar with and knowledgeable about the content and principles of the Trust Challenging Behaviour Policy as part of their clinical risk assessment and management knowledge and skills.

5.10

Suicide Prevention and Risk The fundamental importance of Clinical Risk Assessment and Management in the prevention of suicide is well documented. (Appleby L. et al, 2006) All clinical practitioners should ensure they are familiar with contemporary information about suicide indicators, potential high risk areas for potential self harm and suicidal behaviour and clinically effective risk interventions for the prevention of suicide.

5.11

Supervision All clinical practitioners should be reviewing their clients/patients and their practice on a regular basis within a supervisory setting. A key aspect of this needs to be clinical risk management. A record of supervisory discussion regarding the clinical risk management of a service user case should be recorded in the contemporaneous clinical record of that service user (guidance can be found in the Trust Record Keeping Policy).

6. 6.1

PROCESS/PROCEDURE Responsibilities Clinical risk assessment and management is a multi-disciplinary process for service users supported by more than one professional or agency. It is the responsibility of the clinical practitioner to ensure that the clinical risk assessment, formulation and clinical management plan are communicated to all involved in the service users care and that they are recorded in the specialist risk assessment section of the service users clinical record and on the appropriate Corporate Electronic Record Keeping system.

6.2

Clinical Risk Assessment and Clinical Risk Management Processes Clinical Risk Assessment and Clinical Risk Management are ongoing, dynamic processes and will be under constant review, not once only activities. The level of identified risk for an individual informs treatment options. Formal clinical risk assessment will be completed on initial contact with new services throughout the service users journey and then at regular intervals will be reviewed; changes will be noted and acted upon.

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Clinical risk assessment, clinical risk formulation, intervention/care planning will be completed and reviewed at critical points in the service users journey of care. All assessments, reviews, plans, changes to plans and treatment options, will be documented in the service users clinical record together with the evidenced rationale for any change. The minimum of critical points are: On initial contact with the service. Following any incident during contact with Trust services Any significant change to the service users presentation, physical or mental state. Change or transfer of care responsibilities e.g. change of community practitioner; admission to an in-patient setting; in handovers of periods of enhanced engagement and observation in in-patient settings. Prior to and return from any leave from in-patient residential services. Multi disciplinary team review or any review of care provision. Change in legal status. Change in life events (e.g. loss). Movement to less or more restrictive environments. At the request of a service user, their carer and/or families Prior to and post discharge from in-patient services, on arrival and pre discharge from community or Trust services. (Assessment must include risks to children if the service user may have or resume contact with children and in addition the service user has voiced thoughts of suicidal pacts including children or delusional thoughts) Clinical risk assessment must be based on thorough collection of information from all available sources and cover all aspects of the service users early life experiences, cognitive, emotional, psychological, physical, behavioural and social factors. If the service user is likely to have or resume contact with children the risk assessment must include assessment of the potential risks to children. Details of historical risk factors and history of risk behaviours, recent risk behaviours, severity, frequency, pattern, effect and planned intent will be collated and integrated into the care planning process. An integrated Intervention/care plan will identify the risks the service users present, through their behaviours, cognitions, physical state, disability and in which situations and organisational contexts the risks present. The plan will identify all the actions/interventions that are to be implemented to address those risks, the goal/aim of those actions/interventions and who will act/intervene and when. The type of action/intervention will be congruent with the clinical risk identified and consistent in intensity with the level of clinical risk. A record of the progress and outcomes of the intervention/care plan will be documented in the service users core contemporaneous progress sheets in the clinical record, together with the review and evaluation of the plan and the evidence and rationale for any changes. Evaluations and reviews should not be made on the
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intervention/care plan itself as this results in an incomplete contemporaneous progress record. If specialist clinical risk assessment and management models/tools require the completion of reviews and evaluations on specialist documents then a summary note will be made in the core contemporaneous progress sheets to provide a complete record. 6.3 Discharge Process from Hospital At the pre-discharge (Care Programme Review) meeting a review will take place that will include comprehensive care plan discussion and a new intervention/care plan will be agreed in collaboration with the service user, their family and carers wherever possible. This must include adherence to the standards described in the NPSA Preventing Suicide: A Toolkit for Mental Health Services (2009) and the NPSA Preventing Suicide: A Toolkit for Community Mental health Services (2011). That discharge risk management plan will be communicated to all involved practitioners, the service user, and wherever possible, the family and/or carers. 7. 7.1 IMPLEMENTATION Policy Awareness Team leaders, departmental heads, ward and unit managers will ensure that all clinical practitioners delivering clinical services are made aware of the policy and its contents. They will identify those employees that require specific training and ensure they attend the appropriate training. Mandatory Clinical Risk Assessment and Management training will be delivered as part of the Trust induction programme and will help new employees identify their training needs in developing competency in clinical risk assessment and management. 7.2 Training Mandatory training will be provided in line with the organisational training needs analysis (See Appendix 1 in the Learning and Development policy), with attendance monitored via human resources and reports sent to local managers to ensure mandatory training needs are met. For training that the Trust has not classified as mandatory then managers should consider the necessary competencies for the specific work required and arrange for these needs to be met through the appraisal and personal development plan process. Access to support to meet these needs is outlined in the Learning and Development policy and in the Training portfolio section of the Intranet. The training required to effectively implement the Clinical Risk Assessment and Management models and tools identified for use by services and/or professions, will be provided by those services and professions where required, but would as a minimum be expected to be updated as detailed in the training needs analysis.

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The content, format and frequency of that training will be based upon the model and tool and the requirements of the service or professional group. 7.3 Policy Monitoring and Review The policy lead, together with representatives from professional groups, operational service areas and the educational staff will monitor the implementation of the policy by: Clinical audit of clinical risk documentation in the clinical record Attendance to and feedback from training programmes Lessons learned from incident and investigations reviews Clinical reports to the Patient Safety Group

8.

AUDIT The implementation of this policy will be audited annually using an evidence based audit tool. Results of the audit will be fed back via the clinical governance structures to the Service Managers.

9.

RELATED DOCUMENTS Challenging Behaviours Policy First Response Policy Rapid Tranquilisation Policy Seclusion Policy CPA / Care Coordination Policy Record Management Policy Suicide Prevention Toolkit Suicide Prevention Policy Partnership Suicide Prevention Strategy Health and Safety Policy The Non Compliance with Treatment Policy The Absent Without Leave Policy Advanced Directions and Requests Policy

10.

APPENDICES Appendix 1 Appendix 2 Appendix 3 Protocol for Engagement and Observation of Patients in Inpatient and Residential Services Individual Intervention/care plan Gaining Approval For The Clinical Risk Assessment Tool (Crat) Register

11.

BIBLIOGRAPHY/REFERENCES

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Best Practice in Managing Risk June 2007 Department of Health

12.

AUTHORS Stephen Scorer: Deputy Director, Nursing and Patient Safety Denise Colmer: Senior Practitioner: Suicide Prevention Paul Stephenson: CPA/Clinical Risk Advisor Michael Sykes: Patient Safety Manager Kevin Stubbings: Modern Matron MHSOP Teesside Karen Conlon CPA Manager

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APPENDIX 1 PROTOCOL FOR ENGAGEMENT AND OBSERVATION OF PATIENTS IN INPATIENT AND RESIDENTIAL SERVICES

Within this protocol Practitioner is the term used to describe any member of the multi-disciplinary team who may be involved in engagement and observation practices. Any activity that is solely the duty of a registered practitioner will be highlighted as such.
This protocol will aim to: Facilitate ongoing clinical risk assessment and clinical risk management. Promote the safety of all patients receiving in-patient care and treatment. Promote the safety of others within the clinical environment Facilitate the development of therapeutic engagement as a core intervention in clinical risk management Ensure the practice of observation is used as an intervention in clinical risk management to meet the identified needs of patients and is integral to the care planning process. Ensure that the least intrusive level of observation that is appropriate to the situation of the patient must always be adopted.

1. DEFINITION/GLOSSARY 1.1 Positive Engagement Involves a two-way relationship established between a patient and clinical practitioner which is meaningful, grounded in trust and therapeutic for the patient (UKCC, 2002). The relationship aims to empower the patient to actively participate in their care (NICE, 2005) and ensure the patient receives positive attention. 1.2 Clinical Observation Is the practice of maintaining knowledge of the patients location in the clinical area by use of visual contact and is a therapeutic intervention that can be used intensively to increase safety for patients at risk and should be an integral part of clinical risk management. Clinical observation can be used with different levels of intensity dependent upon the clinical risks and the clinical needs presented by the patient.
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1.3

General Observation Is the minimal acceptable level of observation for all in-patients. of all patients, but not all patients need to be kept within sight of staff. General observation by clinical staff can be supported but not replaced by the use of surveillance via close circuit television. At least once a shift a registered nurse should set aside dedicated time to assess the mental state of the patient and engage positively with the patient. The aim of this time should be to develop a positive, caring and therapeutic relationship with the patient. This assessment should always include an evaluation of the patients moods and behaviours associated with risks of disturbed/violent behaviour and these should be recorded in the notes. (NICE, 2005) Other risks and vulnerabilities should also be evaluated in relation to the individuals clinical risk assessment.

1.4

Enhanced Observation within eyesight Means the patient should be kept within eyesight and accessible at all times during the periods specified for this level of observation and if deemed necessary, any tools or instruments that could be used to harm themselves or others should be removed. Positive engagement with the patient is an essential aspect of this level of observation (NICE 2005) and this observation is not surveillance. This intensive observation is required when the patient could, at any time, make any attempt, by any means to harm themselves or others. It may be necessary to search the patient and their belongings, while having due regard for the patients legal rights and conducting the search in a sensitive way. This observation may also be required during initial assessment whilst clinical risks and behaviours are unknown. (See Trust Policy for Searching of Patients, Patients Property, Patient Areas and Visitors)

1.5

Enhanced Observation - within arms length Is needed for patients at the highest levels of risk of harming themselves* or others, who should be supervised in close proximity. On specified occasions more than one member of staff may be necessary to implement this level of observation. Issues of privacy, dignity, past abuse or history of inappropriate allegations and the consideration of transgender in allocating staff, and the environmental dangers need to be discussed and incorporated into the plan of care. Positive engagement with the patient is an essential aspect of this level of observation. (NICE, 2005) With this observational practice the patient would also be kept within eyesight at all times, Harming themselves needs to apply to any behaviours that could cause harm to self including for example confusion, falls, self neglect

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1.6

Enhanced Engagement The number and frequency of engagements a patient requires during a span of duty, to manage the risks identified through risk assessments, will be identified and an intervention plan will describe the times, frequency and aims of each engagement (interventions) for that patient. The content of these enhanced engagement meetings will be fully recorded in the patient electronic records.

2. 2.1

KEY THEMES Safety patients and all in the clinical environment The promotion and maintenance of safety in the clinical environment should be a fundamental aspect of clinical care. The use of person centred, holistic approaches and positive clinical risk management will aim to maximise safety. Engagement and observation will be used as interventions in the proactive management of risk and promotion of safety not as surveillance techniques.

2.2

Multi-disciplinary involvement Multi-disciplinary assessment and Clinical risk formulation will be best practice in determining the appropriate use of engagement and observation. The intervention/care planning should take into account all professional views wherever possible and skilled practitioners from all disciplines will be involved in the delivery of that intervention/care plan. There are aspects of the planning of engagement and observation interventions that have to be delegated to appropriate practitioners to ensure timely plans and reviews are carried out in the best interests of patients.

2.3

Positive engagement and therapeutic intervention Positive engagement is active and collaborative. The practitioner should endeavour to understand the patients experiences and gain their perceptions of their problems and needs. Staff need to positively engage with patients at all times when practising observation, utilising appropriate therapeutic interventions, diversionary activities and offering support with self care activities if indicated from assessment. The on-going assessment of mental health, physical health and risk should be integral to the process of engagement.

2.4

Clinical Observation Clinical observation of patients is a skilled activity that forms an integral part of the management of risk together with positive engagement. Observation practice needs to provide continuous assessment of symptom presentation, mood and behaviour to continue to inform the clinical risk assessment process.

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Levels of observation should be set in the least restrictive form, within the least restrictive setting to protect the safety of the patient, safety of others and to promote positive therapeutic engagement. Where enhanced levels of observation are indicated, the definitions outlined in Section 1 will apply. The time periods for enhanced observation and any specific directives about use must be included in the individual intervention/care plan.

2.5

Patient, family and carer Involvement Best practice would be that patients are given information about, and are involved in, the planning of engagement and observation. In addition, decisions about observation practice will be negotiated and implemented in collaboration with the understanding of the patient and their families and carers. It is recognised that this may not always be possible but the situation should be reviewed on an on-going basis to ensure that agreement is gained wherever possible. Involvement of advocates should always be considered where this will be in the best interest of the patient. Involvement of patients or reasons for none or limited involvement should be evidenced through entry into the clinical record and collaborative signing of the intervention/care plan, wherever possible.

2.6

Privacy and Dignity Any observation care will be delivered to maximise privacy and dignity of the patient whilst maintaining optimum levels of safety. (CRAG, 2002)

2.7

Cultural diversity and ethnicity This policy, the procedures and training will uphold the Trust strategy on Equality and Diversity and will reflect anti-discriminatory practice.

2.8

Skills of staff The skills of staff to deliver evidenced based engagement and observation practice will include: Knowledge of principles and techniques of clinical risk assessment and management. Skills in the practice of clinical observation Knowledge of mental health symptoms and presentations. Knowledge of physical health presentations. Knowledge and skills in the management of behaviours that challenge. Skills in engagement and therapeutic communication Knowledge and skills in the prevention, de-escalation and management of violence and aggression Knowledge of the systems of reporting, communication and record keeping.

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2.9

Documentation and record keeping The use of documentation and the record keeping process will be benchmarked against professional codes, National Guidance and Trust policy. Contemporaneous record keeping should enhance the processes of care and intervention and provide an accurate reflection and documentation of the care and interventions provided by clinical practitioners.

2.10 Critical Incident Reviews A systematic approach to the critical review of all incidents and near misses should be in place to ensure lessons can be learned about clinical risk management and the efficacy of engagement and observation practice 2.11 Individual Intervention/Care Plans The type, level and use of engagement and observation interventions will be outlined in an individual intervention/care plan for each patient in inpatient and residential services. That plan will be based on the clinical assessment of risk for each individual and will clearly state actions staff will take to manage those risks, at what times/ time periods those actions are to be taken and how actions will alter with a change in circumstances and risk. On admission to an in-patient setting the initial level of observation and engagement must be agreed as part of the initial intervention/care plan based on risk assessment. Consideration should be given to implementing enhanced observation within eyesight (as defined in 1.4) for the first 24 hours where risk assessment indicates, or where the patient is unknown, and risk factors are evaluated. In all new admissions the whereabouts of the patient should be known to staff at all times and the risk assessment and management needs of the patient should be clearly documented. In all cases evidence of the decision making process and the clinical rationale for the decision regarding the level of observation and engagement, must be clearly documented in the patients case record. All individual intervention/care plans will incorporate the type any time directions. A named ward/team practitioner will introduce themselves to the service user. at the beginning of each shift of duty, ensure they are familiar with information about contact during the previous shift of duty and review the clinical risks identified. During each therapeutic contact and through the engagement the practitioner will review mental and physical health presentation by observing appearance and behaviour, monitoring rapport, speech, mood, thoughts, perceptions and cognitive functioning.

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2.12 Decision making process Best practice would demonstrate that the multi-disciplinary team is involved in the decision making process regarding the type, level and use of engagement and observation interventions that result in the individual clinical risk management plan. At a minimum any decision based on the clinical risk assessment must be made by two practitioners on the clinical area with at least 1 being a registered nurse who has personally undertaken a clinical risk assessment review of the patient. The second practitioner may be any member of the multi-disciplinary team that has been involved in the clinical risk assessment of that patient. Wherever possible the patient, their carer and family should be involved in the decision making process and at a minimum level the process and outcomes should be explained and information be made available to them. Involvement of advocates should always be considered where this will be in the best interest of the patient. Involvement of patients, carers and families should be evidenced through entry into the clinical record and collaborative signing of the individual intervention/care plan, wherever possible. Reasons for none or limited involvement of patients, carers and their families should also be evidenced through entry to the clinical record. The decision making process should be transparent and clearly based upon the outcomes and formulation of the clinical risk assessment. The decision making process should be fully documented in the clinical record, specifying the rationale for the decision and who was involved in the decision. The outcomes and the information should then be communicated to all practitioners within the clinical environment and all those involved in the care of the patient. All decision making regarding the uses of engagement and observation as risk management interventions must be based on the ongoing clinical risk assessment review and the contemporary mental and physical state of the patient. 2.13 Review Process Engagement and observation practice will be reviewed at a minimum once every shift handover. Patients on enhanced observations should have their level reviewed and recorded on an ongoing basis but as a minimum every 72hours. Observation levels can be reduced by 2 registered practitioners on the clinical area with at least 1 being a sufficiently experienced Doctor, Nurse or Occupational Therapist who is a band 6 or above. Reduction in the levels of observation should follow a discussion with other professionals within the team and the patient. The rationale supporting the decision to reduce the levels of engagement and observation should be documented in the case notes of the electronic clinical record. The current risks and how the level of observation is being used to manage that risk should also be documented in the case notes section supported by an appropriate intervention plan. The nurse in charge must ensure the rest of the care team are informed of the change in the level of observation.
No: CLIN/0017/v5 Clinical Risk Assessment and Management Policy 21 June 2012

Consultation with Senior Service Operational Managers should occur frequently in relation to staffing levels, skill mix and competencies required to implement engagement and observational practice, particularly with enhanced observation when the demands of engagement and observational requirements places strain on staffing resources. Nursing staff will be required to work flexibly, across and within all areas, to support clinical need and safely manage clinical risk. Individual intervention/care plans should be reviewed at least weekly and at other times in accordance with the Clinical Risk and Assessment and Management Policy.

2.14

Documentation The decision making process, members of the nursing team involved and the outcomes need to be clearly documented in the contemporaneous clinical record. The specific engagement and observation interventions and levels/timing of those interventions need to be clearly documented in the individual intervention/care plan. The specific documents to be used in the recording of clinical risk management planning should be specified within the service area and be registered within the Trust Records Governance systems. (An example of an individual general intervention/care plan template is shown in Appendix 2). This is the minimum standard of the documenting of individual intervention/care plans. The ongoing review of engagement and observation interventions should be documented in the contemporaneous clinical record, including the rationale for any change to the uses of engagement and observation practice. All professionals who are involved in the delivery of engagement and observation interventions should record progress and outcomes in the contemporaneous clinical record. The minimum standard for ongoing progress recording of the clinical risk assessment review and outcomes from the uses of engagement and observation interventions should be once per shift. However best practice would indicate that reporting of activity of interventions in the use of enhanced observation will be more frequent (after each period of engagement by staff members). Practitioners should record their interventions and outcomes in relation to the individual intervention/care plan when making entries into the clinical record. Group checklists for engagement and observation recording will not be acceptable and contravene individualised care planning processes.

2.15

Enhanced Observation The Nurse in charge of the ward/unit will allocate staff that are competent in observation practice to deliver enhanced observations; those staff will be briefed and knowledgeable about the individual clinical risk management planning for the patient with whom they will be engaging and observing. Any use of enhanced observation will be clearly documented in the clinical risk

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management plan with any specific reference to variance, conditions or timing of the particular interventions specified. For example Use within eyesight observation at all times during the waking hours of Mrs Smith whilst the ward has open access. Use general observation intervention for Mrs Smith when the ward has locked access and during her sleep period. Best practice would be that staff who are allocated to deliver enhanced observation would be involved with the patient for a maximum of 2 hours and are supported to take breaks where required. It is acknowledged that clinical demand and promotion of continuity of care for the patient may not always make that possible The staff who are allocated to deliver enhanced observation will record in the contemporaneous clinical record their involvement, time of their involvement, any evaluation based on the time spent with the patient and whom they handed responsibility over to. Those staff will ensure any pertinent information is handed over verbally when ending a period of enhanced observation. Group checklists for enhanced observation recording will not be acceptable and practice should be monitored by senior ward staff to ensure observation has not become purely surveillance. 2.16 Use of handovers Shift handovers on each ward will be used to ensure that the shift team is aware of the individual intervention/care plans for each of the patients on that ward. Specific verbal handovers will be used in the practice of enhanced observation with those practitioners allocated to include pertinent risk issues and information between periods of allocated enhanced observation. Regular discussion of the pertinent risk issues should take place with the registered nurse in charge of the clinical areas who would be qualified to make assessment of the mental state of the patient. Wherever possible patients, carers and their families will be involved in the handover process. Wherever practicable the handover from one health care worker to another who is taking responsibility for engagement and observation should involve the patient, so the patient is aware and involved in discussion relating to ongoing therapeutic engagement and observation needs. 2.17 Involvement of all professionals in interventions All clinical practitioners will be involved in the practice of engagement and observation. When the clinical risk management or therapeutic plan details that the care of the patient is to be handed over to another professional, particularly for off ward activity, then a specific practitioner to practitioner verbal handover must be included with content and those involved recorded in the clinical record. All practitioners involved must be clearly briefed on the engagement and observation interventions required for the safety of the patient and others.
No: CLIN/0017/v5 Clinical Risk Assessment and Management Policy 23 June 2012

2.18 Role of Family/Carers Information about the use of engagement and observation practice will be made available to families and carers. Requests from families and carers to take responsibility for the observation of patients will be dealt with on an individual basis. The situation will be risk assessed and the decision making process clearly documented in the clinical record. The decision should be clearly explained to the families and carers and contingency plans made clear. The wishes of patients should be considered at all times throughout this process. The aim of this process is to maintain and promote social inclusion and families/carers involvement at all times. 2.19 Support and supervision of staff All practitioners should be participating in their own professional, clinical and line management supervision in accordance with Trust policy. In addition, it is noted that delivery, of particularly enhanced observation, can be stressful and practitioners will be offered additional support, supervision and critical analysis and guided reflection as determined by individual need in a timely manner. It should be recognised that less experienced or skilled staff will require more support to ensure therapeutic engagement and observation is being delivered in contrast to the model of watching or surveillance. 2.20 Training Development of skills and knowledge in the practice of engagement and observation will be integrated into the educational programmes for Clinical Risk, Assessment and Management (See Policy 7.2)

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CLINICAL RISK & MANAGEMENT POLICY FLOW CHART INPATIENT SERVICES

Contact with

services

Formal Risk Assessment using Directorate approved tool

Risk Assessment identifies need for admission to hospital

Risk Assessment identifies need for enhanced observation for the first 24 hours to be prescribed

Risk Assessment identifies enhanced observation for first 24 hours not required

Risks identified, formulate into an Intervention Plan describing interventions to manage risk and reporting frequency for PARIS

Detailed record of decision-making process to not implement enhanced observation for first 24 hours

Risk Assessment reviewed as a minimum weekly for inpatient staff and documented fully in PARIS

In addition risks reviewed in the following situations (Bullet points from policy) Record fully on PARIS

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CLINICAL RISK & MANAGEMENT POLICY FLOW CHART COMMUNITY Formal risk Assessment using Directorate approved tool within 72 hours of first contact

First Contact with services

Comprehensive assessment completed

Risk Assessment identifies need for service intervention

Comprehensive assessment on-going

Risk identified, formulated into an Intervention Plan describing interventions to manage denitrified risks This is recorded on PARIS Risk identified, formulated into a Care Plan describing interventions to manage denitrified risks This is recorded on PARIS

Risk Assessment reviewed at each visit and documented in the case record on PARIS

In addition Risk Assessments completed on the following

Patient records on PARIS or paper records identifies the decisionmaking process and care delivery
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CLINICAL RISK & MANAGEMENT POLICY FLOW CHART COMMUNITY-BASED CAMHS* Risk related information documented using the Red Border (RB) risk assessment system in PARIS within 72 hours of first contact

Contact with services

Risk Formulation derived where applicable**and documented within RB System Comprehensive assessment completed Comprehensive assessment on-going

Risk identified, formulated into a Care Plan describing interventions to manage denitrified risks This is recorded on PARIS

Risk identified, formulated into an Intervention Plan describing interventions to manage denitrified risks This is recorded on PARIS

Care plan implemented, addressing both risk related and non-risk related needs as appropriate

Risk assessment, formulation and care planning re-performed if new risk-related information becomes available or if risk factors appeared to have changed

Risk assessments reviewed at CPA or care-planning meetings and re-completed if appropriate (i.e. if new risk-related information becomes available or risk factors appeared to have changed)
*Includes Adolescent Eating Disorder Service, Under 18s seen by Early Intervention in Psychosis Services and Forensic Adolescent Mental Health Out-Patient Services BUT EXCLUDES Child Learning Disability Services **i.e. where significant risk factors to self or others have been identified

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APPENDIX 2 GAINING APPROVAL FOR THE CLINICAL RISK ASSESSMENT TOOL (CRAT) REGISTER The Directorate Management Team Governance Group will receive applications from services or professional groups to register service or profession specific risk assessment tools. The application will need to include: The clinical rationale for the use of that model and/or tool The clinical rationale to demonstrate increased efficacy and outcomes than the FACE model and tool for that service/professional group The evidence base for the clinical effectiveness of that model and/or tool The licensing and copyright requirements The documentation requirements and compatibility of electronic based tools with current Trust IMT systems The training requirements, a training needs analysis and a training plan to meet training needs. The procurement and licensing costs if applicable If the model/tool is approved it will be entered onto the Trust Risk Assessment Model and Tool Recording System and the documentation registered with the Information Governance systems. The database will be co-ordinated by the policy lead. This database will record:Date of committee approval The name and origin of the model/tool Clinical areas of use Licence and /or copyright criteria Evidence base Training plans The database will consist of two categories: 1. Holistic clinical risk assessment models including the tools that provide all elements of risk theory and evidence base. They will demonstrate a set of values, links to risk formulation and processes for data collection and guidelines for development of risk management plans. The Clinical Risk Assessment Model and tool for use across the Trust, the FACE model is based on those fundamental principles. There will however be services that will register more service specific models and tools in this category for example, SAMURI III, Red Border, Traffic Light System, START and the GENERIC Risk Assessment Tool for Substance Misuse. 2. The second category is clinical risk screening documents and guidance that will assist the practitioner in data collection in the risk assessment process. These are likely to be more service user group specific.
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PROCESS FLOWCHART FOR THE MAINTENANCE OF THE CLINICAL RISK ASSESSMENT TOOL (CRAT) REGISTER
1. Clinical service to identify proposed clinical risk assessment tool (CRAT) as alternative to default tool FACE: Evaluate rationale and evidence base with respect to clinical requirements If tool clinical rationale and evidence base meets clinical needs more effectively than FACE proceed to 2 or if not identify alternative CRAT and repeat 1 Check compatibility with electronic patient information systems If compatible proceed to 2 or if not identify alternative CRAT and repeat 1

2. Clinical service to: Check licence and copyright requirements for proposed new CRAT Identify funding for any licence or copyright fees Outline training requirements Complete training needs analysis for service teams that will use tool. Complete training plan to meet training needs analysis Gain service approval through DMT

3. Clinical Service DMT to submit proposal for registration of new CRAT to Clinical Governance Group for ratification by Clinical Governance Committee.

4. Proposal to include: Details of new CRAT and service areas where CRAT will be implemented Summary of clinical rationale and evidence base for CRAT Any licensing or copyright requirements and fees Training requirements, training needs analysis and training plan

OR
5A. Clinical governance committee ratifies CRAT and transfers information to Associate Director of Nursing for registration. 5B. Clinical Governance committee refers CRAT back to clinical service DMT. Return to stage 1 and repeat process as recommended by Clinical Governance

6. Clinical Service to: Implement CRAT with appropriate license/copyright (fees) Implement training plan Submit annual training updates to Associate Director of Nursing for register update

7. Associate Director of Nursing to: Maintain electronic CRAT register and implement annual audit of register Update on receipt of information of ratified tools from Clinical Governance Committee Collate annual training data updates from Clinical Services Produce annual update position paper for Clinical Governance Committee.
No: CLIN/0017/v5 Clinical Risk Assessment and Management Policy 29 June 2012