Clinical risk assessment and management policy

1 Policy summary

This policy outlines the procedure regarding clinical risk assessment of patients in receipt of treatment and care in the trust.

Together with a number of closely associated trust procedural documents listed in section 10, it provides a framework for the assessment and management of clinical risk, within the overall context of the provision of high-quality clinical care.

1.1 Quick guide

1.1.1 identification

1.1.2 Assessment and management

The process of risk assessment and risk management is ongoing and dynamic, it is truly effective when all members of the multi-disciplinary team contribute and are involved in the patients care. Whilst the process of assessment will never completely eliminate risk, identification of potential risk and taking a strengths based approach to recovery will allow steps to be taken to manage it.

1.1.3 Planning

Completion of the risk assessment informs the risk management plan and strategies with a focus on strengths, supporting mental health recovery by focusing on a persons’ ability. This in turn supports formulation of a plan of care and care planning with the patient, family, carer, significant others involved where possible. It is important to identify and involve multi-disciplinary team members and other agencies in the risk assessment, risk management and care planning.

1.1.4 Implementation

There is a plan of care or care plan that the patient and all involved with the patient are aware of, the patient has a copy of the care plan, risk assessment and risk management plan. The objectives are clear, reviewed in line with agreed review dates and updated in light of new risks or information that becomes available.

1.1.5 Review

The process of risk assessment to formulate risk management and care planning is ongoing and dynamic, it is truly effective when all members of the multi-disciplinary team contribute and are involved in the patients care. Patient risk assessment is a dynamic and continuous process. Involvement of the patient (and where possible their families or significant others), advocates, and practitioners from a range of services and organisations will help to improve the quality of risk assessments and decision-making.

2 Introduction

“Life is about risk; we take risks every minute of the day. We must not let it inhibit us, we must use it to guide us and make us think, but it should not restrict us in our daily lives” (Independence, Choice and Risk DoH 2007).

In life there are risks that cannot be avoided, but can be both minimised and prepared for in a balanced way.

The Mental Capacity Act 2005 is based on the principle that every adult has the capacity to make all decisions affecting their own life unless; (in particular circumstances) there is evidence that this capacity is lacking.

Individuals therefore retain both the right and responsibility for their own decisions even if those decisions may at times be seen by others to be unwise or eccentric. Where support is needed to help individuals make decisions, this should be on the basis of safeguarding the person’s best interest and be achieved in the least restrictive manner possible.

The 12 Points to a safer service (National Confidential Inquiry, 2006), shown in appendix C, is intended to be used as a checklist for local services and has been used by the trust to underpin a number of interrelated procedural documents listed in Section 10.

Clinical risk assessment and management are key skills when promoting safety and positive risk taking. It is also important to empower patients to decide the level of risk they are prepared to take with their own health and safety.

This includes working with the tension between promoting safety and positive risk taking, including assessing, and dealing with possible risks for patients, carers, family members and the wider public.

The identification and management of clinical risk is a key trust responsibility and is achieved through an ongoing process of assessment to identify any potential harm to patients, staff, and the public. The process is ongoing and dynamic, it is truly effective when all members of the multi-disciplinary team contribute and are involved in the patients care.

Whilst the process of assessment will never completely eliminate risk, identification of potential risk will allow steps to be taken to manage it.

Within the trust, the assessment and management of clinical risk is incorporated within an approach to individual patient needs assessments and the responsive planning, implementation, and evaluation of care to patients.

The Samaritans’ research into men’s suicide suggest these areas for action:

suicide prevention policy and practice must take account of men’s beliefs, concerns, and context, in particular, their views of what it is to ‘be a man’
recognise that for men in mid-life, loneliness is a very significant cause of their high risk of suicide and enable men to strengthen their social relationships
there must be explicit links between alcohol reduction and suicide prevention strategies; both must address the relationships between alcohol consumption, masculinity, deprivation, and suicide
support general practitioner’s (GP’s) to recognise signs of distress in men, and make sure those from deprived backgrounds have access to a range of support, not just medication alone
provide leadership and accountability at local level, so there is action to prevent suicide

3 Purpose

The purpose of this policy is to set out the arrangements for managing the risks associated with ensuring that all staff who undertake assessments of patients are competent in relation to clinical risk assessment and management.

4 Scope

This policy forms part of a wider approach to ensuring that risks facing the trust, and all those to whom it has a duty of care (including its staff, patients, and visitors), are well managed.

The policy applies to all staff within all care groups where clinical risk assessment and evaluation is undertaken.

5 Responsibilities, accountabilities and duties

5.1 Board of directors

Is responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for clinical risk assessment and management.

5.2 Chief executive

The board of directors delegates to the chief executive the overall responsibility for ensuring the trust employs a comprehensive strategy to support the management of risk, including clinical risks associated with patient care.

5.3 Director of nursing and allied health professionals

The chief executive delegates responsibility for effective management of clinical risk to the director of nursing and allied health professions who liaises with the care group directors and the medical director. The director of nursing and allied health professions has delegated responsibility for infection prevention control, safeguarding (adults and children), clinical effectiveness, clinical audit and will bring to the attention of the board risk that may affect patient safety and, or failure to meet the care quality commission fundamental standards of quality and safety and other specified standards and requirements.

5.4 Chief operating officer

Delegates responsibility for effective management of clinical risk to the care groups via the care group directors.

5.5 Medical director

Is responsible for ensuring that all medical staff within their domain are competent in risk management, receive up-to-date training and continuously improve practice.

5.6 Deputy director of safety and quality

Is responsible for aligning the trust clinical audit programme to the implementation and monitoring of clinical risk assessment and management practice. Making links to other relevant trust committees and groups with responsibilities for aspects of clinical risk assessment and management as appropriate.

5.7 Head of patient safety (patient safety specialist)

Is responsible for the review of the clinical risk policy and implementation to include adverse Incident reporting and investigation processes (including Serious Incidents).

5.8 Chief pharmacist

Is the responsible assurance lead for medicines management (accountable officer for controlled drugs).

5.9 Care group directors

Recognition and monitoring of identified risks within their clinical services.
Overseeing and monitoring effective management of clinical risk.
Overseeing the implementation and monitoring of the authorised risk assessment tools or processes within their care group.
Disseminating, implementing, and monitoring this policy within their services.
Embedding the 16 best practice points for effective risk management shown in appendix C within their services.
Safer services, a toolkit for specialist mental health services and primary care

5.10 The quality committee

Has responsibility for overseeing the management of clinical risk within the trust and will monitor compliance with this policy. It reports to the board of directors through its minutes on a monthly basis. Modern matrons and service managers Are responsible for ensuring that all staff within their teams are in receipt of regular supervision, are properly supported, receive annual appraisals, and have a current personal development plan. They should use these arrangements to ensure all members of the clinical team are confident and competent in undertaking clinical risk assessments, and they should address any development needs that may arise. In addition they are to:

include the contents of this policy as part of local induction for any new starters
plan and monitor the training of their staff in relation to this policy, see mandatory and statutory training policy and training needs analysis
facilitate collaborative working between care groups, clinical specialities, and other provider agencies in order to provide high quality risk assessment and management for patients with a dual diagnosis, who are in transition or transferring between services or who have a multi-agency care package
Ensure that all incidents relating to clinical risk assessment and management are reported on Ulysses in line with the requirements of the incident reporting policy; and investigated as per the Incident management policy to reduce or prevent the risk of recurrence; and sharing of key learning points within and across care groups
ensure effective systems of supervision for staff are in place within their services, where clinical risk assessment and management is discussed as a core supervision agenda item, as per the supervision policy

5.11 Clinical staff

The assessment and management of clinical risk is the responsibility of all members of the multi-disciplinary team and therefore all clinical staff are responsible for:

implementing the authorised clinical risk assessment tools or processes within their care group
working with a strength-based approach as to promote and support positive risk taking with patients and carers with the aim of enabling recovery and self-management
maintaining and developing their knowledge and skills in relation to clinical risk assessment and management by attending training as detailed in the mandatory and statutory training policy and training needs analysis
working collaboratively with staff from other care group or services or agencies or interpreters in order to provide high quality risk assessment and management for patients, who are transitioning or transferring between services or who have a multi-agency care package. Where multiple trust services are involved with a patient, the mental health team will take the lead in developing the risk assessment with input and collaboration from other services. The risk assessment is shared with the relevant services
reporting all incidents relating to clinical risk assessment and management on the Ulysses incident reporting system in line with the requirements of the incident reporting policy and contributing to investigations in order for action to be taken to reduce or prevent the risk of recurrence
making effective use of supervision to discuss clinical risk assessment and management as a core supervision agenda item, as per the supervision policy

5.12 All other staff

All staff, at all times, should be alert to hazards and the risk of harm. There are no circumstances under which a staff member should feel it to be legitimate or appropriate to ignore a risk they have noticed. If a member of staff, who is not professionally qualified notices a potential hazard or risk, they should report the matter to their line manager.

6 Procedure or implementation

6.1 16 Best practice points for effective risk management

Best Practice in Managing Risk (Department of Health, 2007) is a framework document intended to guide practitioners who work with patients to manage the risk of harm.

It sets out the framework of principles appendix C, that should underpin best practice across all settings.

The philosophy underpinning the framework is one that balances care needs against risk needs, and that emphasises:

positive risk management
collaboration with the patients and others involved in care
the importance of recognising and building on the patient’s strengths
the organisation’s role in risk management alongside the individual practitioners

The trust has adopted these principles and will seek to benchmark practice against the principles on an ongoing basis, through the monitoring activities set out in section 8, with a view to embedding them in daily practice.

6.2 The care programme approach (CPA)

The CPA framework is intended to create an environment in which recovery is enabled, involvement is fundamental to everyday practice and the approach to care is one which maximises the safety and well-being of all as a priority.

It is the foundation for excellent service provision and high-quality patient experience provided through a multi-disciplinary and inter-agency approach. The trusts care programme approach (CPA) policy provides a framework for the implementation of this policy and detailed procedural guidance which will not be duplicated here.

6.3 Tools or processes authorised for use within the organisation, including timescales for use (see appendix A)

Whilst the assessment of risk is a continuous process, a formal assessment of risk must be completed and documented at:

the point of initial treatment contact
at each subsequent review for all patients (those subject to CPA or otherwise)
when prompted by a change of circumstances for example, admission, discharge, movement between services, shared care, personal circumstances etc.

The clinical risk assessment tools or processes authorised for use within the trust are:

Functional Analyses of Care Environment (FACE)
Historical Clinical Risk 20 (HCR 20), (in addition to the FACE assessment being completed a HCR 20 is the required risk assessment for forensic services to complete for NHS England. It may be necessary in some instances to also complete the Risk for Sexual Violence Protocol (RSVP) (or Sexual Violence Risk (SVR)) if indicated and agreed by multi-disciplinary team (MDT).

The risk assessment tools are a vehicle for collecting information in a structured way and do not replace clinical judgement. If there is still a perception of risk on the part of the assessing clinician contrary to the information obtained in the risk assessment tool, they should continue to explore the issue of risk more fully.

6.4 How clinical risk assessments are reviewed, including timescales

Due to the diversity of clinical services provided by the trust, in community and hospital settings, timescales for review will vary considerably depending on the identified risks.

Patient risk assessment is a dynamic and continuous process. Involvement of the patient (and where possible their families or significant others), advocates, and practitioners from a range of services and organisations will help to improve the quality of risk assessments and decision-making.

Review timescales following initial treatment contact may vary from for example, a daily review in an inpatient setting to a 6 monthly, depending on identified risk and patient need and within a minimum of at least 12 months. The timescales for review will be determined by the relevant clinical staff and clinical team. The authorised tools or processes will be used for this purpose

6.5 Clinical risk assessment and risk management

Risk assessment is an essential and ongoing element of good mental health practice and a critical and integral component of all assessment, planning, and review processes.

Of particular importance within any care process is:

that the patients individualised care plan needs to be developed collaboratively and clearly written and is linked to the risk assessment, communicated to all concerned if it is to protect the individual and, or others, that will include:
- the assessment of risk and the development of a risk management plan
- the documentation of risk information see records management policy
- the communication of risk information
- the adoption of appropriate risk management strategies based on the assessment

Risk assessments and risk management plans will be discussed as often as is reasonably practicable within the supervision arrangement for the service. Incidents relating to clinical risk assessment and management will be reported on the Ulysses incident reporting system, in order that they can be investigated, actions taken to reduce or prevent the risk of recurrence and key learning points shared.

Training will be undertaken by staff as detailed in the mandatory and statutory training policy and Training needs analysis.

Clinical audit and monitoring processes associated with the following policies will provide key information to inform the monitoring of this policy:

7 Training implications

7.1 All clinical staff

How often should this be undertaken: Once.
Length of training: 30 minutes.
Delivery method: Corporate induction.
Training delivered by whom: All clinical staff.
Where are the records of attendance held: Once.

7.2 All clinical Staff, doctors of all grades, nurses, allied health professionals and psychological therapists, social workers and all clinical support staff who have involvement in some aspect of direct clinical care of a patient

How often should this be undertaken: Initially and then 3 yearly updates.
Length of training: Training length varies, dependent upon risk assessment training.
Delivery method: Care group specific training days and other training which also covers clinical risk management includes:
- Introduction to Mental Health Act
- Mental Capacity Act training
- clinical record keeping
- managing work related violence
- core risk management training
- medicine management
- safeguarding children or safeguarding adults
Training delivered by whom: As determined by care groups.
Where are the records of attendance held: Electronic staff record system (ESR).

8 Monitoring arrangements

8.1 Tools or processes authorised for use within the trust, including timescales for use

How: Decision-making.
Who by: Safety and quality operational assurance group and care group assurance meetings (discussions will be recorded in the meeting minutes).
Reported to: Quality Committee.
Frequency: As required.

8.2 How risk is being assessed

How: Audit.
Who by: Manager and service leads.
Reported to: Care group quality meetings and safety and quality operational assurance group.
Frequency: Monthly.

8.3 How the trust trains staff, in line with the training needs analysis.

How: Mandatory Training compliance report.
Who by: Head of learning and development.
Reported to: Monthly care group assurance meeting.
Frequency: Monthly.

9 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

9.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

9.1.1 How this will be met

9.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

9.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the principles of the Mental Capacity Act (2005).

10 Links to any other associated documents

All the documents listed below cover various aspects of record keeping, maintenance and storage and employees should familiarise themselves with:

In addition, many other trust procedural documents which can be found on the trust website provide subject specific guidance, including:

10.1 Useful links

National Institute for Clinical Excellence Evidence for strengths and asset-based outcomes (2019) (opens in new window).
Health service executive risk management in mental health services (opens in new window).
Healthcare Quality Improvement Partnership Assessment of clinical risk in mental health service, an NCISH report, HQIP (2018).
Royal College of Psychiatrists assessing and managing risk of patients causing harm (opens in new window).

Please note, this is not intended to be an exhaustive list.

11 References

12 Appendices

12.1 Appendix A Recommendations for services from the national confidential inquiry into suicide and homicide by people with mental illness annual report July 2013

Services should:

maintain services for dual diagnosis patients and the use of community treatment order’s (CTOs) in the care of people with risk of violence
address the economic difficulties of patients who might be at risk of suicide, ensuring they receive advice on debts, housing and employment
improve safety in crisis resolution or home treatment (CR or HT) as a priority for suicide prevention in mental health care; particular caution is needed with patients who live alone or refuse treatment and when patients are discharged from hospital into CR or HT
be vigilant about the suicide risk from opiates, currently the main self-poisoning method; clinicians should check patients’ access to opiates
continue the successful safety focus on wards, including measures to prevent absconding and ensure safe detention
strengthen specialist services and risk management for patients who are misusing alcohol or drugs
use CTOs more effectively to address treatment refusal and loss of contact in patients at risk of suicide
assess risk of violence to spouses and family members and collaborate with social care and child protection services
ensure that all in-patients, including younger in-patients, are included in reviews of physical health and poly pharmacy
introduce or maintain assertive outreach services
engage in the debate over public concerns about the risk of homicide and the potential and limits of prevention by mental health services

12.2 Appendix B 16 Best practice points for effective risk management

Best practice involves making decisions based on knowledge of the research evidence, knowledge of the individual patient and their social context, knowledge of the patient’s own experience, and clinical judgement.
Positive risk management as part of a carefully constructed plan is a required competence for all mental health practitioners.
Risk management should be conducted in a spirit of collaboration and based on a relationship between the patient and their carers that is as trusting as possible.
Risk management must be built on recognition of the patient’s strengths and should emphasise recovery.
Risk management requires an organisational strategy as well as efforts by the individual practitioner.
Risk management involves developing flexible strategies aimed at preventing any negative event from occurring or, if this is not possible, minimising the harm caused.
Risk management should take into account that risk can be both general and specific, and that good management can reduce and prevent harm.
Knowledge and understanding of mental health legislation is an important component of risk management.
The risk management plan should include a summary of all risks identified, formulations of the situations in which identified risks may occur, and actions to be taken by practitioners and the patient in response to crisis.
Where suitable tools are available, risk management should be based on assessment using the structured clinical judgement approach.
Risk assessment is integral to deciding on the most appropriate level of risk management and the right kind of intervention for a patient.
All staff involved in risk management must be capable of demonstrating sensitivity and competence in relation to diversity in race, faith, age, gender, disability and sexual orientation.
Risk management must always be based on awareness of the capacity for the patient’s risk level to change over time, and a recognition that each patient requires a consistent and individualised approach.
Risk management plans should be developed by multidisciplinary and multiagency teams operating in an open, democratic and transparent culture that embraces reflective practice.
All staff involved in risk management should receive relevant training, which should be updated at least every three years.
A risk management plan is only as good as the time and effort put into communicating its findings to others.

12.3 Appendix C 12 Points to a safer service

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness has developed a set of recommendations to improve policy and practice in mental healthcare settings.

These 12 points are intended to be used as a checklist for local services and recommend:

staff training in the management of risk, both suicide and violence, every three years
all patients with severe mental illness and a history of self-harm or violence to receive the most intensive level of care
individual care plans to specify action to be taken if patient is noncompliant or fails to attend
prompt access to services for people in crisis and for their families
assertive outreach teams to prevent loss of contact with vulnerable and high-risk patients
atypical anti-psychotic medication to be available for all patients with severe mental illness who are non-compliant with ‘typical’ drugs because of side effects
strategy for dual diagnosis covering training on the management of substance misuse, joint working with substance misuse services, and staff with specific responsibility to develop the local service
in-patient wards to remove or cover all likely ligature points, including all non-collapsible curtain rails
follow-up within seven days of discharge from hospital for everyone with severe mental illness or a history of self-harm in the previous three months
patients with a history of self-harm in the last three months to receive supplies of medication covering no more than two weeks
local arrangements for information-sharing with criminal justice agencies
policy ensuring post-incident, multidisciplinary case review and information to be given to families of involved patients

Document control

Version: 9.1.
Unique reference number: 368.
Approved by: Clinical policies review and approval group.
Date approved: 3 October 2023.
Name of originator or author: Head of patient safety.
Name of responsible individual: Director of nursing and allied health professionals.
Date issued: 27 October 2023.
Review date: October 2025.
Description of change: Amendment to monitoring arrangements following an action from 360 internal audit around clinical policies.

Page last reviewed: November 15, 2024
Next review due: November 15, 2025

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