FOI REQUEST NUMBER 275 2015 2015.pdf · Details of previous injuries involving the ramp, including date, type of injury and how the injury was caused?

Compliance Team – Health Records Kestrel House

Hellesdon Hospital Drayton High Road

Norwich Norfolk

NR6 5BE

Tel: 01603 421687 Fax: 01603 421411

FOI REQUEST NUMBER 275 2015

Request & Response Thank you for your recent request under the Freedom of Information Act. I apologise for the delay in responding.

I can confirm the following:-

Details of previous injuries involving the ramp, including date, type of injury and how the injury was caused?

Below are the entries relating specifically to the area outside the Section 136 Suite:-

19/10/2012 Low harm Graze

Slip, Trip, Fall on same level - staff

Churchill Ward, Fermoy Unit (Under 65 / Non Pt related)

I pulled the door handle in G49, the fire exit door leading to the car park, the handle fell off in my hand, causing me to fall on the floor. I grazed my left elbow on the wall and my coccyx feels sore.

None

All environmental risk assessments and audits relating to the area outside the Section 136 Suite at the Fermoy Unit undertaken with reference to: See Attached

The Trust “Ligature and Suicide Risk: Environmental Assessment and Management Policy” The Policy Ligature and Suicide: Environmental Assessment and Management Policy wasn't in place until July 2013 – copy attached.

The National Patient Safety Agency’s “Preventing Suicide – A Toolkit For Mental Health Services” document. Please find the link to the website which provides this information http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65297

Any other policy or document The Trust has a number of different polices and hundreds of documents relating to patient safety and guidance across patient care. Unfortunately, to locate and review

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65297

all of these documents for those that would specifically apply to this request would be over the 18 hours appropriate time limit set under the Freedom of Information Act. Details of any regulation and guidance on the design of areas outside Section 136 suites Details of any regulations and guidance on the design of areas outside acute mental health units I confirm that our Strategic Estates Department have look into this part of your request. The only guidance which is relevant is the Health Building Notes 03-01 – Adult Acute Mental Health Units. Although the document offers design guidance on Section 136 (place of safety suites) none of the guidance relates to the area directly outside the units other than advising (in simplistic terms) it should have its own discreet designated entrance with vehicular access. The Trust provides a complaints procedure to deal with complaints about the Trust's handling of requests for information. If you feel you need to make a complaint, in the first instance, you should contact a Non-Executive Director via the Chair of the Trust. If you feel you have exhausted our internal complaints procedure, you also have the right and may feel you wish to write to the Information Commissioner who can be contacted on telephone number 01625 545740 or at www.ico.gov.uk.

http://www.ico.gov.uk/

Physical environment at all NSFT 136 suites.

All NSFT suites to be re-evaluated in relation to raised areas that may pose a risk if a similar incident were to occur again.

Where risk from a raised area is identified work to be undertaken to minimise the risk.

For NSFT Risk and Security Management to undertaken assessments of 136 suites and to organise work where identified.

Fermoy Unit 136 suite

Work to be undertaken to the 136 suite to minimise the risk of a similar incident occurring.

Woodlands 136 (Lark Ward) No raised areas Waveney Acute (Lowestoft) No raised areas G Yarmouth Acute (Northgate) No raised areas Areas still to be checked: Wedgewood, Norvic, Rollesby and other Hellesdon wards. Also to visit Fermoy Unit to recommend work to be done to minimize risk of recurrence.

Fermoy Unit 136 Suite



HEALTH, SAFETY, ENVIRONMENTAL INSPECTION CHECKLIST INCLUDING SECURITY AUDIT (NHS SMS) INSTRUCTIONS FOR USE 1. The checks should be carried out at intervals decided by local Health and Safety Committees. 2. Reference should be made to the previous checklist to ensure deficiencies have been rectified. 3. Any action necessary will result, including (if relevant) the name and position contacted, should be noted in the appropriate column on the

checklist. 4. Please return one copy of the form to the Trust Health and Safety Advisor when completed and retain a copy for reference. Names and positions of persons carrying out check 1. Roseanne Taherinia Date of check: 24 March 2014 2. Maggie Harrison – Modern Matron

Item(s), Area(s) to be checked Satisfactory , X, N/A

Deficiencies

(State precisely)

Action to be taken

Action Completed

Date/Signature 1. Documentation

Trust H & S Policy Department Policies Fire Procedure H & S Notice Board (to include

all statutory notices)

2. Risk Assessments General Manual Handling Display Screen Equipment COSHH

*

There is no site specific risk assessment.

Roseanne to send risk assessment template to lead for this area for completion and inclusion in documentation. This will be shared with new staff at local induction. Maggie will include this in her RA for Churchill Ward.

3. Training Induction

Location: Kings Lynn Ward Areas: Fermoy Unit – 136 Suite

Manual Handling Fire

Item(s), Area(s) to be checked

Satisfactory , X, N/A

Deficiencies

(State precisely)

Action to be taken

Action Completed

Date/Signature 4. Accident Reporting/First Aid

Equipment Awareness Documentation Notice of who are first aiders and

position of first aid box/contents

5. Ligature Points Fixed Opportunistic Breakaway fittings

N/A as clients always escorted in this area

6. Electrical Safety Visual check for electrical

equipment, ie plugs, leads, worn/fraying wires.

Sufficient power points No training leads.

7. Environmental Lighting Temperature Humidity Ventilation Noise

The plaster around the ceiling light in the main 136 suite area, is flaky and peeling away.

Maggie to raise job with estates to have this repaired as it creates ligature point.

8. Welfare Facilities Changing/storing clothes Washing - soap etc Toilets

.

9. Kitchen Areas Cleanliness of food preparation

areas Cupboard where food is kept Refrigerators including

temperature

N/A



Deficiencies

(State precisely)

Action to be taken

Action Completed

Date/Signature 10. Storage

Space Cupboards Shelving

11. Housekeeping General cleanliness/tidiness Access/egress Work surfaces Rubbish Floor surfaces Decoration Furniture

12. Personal Protective Equipment Availability Suitability Cleanliness Training/maintenance records

13. Security Arrangements Identity badges Valuables Visitors Violence

14. Exterior Lighting - check working order Grounds/pathways - free from

hazards

*

*Fence on entrance ramp has been raised following an incident in which a client intentionally tumbled himself over the fence resulting in serious injury.

Monitor incidents to ensure that solution provided does not result in further incidents.

15. Windows - Check all windows above

ground level have restricted opening

N/A

NOTES:

NORFOLK and SUFFOLK FOUNDATION NHS TRUST RISK ASSESSMENT PRO FORMA 07 ENVIO. RM/RA?RAPROF6(draft rev) – 4/11/09

From the highlighted matrix, risk to the Trust of business disruption complaint, personal distress or potential for injury should be considered within each hazard and risk associated.

LIKELIHOOD SEVERITY 1

Insignificant 2

Minor 3

Moderate 4

Major 5

Catastrophic 1 Rare LOW – 1 LOW – 2 LOW – 3 LOW – 4 LOW – 5 2 Unlikely LOW – 2 LOW – 4 MED – 6 MED – 8 MED – 10 3 Moderate LOW – 3 MED -6 MED – 9 HIGH –

12 HIGH – 15 4 Likely LOW – 4 MED – 8 HIGH –12 HIGH –16 HIGH – 20 5 Almost Certain LOW – 5 MED – 10 HIGH – 15 HIGH –

20 HIGH – 25

*FOR USE OF THE MATRIX SEE THE RISK RATINGS USED NSPA DOC.

RISK TITLE Generic risk format and assistance to undertake an environmental risk assessment of your workplace clinical or office based. Fermoy unit

ASSESSMENT REFERENCE NO:

ASSESSOR(S)

Maggie Harrison Stephanie Payne

DATE CARRIED OUT 11th March 2014

11111111

INTRODUCTION: Following recent Health and Safety visits there has been identified the need to review and formally record the risk assessment. This review has been undertaken from guidance in the Risk Management Strategy, and guidance on the Health & Safety Executives website http://www.hse.gov.uk/pubns/indg163.pdf

We have used recent information from incident reports, the knowledge of workplace equipment or systems used by staff and national data or strategies (i.e. RCN campaigns on Preventative Management of Aggression (PMA) restraint management)

The findings of the assessment will be shared with staff and contractors on site and made readily available within the working area for reference and new inductees.

IDENTIFIED HAZARD

PERCEIVED RISKS CURRENT PROCESS, PROCEDURE & CONTROLS RISK H/M/L

PROPOSED CONTROLS RESIDUAL RISK H/M/L

http://www.hse.gov.uk/pubns/indg163.pdf

Physical Violence and Aggression

Service users may inflict or attempt to injure staff, other users or visitors either with capacity or as part of their medical condition

• Physical Intervention and Prevention and Management of Aggression policies in place.

• Staff and contracted employees are given training in PMA and hold pin point alarms.

• Staff who are deemed long term ‘unfit’ for PMA training are redeployed (where possible).

• Patient Safety group review monthly data for trends and assurance of the actions from incidents.

• Staff follow Trust policy C30 Physical intervention,C66 Prevention and management of violence, C107 Seclusion and Segregation,

• All service users have clinical risk assessment, which will identify triggers in behavior.

L Pinpoint systems are to be tested daily Ensure full PMA team in each shift

L

Verbal Threats of Violence and Aggression

Service users may threaten, other users or visitors either with capacity or as part of their medical condition

• All service users have clinical risk assessment, which will identify triggers in behavior.

• All threats are recorded (Datix) and reviewed by the MDT.

• All staff undertakes induction at the commencement of employment, including incident reporting and personal protection.

L L

Slips and Trips

Service users, Staff and visitors may be injured if they trip over objects or slip on spillages

• General good housekeeping • All areas well lit • No trailing leads or cables • Staff keep work areas clear – items stored immediately,

cleared before start and finish of each activity. • Service users falls monitored monthly in modern

matrons audit • Staff wear appropriate footwear and service users are

encouraged to maintain good sensible footwear. • Falls assessment completed on admission

L L

Hazardous substances

Staff using substance and anyone who may come into contact with the area.

• COSHH data sheet received from the supplier • Training for specific staff involved in the use of

substance

L • Assessment on Trust pro forma available at the place of use

COSHH information to be made available for all staff in the area

L

Display Screen Equipment

Staff working at computers for long periods

• DSE workstation self assessment available on the intranet –with follow up from a local assessor or Trust manual handling advisor.

• Risks included at induction and mandatory training • Reviews supported by Occupation Health and advisers • Support for eye tests and prescribed glasses as

required within current HSE guidance

L • Individual workstation checklists are reviewed by on-site safety representative. and discussed any action plans with the line manager / supervisor

L

• • L

Temperature Staff , Service users, and visitors may feel exposed to extreme hot or cold environments

• Fans and fluid provided during excessive heat • Heaters are provided for any staff complaining of

excessive cold.

L • Monitoring of cold temperatures where staff have little or no physical activity, consider supply of safe additional heating sources

L

Workspace Contained environments

• Risks included at local induction training • 2 sets of mandatory ergonomics elearning and the DSE

workstation self assessment on the intranet.

L • Individual workstation checklist are reviewed by on-site safety representative, and discuss any required action plans with the line manager / supervisor

L

Equipment Lack of equipment may result in staff undertaking activities with inappropriate aids

• Estates requisition line informed of any malfunction Equipment to be stored appropriately and not removed from site without authorization • Trusts Medical devises policy informs practice C78

L • No further action is needed at present L

Electrical Staff, Service users and others at risk of electric shock or burns from faulty electrical equipment

• Staff check for damaged plugs, cables and on/off switches before using equipment

• If defect is noted item put out of use and reported to estates.

• No water near to electrical equipment

L • Audit of electrical equipment undertaken by Estates annually, unless requested more frequently

L

Windows Service users and /or Staff being injured or trapped by faulty window

• Ligature plan in place, windows handles removed and observation of service users at risk policy is applied.

• Restrictors on clinical environments • Staff to report any faulty windows to Estates

L • Annual audit of windows by on-site safety representative, and discuss any action plans with the line manager.

• Annual ligature risk assessment undertaken • 2 Windows waiting anti ligature handles. • Wardrobes waiting anti ligature rails.

Q46 Ligature and Suicide Risk. Version 0

L

Working at height

Anyone working at height could suffer injuries if they fell

• Onsite staff do not use steps, access to medical records is by means of ‘step-ups’ any faults are reported and removed immediately

• Maintenance staff use appropriate stepladder for accessing the work to be undertaken

• Staff to understand the risk of working at height

L • No further action L

SUMMARY & RECOMMENDATIONS: Maintenance that needs to be in place, any standard operating procedures and/ or any manufactures instructions are discussed as appropriate within the Security meetings and where necessary Estates teams.

Action Plan – for monitoring by Division / Health & Safety Committee Area of Concern Action Lead Target date Which committee /group advised outstanding

issue(s) ASSESSOR RECORDING

Stephanie Payne Maggie Harrison

CONTACT TEL NO

01553 736360

Overall risk rating (all hazards) Low REVIEW DATE (no greater than 1 year) March 2015 Manager approval - DATE

Entered on RAF - DATE DISTRIBUTION: GENERAL/SENIOR MANAGER – Acceptance of assessment, as indicated signed

The above assessment has been acknowledged and current controls; Please delete below statements that are NOT APPLICABLE Provide adequate management of the risks at the present time – NFA until review Require additional resource and/or systems in place – as outlined in action plan Requires support of other directorates and monitoring through Health & Safety Committee - as outlined in the action

plan Maintain the interim risks, prior to ED’s approval for management or system change– as outlined in above action

plan Maintain interim risks, subject to Board awareness of the affects to the strategic actions of the Trust – as outlined

above

RISK MANAGEMENT DEPARTMENT General Manager Estates & Facilities

HEALTH, SAFETY, ENVIRONMENTAL INSPECTION CHECKLIST INSTRUCTIONS FOR USE 1. The checks should be carried out at intervals decided by local Health and Safety Committees. 2. Reference should be made to the previous checklist to ensure deficiencies have been rectified. 3. Any action necessary will result, including (if relevant) the name and position contacted, should be noted in the appropriate column on the

checklist. 4. Please return one copy of the form to the Trust Health and Safety Advisor when completed and retain a copy for reference. Names of persons carrying out check 1. Roseanne Taherinia HSE Lead 2. Carl Burton LSFMS 3. Jo Russell Date of check: 15 April 2015 Report sent to: Maggie Harrison, Jo Russell, Stephanie Payne, Andrew Lillywhite Date Sent:

Item(s), Area(s) to be checked Satisfactory , X, N/A

Deficiencies or Comments

(State precisely)

Action to be taken

Action Completed

Date/Signature 1. Documentation

H & S Notice Board (to include all statutory notices)

Trust H & S Policy (staff aware) Department Policies (visual

check) “Top Ten Policies” Fire Procedure

2. Risk Assessments (non Clinical) Site Specific to include: Manual Handling Display Screen Equipment COSHH V&A Low staffing Environment etc

To All

3. Training % compliance Local Induction Manual Handling Fire Datix and/or Dashboard

To All

Location: Kings Lynn Work Areas: Fermoy Unit - Churchill Ward (all other areas covered in separate inspection list)



Deficiencies or Comments

(State precisely)

Action to be taken

Action Completed

Date/Signature 4. Accident/Incident Reporting/First

Aid Equipment Datix Awareness Notice of first aiders/Appointed

persons First Aid Box and contents

To All

5. Ligature Points Check up-to-date ligature audit New ligatures since audit?

* See items at end of report.

There is a completed Ligature Audit, but I will seek clarification from Maggie/Jo as to how often this is checked and ensure that these checks are dated and “no changes since last check” documented.

A mirror should be put up so that the phone can be monitored. The leaflet racks could be moved to the long wall so that they are visible and any that are not should be removed. Maggie/Jo to clarify how often the ligature audit is checked and advise on where the checks are to be recorded.

6. Electrical Safety PAT testing in date

7. Environmental (Workplace Regs) Lighting Temperature Ventilation Noise

8. Welfare Facilities Changing/storing clothes

(clinical areas) Washing - soap etc Toilets Drinking Water

9. Kitchen Areas Cleanliness of food preparation

areas Cupboard where food is kept Refrigerators

10. Storage Cupboards Medication (including fridge

temperatures)

X

The temperature checks for the medicine fridge were not up-to-date and had not been completed for several days. There is also no key so the fridge cannot be locked.

Temperature records to be kept up-to-date and key to be sourced.

11. Housekeeping General cleanliness/tidiness Work surfaces Rubbish Floor surfaces Decoration Furniture

12. Personal Protective Equipment Availability Suitability

14. Exterior Lighting - check working order Grounds/pathways - free from

hazards

*

15. Windows Check all windows above

ground floor level have restricted opening where required

N/A

16. Legionella checks (as per policy) Evidence of temperature checks Notification of change of use of

areas with baths/showers/sinks Y/N

X

See items at end of report re little used bedrooms/shower rooms/toilets and other water outlets.

17. Asbestos Register Evidence of staff awareness Works staff requesting?

X

There was uncertainty about where the asbestos register for the unit is kept.

Roseanne to discuss with estates to establish what system is in place.

18. Safety Folder Safety Folder in Place? Y/N If no, implementation dates.

N

Discussed establishment of safety folder to include all non-clinical risk assessments eg site specific, ligature audit, fire safety information, and COSHH sheets (currently held in cleaning cupboard)

Roseanne to discuss with Jo and Maggie over next few months to set this up.

Room G12 is used for therapeutic activities and is kept locked. This could benefit from a slam lock to ensure it is not left accidentally open. The same applies to G08, G09, G13, G20, G21, G22, G38. Bedrooms G43 and G44 have ligature items that are not in other bedrooms and it was reported at inspection that only low risk clients can be put in these rooms. However, there is a concern that if a client leaves the room door open, a higher risk client could access the bedroom. Therefore these rooms should be brought up to the standard of all of the other bedrooms on the unit as a matter of urgency, unless they can be locked off and put out of use (it was noted that these are not used very often). As it was reported that bedrooms G43 and G44 are infrequently used, there needs to be liaising with estates staff to establish a flushing programme for these rooms and/or the adjacent shower rooms/bathrooms/toilets as these will also be infrequently used. See Legionella Policy. The bathrooms and shower rooms (on both sides of the ward) have various ligatures within, but are kept locked and clients risk assessed before given access, however a plan should be put in place for ensuring these are locked as soon as the risk assessed clients have vacated. Shower room G72 has had a block of wood attached to wall above the shower head. The purpose of this is unclear, but a ligature could be placed between the showerhead and the wood. The need for the wooden block should be established, and then either a solution found if necessary, or the wood removed. In the meantime, this should be added to ligature audit if it is not there already. There are various pictures (and notices, including fire notices and a high voltage warning sign in the ladies corridor) on the walls throughout the unit that do not have anti-pick mastic around them and do not appear to have either anti-lig screws or anti-tamper screws fitted. Again this needs liaison with estates to find a solution eg following other areas which have adopted having the pictures put up with anti-tamper screws, then anti-pick mastic put around the entire picture so that the chance of ligaturing is greatly reduced, if not eliminated. Room G51 has boards fitted to the walls and these do not have anti-pick mastic around the edges, thus posing a ligature point risk around the corners. Remedy – anti-pick mastic should be applied around the edges of the board.

Norfolk and Suffolk NHS Foundation Trust Q46: Ligature and Suicide Risk. Version 02 Page 1 of 5

Appendix 3

Environmental Suicide and Ligature Point Risk Assessment and Audit Tool

(See Q46: Ligature and Suicide Risk: Environmental Assessment and Management policy for guidance on completion)

A. Assessment 1. Name of care area/ward/unit: 2. Name/s of assessors: 3. Completed on (date): 4. Type of care area: 5. The risk potential for the service user group in this area is considered to be: High / Medium / Low (Circle or delete) 6. The area(s) covered by this assessment is/are (tick one box only):

All corridors Patient bedrooms Laundry rooms Clinics Lounge/Dining rooms Shower/bathrooms External recreation areas Kitchens/Beverage bays Hairdressing salon Therapy areas Sluice/Cleaners store Toilet accommodation Other (describe)

7. The reference room or area used to start this assessment is: 8. If the reference area is a room - does it have a viewing panel? (Circle or delete) Yes / No /Not applicable 9. Are all the comparable rooms in the assessment area designed to this same specification or standards? (eg all individual service user bedrooms, treatment or therapy rooms)

Yes

Comments:

No

CHURCHILL WARD

MAGGIE HARRISON

18TH JUNE 2014

INTERGRATED AGE ACUTE WARD

AS ADVISED – AREAS DOCUMENTED ON PAGE 2


10. Reference room or area accessed by service users: tick one box from each column Unlocked Patient access Unlocked some of the time Escorted patient access Locked at all times No Patient access

B. Management Confirmation The risk assessment documentation has been completed and appropriate actions and responsibilities have been identified on the attached clinical risk assessment sheet(s)

Date of assessment: Review date for assessment: Signed (Service Manager): Name/Designation: C. Identified risks which could result in self harm/suicide

Description

Control code (see overleaf)

Rooms covered by standard reference assessment

1 ASSISTED BATHROOM – EQUIPMENT MEANS THE ROOM HAS LIGATURE RISKS AND IS KEPT LOCKED WHEN NOT IN USE. USED BY ABLE BODIED MALE PATATIENTS TO SHOWER AS THEIR SHOWER ROOM IS NOT FUNCTIONAL. STAFF AWARE OR THE LIGATURE RISKS IN THE ASSISTED BATHROOM AND WOULD ACCOMPANY ANBODY WHO WAS AT RISK OF SELF HARM

CP, BM

2 LOUNGES – TV’S ARE LIGATURE RISKS – WORKS DUE TO BOX THE TV SETS IN VARIOIUS PIECES OF FURNTIURE HAVE HANDLES AT A RELATIVELY LOW LEVEL

SA

3 RADIATORS THROUGHOUT THE WARD – MOST OF THE RADIATORS HAVE LIGATURE POINTS IN THEIR STRUCTURE

SA

4 PATIENT CALL ASSIST BUTTONS – SITED THROUGHOUT THE WARD

SA

5 WINDOWS THROUGHOUT THE WARD – ALL WINDOWS HAVE SIDE BARS TO PREVENT THE WINDOW OPENING FULLY CREATING A LIGAUTRE RISK

SA

6 BEDROOM FURNITURE – WARDROBE DOORS ARE NOT ANTILIGATURE

SA

7 MIRRORS IN BATHROOMS – MAINTENANCE HAVE BEEN REQUESTED TO PUT ANIT PICK MASTIC AROUND THE FROAMES TO REDUCE

MC

STEPHANIE PAYNE

18 TH JUNE 2014


THE LIGATURE POINT

8 MULTIPLE NON LIGATURE DOOR HINGES THROUGHT THE WARD

SA

9 NEW ANTI LIGATURE LIGHTS – HAVE A LIP IN THEM WHICH COULD POTENTAILLY BE A LIGATURE POINT (3 BEDROOMS)

SA

10 CEILING LIGHTS – VARIOUS THROUGHOUT THE WARD ARE NOT FLUSH WITH THE CEILING

SA

11 LEAFLET RACKS IN DAY AREAS REGULARLY USED AREAS BY SERVICE USERS AND STAFF MEANS VERY LITTLE CHANCE OF SOMEBDOY BEING LEFT ALONE IN THESE AREAS

SA

12 G90, G71 and G69 TOILET TAPS ARE A LIGATURE POINT – WORKS DUE TO CHANGE THEM

SA

13 G42 TOILET – HAS EXPOSED PIPEWORK AND ORDINARY TAPS – REPORTED TO WORKS

SA

14 DINING ROOM – CUPBOARD DOOR HANDLES AND NON ANTILIGATURE DOOR HANDLES – WELL USED AREA – LOW CHANCE OF SOMEBODY BEING ALONE IN THIS ROOM FOR A PERIOD OF TIME

SA

15 BEDFRAMES – ALL THE BED FRAMES HAVE LIGATURE POINTS

SA

16 G09 AND G09 INTERVIEW ROOMS WINDOW HANDLES – PATIENTS ARE NOT LEFT ALONE IN THESE ROOMS

SA

Control Codes for Use with This Assessment/Audit To meet the needs of the whole client group as safely as possible risks identified through the environmental assessments/audits may need managed differently. The list below provides codes and examples for the different risk management approaches (or risk controls) that can be applied to each identified environmental risk - to remove, reduce or manage the identified risk. CP: Individual care planning

• Clinical risk assessment and management including care planning • Observation of service users, including appropriately sited vision panels • Control of individual service user access eg to identified rooms such as kitchen

BM: Buildings management controls

• Locking areas with potential risks for self harm - such as laundry, kitchen, clinics, cleaning and maintenance areas

• Secure storage of substances eg cleaning materials • Fixtures with low weight bearing potential eg curtain and shower rails • Emergency lock over-rides eg bathrooms • Outward opening doors • Secure fitting of covers • Security of voids, service ducts, cellars etc


• Window restraints at all levels • Solid ceilings where necessary • Limit number of exit routes from building (compliant with Fire Regulations) • Fire exits with fail-safe locking systems • Fire detection in all areas including bathrooms and toilets • Fire fighting equipment • Control of water temperatures • Use of non breakable glazing and anti-shatter films

SA: Staff awareness • Staff awareness and training re emergency procedures • Resuscitation training and equipment

MC: Managerial Controls • Removal of obvious hazards • Safe disposal of packing materials and waste • COSHH information availability in case of ingestion or exposure of products • Instruction & supervision of contractors, domestic & estates staff • Control & supervision of people likely to bring harmful substances onto premises • Control of lighters and matches • Fire retardant textiles and furnishings provided by the Trust comply with HTM 87 • Where sleepwear is provided by the Trust it should comply with BS5722 • Safe and secure use, storage and disposal of sharps, tools etc • Control of issue of knives & sharp tools • Use of ‘shadow boards’ for tools/items in high risk areas – so it is clear when an object is not in

its place


D. Environmental audit action plan

Area(s) inspected

Date inspected

Inspected by: PRINT NAME (s) Signature (s) Date due for next inspection: Copied to (Name of responsible manager):

Location of hazard/risk

Description of hazard/risk Comments Action required/ recommendations

Who By when

Estimate of any costs

When complete send to Service Manager with a copy to Clinical Team Leader/Ward Manger and Modern Matron

Physical environment at all NSFT 136 suites. 01 July 2013

All NSFT suites to be re-evaluated in relation to raised areas that may pose a risk if a similar incident were to occur again.

Where risk from a raised area is identified work to be undertaken to minimise the risk.

For NSFT Risk and Security Management to undertaken assessments of 136 suites and to organise work where identified.

Fermoy Unit 136 suite

Work to be undertaken to the 136 suite to minimise the risk of a similar incident occurring.

Woodlands 136 (Lark Ward) No raised areas Waveney Acute (Lowestoft) No raised areas G Yarmouth Acute (Northgate) No raised areas Wedgewood No raised areas Norvic No raised areas Rollesby No raised areas Hellesdon Wards No raised areas Also to visit Fermoy Unit to recommend work to be done to minimize risk of recurrence.




Anti Ligature Audit Process - Assessment Form

Service Location:Ward / Department: Churchill Ward (1 of 2) TBCAudit Team Members: Maggie Harrison, Robert Foster, Neil Paull Slam lock

ReviewingDate of Audit 5th June 2015

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Corridor Vent handle 1 3 closure knob for heating vent 1 2 6 4

Corridor Door closures 1 3 closures above doors in observed area 2 2 12 8 TBC

Garden Door handle 2 3Fixed handle in area with minimum direct supervision 2 2 24 12

identify alternative

Garden Hand rail 2 3 open frame handrail 2 2 24 12consider fillining in TBC

Interview room IT equipment 2 2 Wires from IT system - Patient risk assessed 2 2 16 9 awareRecess Leaflet racks (metal) 2 3 Untested for weight bearing fixed to the wall 2 2 24 12

Dining room Drinks dispenser & wires 2 3 Drinks dispenser on hire - facilities are available 3 2 36 16Assess / Remove

Dining room Radiator cover 2 3 Current covers have gaps for ligature 2 2 24 12

alternative is available

Dining room Door hinges 2 3 squared hinges are in an observed area 2 2 24 12 TBC

Dining room Leaflet racks (metal) 2 3 Untested for weight bearing fixed to the wall 2 2 24 12 replace with plastic alternative

WC (G15) Towel dispenser 3 3Fixed square to the wall, untested for weight bearing 2 2 36 16

WC (G15) Toilet seat 3 3Fixed points on toilet seat at low level - consider patient assessment 1 2 18 10 TBC

WC (G15) Sink 3 3 Fixed square to the wall, ligatue point 2 2 36 16

Open ward /Ma Door closures 2 3 LINE OF SIGHT management 2 2 24 12 CCTV TBC

LINE OF SIGHNo CCTV 2 3 Limited supported by mirrors. Garden - none 3 2 36 16 Review

0 #N/A

Consider Trust programme

Consider Trust programme

Recommended / Remedial Action - statemented in appropriate area of control

KEYTo be communicated to staff as Door with self closure that locksEstates and Risk reviewing Trust

Consider removing and staff holding device to alter

replace with plastic alternative


Service Location:Ward / Department: Churchill Ward (2 of 3) TBCAudit Team Members: Maggie Harrison, Robert Thorpe, Neil Paull Slam lock


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Bedroom Ensuite panels 3 3Tops of access panels to be covered with sloping beading 2 2 36 16 Estates argeed

Bedroom Ensuite door/hinge 3 3Made aware of recent event with anti-ligature fitting 2 2 36 16

Bedroom Beds 3 3 Framed and electrical raised risk 2 2 36 16

Bedroom Radiator cover 3 3 Gaps in radiator cover 1 2 18 10alternative available

G42 Movable shower 3 3 To be removed 3 2 54 20 Agree CTL to action

TV room Lighting 2 2from the ceil in area with minimum direct supervision (patients at risk additional obs) 3 2 24 12 TBC

TV room Window catch 2 3 poit of ligature on window closure 2 2 24 12 TBC

TV room Radiator cover 2 3 Gaps in radiator cover 1 2 12 8alternative available

Corridor Air freshener 1 3 untested- unlikely to weight bear fixed to wall 3 2 18 10Not working

Corridor LINE OF SIGHT 1 3 Wall obtrudes line of sigt 2 2 12 8

Bathroom Towel dispenser 3 3 Fixed square to the wall 2 2 36 16

Bathroom Sink 3 3 Fixed square to the wall 1 2 18 10

G34 Radiator cover 3 3 Gaps in radiator cover 1 2 18 10alternative available

Laundry room Cabinet doors 1 3 Supervised - consider slam lock to control 3 1 9 6

Laundry room Towel dispenser 1 3 Supervised - consider slam lock to control 3 1 9 6

Laundry room Cables 1 3 Supervised - consider slam lock to control 3 1 9 6



TBC formal risk assess-ment

Risk & Estates addressing TrustwideConsider Trustwide programme

Estates agreed mirror placementConsider Trustwide programmeConsider Trustwide programme


Service Location:Ward / Department: Churchill Ward (3 of 3) TBCAudit Team Members: Maggie Harrison, Robert Foster, Neil Paull Slam lock


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G67/68 Taps 3 3 replacement programme underway - ?missed 2 2 36 16Estates agreed

Female area Radiator cover 2 3 Gaps in radiator cover 1 2 12 8alternative available TBC

Female area Anti-baracade doors 2 3 Doors do not allow access and could form ligature 2 2 24 12replace closure TBC

136 suite Towel dispenser 1 3 Fixed square to the wall 2 1 6 4alternative available TBC

137 suite Sink 1 3 Fixed square to the wall 2 1 6 4 TBC

138 suite Fire alarm 1 3 Fixed square to the wall 3 1 9 6 TBC0 #N/A

0 #N/A0 #N/A

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Title: Ligature and Suicide Risk: Environmental Assessment and Management

Outcome Statement: There will be effective management of both clinical (patient-related) and non-clinical risk so as to provide a safe environment for service users, their families and carers, visitors and our staff.

Written By: Jim Shackel – Head of Risk Management and Security Neil Paull – Deputy Risk Manager Caren Maidment – Clinical Effectiveness Lead Sharon Hadley – Assurance Manager

Reviewed By: Neil Paull – Deputy Risk Manager In Consultation With: Acute Services Forum

Carl Burton – Local Security Management Specialist Stuart Higgins – Clinical Training Manager and PMA Lead Practitioner Sue Bridges – Modern Matron (Learning Disability Services) Neil Brandon – Clinical Team Leader (West Suffolk)

Approved By and Date:

Clinical Effectiveness and Policy Board – July 2013

With Reference To: Seven Steps to Patient Safety in Mental Health. National Patient Safety Agency (2008) NHSLA Risk Management Standards (2012/13) Essential Standards of Quality and Safety. Care Quality Commission (2010) Quality Governance Framework. Monitor (2010) The Report of the Eternal Review of Safety and Clinical Governance Arrangements within Suffolk Mental Health Partnership NHS Trust Dec The Rae Report (2011) Safety Alerts and Bulletins (SABS) see Section 12.0

Associated Trust Policies and Documents:

C35: Searching Patients Including Rooms C36: Observation and Engagement of Service Users C54: Privacy, Safety and Dignity C66: Prevention and Management of Violence and Aggression C82 Clinical Risk Assessment and Management C90: Safeguarding Vulnerable Adults C98: CPA and Non-CPA Q11: Serious Incidents Requiring Investigation Q11a: Unexpected Death (In-patient areas) Q18: Risk Management Strategy and Policy Q20: Accident and Incident Reporting Q21: Security Management Q23: Health and Safety Q39: Clinical Effectiveness HRP006: Pubic Interest Disclosure Suicide Prevention Strategy Infection Prevention and Control Procedures

Applicable To: Trust wide – Inpatient Areas For Use By: All Staff Reference Number: Q46 Version: 02

Published Date: July 2013 Review Date: July 2015

Impact Assessment N/A


Implementation Clinical Team Leaders must ensure that all their areas must have a hook knife and scissors and a clearly identified place where they are kept for easy access in an emergency. Routine distribution procedures (publication on the Trust intranet, email notification to identified senior staff for distribution throughout the team and inclusion in the Trust Update e-bulletin).


Review and Amendment Log Version Number

Reasons for Development/Review Date Description of Change(s)

01 Developed in response to National Guidance (See Sections 3.0 and 4.0)

October 2012

New policy

02 Planned review July 2013 Observations terminology updated

Contents 1.0 Introduction

3

2.0 Purpose

3

3.0 Rationale for Development

3-4

4.0 Ligature and Suicide Risks in In-patient Areas – National Guidance

4-5

5.0 Definitions

5

6.0 Duties and Responsibilities

5-7

7.0 Undertaking an Environmental Suicide and Ligature Point Risk Assessment

7-8

8.0 Decisions and Actions following an Environmental Suicide and Ligature Point Risk Assessment

8

9.0 Other Considerations in Decisions and Actions to Manage Risks

8-9

10.0 Assessing and Removing Personal Items which could potentially be used as a Ligature – summary. See Appendix 1 for full protocol

9

11.0 Safety Alerts and Bulletins (SABs)

9

12.0 Monitoring Statement

10

Appendices 1 Assessing and Removing Personal Items which could potentially be used as a

Ligature. Protocol to Support Good Practice 11-12

2 Environmental Suicide and Ligature Point Risk Assessment and Audit Tool – Guidance

13-16

3 Environmental Suicide and Ligature Point Risk Assessment and Audit Tool – form

17-20


1.0 Introduction This document sets out the Trust’s approach to managing environmental risks for suicide and self harm in in-patient and other relevant units and areas managed by the Trust. It forms a component part of managing overall clinical risk and incorporates: The annual environmental risk assessment of suicide and self harm for use in in-patient, day care, residential wards or units, and other areas operated by the Trust accessed by service users who may be at risk of suicide. It includes undertaking a review of the area to identify:

• structures or fittings which could be used in suicide by hanging or strangulation

• obstructions to observing high-risk patients

• identifying potential ligatures

• identifying other risks for self harm or suicide in the environment It also sets out

• The process for evaluating and managing identified risks

• A protocol to support good practice in assessing and removing personal items which could potentially be used as a ligature (Appendix 1)

• Environmental Suicide and Ligature Point Risk Assessment and Audit Tool (Appendix 3) This document outlines how these processes link with other Trust policies, procedures and risk assessment processes and takes account of:

• The service user group in a unit and its environs

• The physical characteristics of a unit and its environs

• The ligature points in a particular unit and its environs

• The operational policies on the unit related to the assessment and management of risk

• Individual clinical risk assessment and care planning processes

• Therapeutic and positive risk-taking A strict policy on the removal of ligatures in a unit may be inappropriate for a particular service user group, but necessary because the physical environment offers many ligature points and observation is difficult. Equally removal of ligature points may be inordinately expensive or physically impossible in a particular unit, which would lead to either stricter operational policies or consideration as to whether the unit was suitable for the patient group it is being used for. All in-patient, day care, residential wards or units, and other areas operated by the Trust which are accessed by service users who may be at risk of suicide will develop and maintain a culture of monitoring in which there is constant vigilance and observation to identify and assess potential risks. In this context a more formal environmental suicide and ligature point risk assessment will be undertaken at least annually 2.0 Purpose The purpose of this policy is to describe how the organisation assesses and manages environmental risks for suicide and self harm, including ligatures and ligature points, in inpatient units and other areas managed by the Trust. It is intended to support Trust staff in discharging their duty of care to service users, and to provide consistency and assurances of processes for the Trust. 3.0 Rationale for Development National policy requires Trusts to ensure that ligature points in all in-patient wards are removed or covered, including all non-collapsible curtain rails (see Section 4.0). This occurrence is now classed as a ‘never event’ under the NPSA definition. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Safety is the centre of all good health care, and a systematic approach to risk assessment and risk management is essential. In mental health this is particularly challenging due to the nature of some of the risks presented by service users, including the risk of suicide and self harm. The Trusts is committed to patient safety and ensuring that in-patient units and other Trust areas provide a safe environment


Clinical risk assessment is complex and involves assessment of the risks an individual presents in the context of their environment. In the context of an inpatient environment this includes the buildings and fittings, the items the person has access to and other people. There is no way of creating a completely risk and ligature free environment that does not also adversely impact on other key principles of providing mental health care, including privacy and dignity, recovery and positive risk taking. To some extent clinical risk in in-patient environments will be managed through individual risk assessment, formulation and care planning involving the appropriate use of observation and engagement, including the use of positive risk-taking. However the organisation is committed to identifying, removing or managing potential ligature points and other risks for suicide and self harm on premises managed by the Trust and in particular in-patient areas in line with national good safe practice and guidance. This is supported by the Health and Safety and Environmental audit processes. The Trust also continues to review and improve its policies and procedures in relation to the management of clinical risk. In mental health services consideration while recognising that in mental health no environment is entirely risk free and that no risk assessment or risk decision-making process can be guaranteed to be 100% accurate taking into account human behaviour. 4.0 Ligature and Suicide risks in In-patient areas – National Guidance Hanging is the most frequent method of suicide in in-patient areas. There is evidence that the likelihood of suicide will depend on the ease of access to effective means. In the last decade a number of national reports and safety alerts (see front page and Section 12.0 for details) have highlighted the need to take steps to remove or manage the risks for suicide, particularly ligatures and ligature points, in inpatient areas. In 2000, the report of the Chief Medical Officer, ‘An organisation with a memory’, instructed Mental Health Trusts to take steps to remove all non-collapsible bed and shower curtain rails in psychiatric in-patient settings by 2005 and to reduce the number of suicides by this method to zero. Subsequently this was brought forward to 31st March 2002. The report emphasised the duty of care that NHS Trusts have towards patients, and that compliance to this instruction would partly perform that duty.

Department of Health (DH) Safety Alert Bulletins (SABs) available on the DH website have all highlighted issues related to ligature points following actual incidents in mental health in-patient units. These are listed are available through the safety alert liaison lead but further bulletins may have been issued and the DH website should also be checked.

The ‘Preventing Suicide: A toolkit for Mental Health Services’ produced by the National Institute for Mental Health (NIMHE) was used by the Healthcare Commission as a monitoring indicator against the national target for suicide prevention relates. This toolkit sets out eight standards for suicide prevention and describes a process by which audits against these standards may be carried out. The Trust has used this to inform its annual suicide audit process. Standard two: in-patient suicide prevention includes:

• Wards are audited at least annually to identify and minimise opportunities for hanging or other means by which patients could harm themselves.

• Likely ligature points on in-patient units have been removed or covered.

• A protocol has been developed to allow potential ligatures to be removed from patients at high risk of suicide.

• Environmental difficulties in observing patients are made explicit and remedial action is taken as far as possible.

• Observation policy and practice reflects current evidence about suicide risk.

• Patients under any form of increased observation are not allowed leave or time off the ward (see C36: Observation and Engagement of Service Users and C55: Leave for Detained Patients and Informal Service Users for details on Trust procedures).


The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness reports have highlighted that inpatient suicides are considered by health professionals to be the most preventable. The 2001 report Safety First showed that the use of bed and curtain rails was the commonest method of suicide amongst mental health In-patients. The National Patient Safety Agency has issued:

• A suicide prevention checklist and audit tool for acute inpatient settings which the Trust is using

• A ‘signal’ alert relating to potential ligature points in the form of door and wardrobe hinges following reported incidents. The NPSA regularly issues updates and staff undertaking environmental and ligature reviews should be aware of these.

5.0 Definitions

Term Definition Ligature Something which binds or ties. In this document specifically something which

could potentially be used or has been used for self strangulation. Examples include chains, linen, clothing (including belts, laces, bras, ties, tights stitching) pull cords, medical and non medical tubing, cables or wires, audio and video tapes, toilet rolls, paper towel rolls, self adhesive leaflet backing paper, wallpaper borders etc.

Ligature point In this document anything fixed that could be used to attach a cord, rope or other material for the purpose of strangulation. A list of potential ligature points is given in the risk assessment tool guidance (See Appendix 2)

Clinical risk Risks which may impact on the safety or well being of service users – through individual care delivery or through service delivery. The risk assessment needs to take into account a range of factors including the environment, mental state and risk history

Environment The external surroundings conditions in which a person interacts. This could be the physical or built environment – the actual buildings, fittings etc and the social environment. Personal possessions may also need to be taken into account including clothing (See Appendix 1)

Hook knife Tool used to release a ligature safely. All areas must have a hook knife and scissors and a clearly identified place where they are kept.

6.0 Duties and Responsibilities Executive Directors The Directors have overarching responsibility for the development, implementation and review of this policy on behalf of the Chief Executive, which may be delegated to the business development units (BDU). This includes ensuring:

• The annual environmental assessment and audit process is undertaken in the appropriate clinical areas (See Appendices 2 and 3 for tool and guidance)

• That a prioritised programme for risk and ligature point removal is developed within a phased programme for action (which the Estates Project will oversee).

• That further environment assessments and actions are undertaken as necessary in response to safety alerts, incidents and current best practice.

• That there is a culture of constant vigilance and observation to identify and assess potential risks.

• That any unacceptably high risks are recorded on the appropriate service and locality risk register/s and brought to the attention of the Estates and Risk Management Team for consideration.

The Lead Directors for incident management, compliance, health and safety and estates will be responsible for actions related to their area of responsibility in relation to implementation of this policy and procedure. The Director with responsibility for safety alerts will ensure that new safety alerts are distributed in a timely way, the required actions taken within the defined timescales. And responses monitored and recorded. This process will be delegated to the Trust officer with the responsibility for distributing safety alerts and bulletins.


Service Governance sub-Committee

• Ensuring that ligature actions are reviewed and that Service Managers support the annual environment assessment of suicide and ligature point risks assessment and audit process

• Ensuing that Risk Management and Estates Leads review the action plan

• Ensuring that areas identified as priority in-patient risks on the action plan are monitored and that further phased assessment programmes are continued, reporting any new risks to the appropriate Service Manager and advising the Trusts Service Governance sub-Committee of any alterations to the project programme.

Estates

• Phased Ligature Project work with Service Managers following environmental assessment

• Advising on capital projects and on the practicalities of ligature point removal or other required change to buildings and structures

• Overseeing the prioritised programme for ligature point removal

• Actively involvement if the level of work such as ligature point removal is so expensive that the question arises of whether a services should be a in a particular facility or not.

Senior Managers

• Ensuring that all staff are made aware of the relevant policies and procedures

• Commissioning and coordinating the annual environmental assessment (See Appendices 2 and 3) and audit process in the clinical areas, to ensure that:

o All units and areas are assessed at least annually o Additional assessments are undertaken where there is environmental change which could

impact on risk o Completed assessment documents are reviewed o Appropriate actions are taken to ensure that the identified issues are addressed and

effectively managed o A prioritised programme for work, including ligature point removal is developed (which will

be overseen by the Estates Phased Ligature Project)

• Ensuring that there is constant vigilance and observation to identify and assess potential risks and that appropriate action to manage the risk is taken

• Circulating safety alerts and bulletins to the appropriate staff and ensuring that these are acted on/responded to as necessary.

• Including any unit identified to have an unacceptably high level of risk in the Trust risk register, including mitigating action being taken, and that this is brought to the attention of the ERMT for consideration.

Locality/Service Managers Ensuring that:

• All staff are made aware of the relevant policies and procedures

• There is constant vigilance and observation to identify and assess potential risks

• That safety alerts relevant to suicide risks in Trust premises lead to an assessment of risk, actions are taken as necessary and a response sent to the Trust Officer with responsibility for safety alerts within the required timescales.

• Environmental assessment and audit teams are identified

• Assessments are undertaken in all identified units and service areas at least annually as required and that the assessment covers the issues identified in both past and recent safety alerts

• Completed risk assessments are fully completed and returned as required

• Actions are taken as necessary to manage the risk and/or alert more senior managers

• Any identified issues of immediate concern receive particular attention

• Specialist advisers (such as the Infection Prevention and Control Team) are involved where a managing a suicide risk may impact on other safety issues.

• Any adverse incidents or near misses, including those involving ligatures in an in-patient setting, are reported according to the Q20: Accident and Incident Reporting policy and is investigated accordingly.


Ward/Unit Managers/Clinical Team Leaders (in-patient areas and other units/areas identified for assessment) ensuring that:

• All staff are made aware of relevant policies and procedures and their responsibilities in relation to them

• There is constant vigilance and observation to identify and assess potential risks

• That safety alerts relevant to suicide risks in Trust premises lead to an assessment of risk, actions are taken as necessary and a response sent to the Trust Officer with responsibility for safety alerts within the required timescales.

• Formal assessment is undertaken in line with this policy and procedure and as required

• Completed ligature assessments are returned to the identified or service manager promptly

• The Service Manager is alerted to any identified issues of immediate concern immediately

• Specialist advisers (such as the Infection Prevention and Control Team) are involved where a managing a suicide risk may impact on other safety issues.

• Any adverse incidents or near misses, including those involving ligatures in an inpatient setting, are reported according to the Trust Incident policy and investigated accordingly.

All Clinical Staff

• Ensuring that they are aware of relevant Trust policies and the impact it will have on their practice.

• Assessing and managing clinical risk in line with C82: Clinical Risk Assessment and C36: Observation and Engagement of Service Users, and other relevant Trust policies

• Maintaining constant vigilance to identify and assess potential risks; clinical staff are expected to be alert to any other potential environmental risks for suicide that may be identified during practice potential suicide risks and if a new risk is identified to:

• Assessing the level and likelihood of risk and taking action to manage this risk and make the area as safe as possible at the time; e.g. by managing either the environmental risk or managing the individual risk

• Alerting their Line Manager for advice and action as soon as possible

• Reporting all incidents and near misses in accordance with the Q20: Accident and Incident Reporting policy

• Taking immediate action where an incident identifies an issue with regard to a physical ligature, and reporting this as soon as practical so that a report can be completed on the Trust’s Health and Safety incident report system and consideration can be given by EDMT to removing other ligatures so identified.

Environmental Assessment and Management of Ligature and Suicide Risk Procedure 7.0 Undertaking an Environmental Suicide and Ligature Point Risk Assessment (See Appendices 2 and 3) The Trust will undertake annual environmental risk assessments for suicide and self harm for in all in-patient, day care, residential wards or units, and other areas operated by the Trust which are accessed by service users who may be at risk of suicide. The Trust has developed the Environmental Suicide and Ligature Point Risk Assessment and Audit tool (Appendix 3) for this assessment. The purpose of this assessment process is to ensure that:

• Environmental risks for suicide and self harm are identified, taking into account a range of factors including safety alerts

• Identified risks can be assessed and evaluated as objectively as possible, taking into account a range of risk factors.

• Management actions can be agreed and implemented appropriate to the level of risk identified through the above process

The Service Manager for each care group will:

• Identify which units and areas are assessed

• Identify responsible managers who will sign-off the environmental risk assessment and audit tool

• Ensure that the annual assessment process is undertaken and that actions are taken to address


any identified risks.

• This assessment will cover adjacent areas such as corridors and outdoor areas used by service users on the unit.

The assessment will undertake a review of the area to identify:

• Risks identified in existing safety alerts.

• Structures or fittings which could be used in suicide by hanging or strangulation

• Potential ligatures

• Obstructions to observing high-risk patients

• Other risks for self harm or suicide in the environment including access to heights, hazardous substances, fires, burns, scalds, potential asphyxiates, blades and other sharps

Assessments will be undertaken by a group of at least 2 or 3 people, including the ward/unit manager (or another delegated experienced member of staff from the unit), a senior member of staff from another unit who can bring objectivity to the assessment and another person. Although no special training is required anyone undertaking the assessment should be briefed on the process. In addition to the annual assessment an assessment should be carried out:

• When changes to an identified area are planned, consideration of the risks for suicide will be included throughout the planning process and an environmental assessment undertaken on completion.

• Following receipt of a new safety alert relating to environmental suicide risks on Trusts premises an environmental assessment of that risk will be undertaken immediately.

The outcome of the assessment and the action plan to address the risks will be recorded on the environmental risk assessment and audit tool (see Appendix 3) and signed off by the identified manager, including their own comments as necessary. 8.0 Decisions and Actions following an Environmental Suicide & Ligature Point Risk Assessment Following the environmental assessment operational management will review the information from the assessment process and:

• Assess and evaluate all identified risks as objectively as possible, taking into account a range of risk factors.

• Decide whether the appropriate response is a change in operational procedures on a unit and/or removal of the identified risk e.g. ligature point removal.

• Agree and implement management actions appropriate to the level of risk identified through the above process

Decisions about actions requiring changes to buildings or fittings will be taken at a service management level and above and if necessary considered in the Estates Strategy The Director of Operations (or delegate) will then agree a prioritised programme for ligature point removal, which the Estates department will oversee. Capital projects will advise on the practicalities of structural changes, such as ligature point removal. The Estates department will become involved in the process if the level of work required (such as ligature point removal) is so expensive that the question arises of whether a services should be a in a particular facility or not. Assessments will be made available to Clinical Team Leaders/Ward Managers who should ensure the outcome is communicated to staff at ward or unit level, with an explanation as to what action will/will not be taken and why. 9.0 Other Considerations in Decisions and Actions to Manage Risks While every effort will be made to reduce and manage environmental risk by removing or making safe the most hazardous and obvious risks e.g. ligature points, the following factors also need to be


considered:.

• It is extremely difficult to completely eliminate environmental risk, and this may not be achievable or desirable - in some areas there will be positive reasons why some risks are taken and managed in a different way e.g. through individual clinical risk assessment and management, or through observation and engagement.

• Environmental risk including the risk of suicide by ligature has to be weighed up against other factors and risks. This includes balancing the risk against costs and benefits (such as the intended length of occupancy of the premises) and the availability of funding. The management of other risks such as fire, infection control or violence and aggression will be considered. Recommended actions will not necessarily be taken, particularly if the costs balanced against the level of risk are prohibitive, and/or there is identified increase to other risks to other patients, staff or others.

10.0 Assessing and Removing Personal Items which could potentially be used as a Ligature Protocol – See Appendix 1. Individual service users may have personal items which could present a risk for suicide - such as clothing which could be used as a ligature. The Trust has developed a protocol to support staff in taking decisions relating to assessing and removing these items. This protocol is included as Appendix 1. 11.0 Safety Alerts and Bulletins (SABs) A number of safety alerts and bulletins relate to the removal of ligatures and ligature points from in patient units and other clinical areas. All alerts and actions are reported to Service Governance sub-Committee. New alerts can be issued at any time; the current list can be accessed on the Department of Health website www.doh.nhs.uk or from the NPSA website www.npsa.hns.uk These are some of the existing alerts EFA/2010/003: Anti-ligature curtain rails (including shower curtains): Risks from incorrect installation or modification EFA/2010/002: Risks of unauthorised access to unsecured ceiling hatches NPSA signal alert Reference number 1104 I - Wardrobes used as ligature points (Issue date24 September 2009) DH (2008 - 02) Gateway Ref: 9594 Estates and facilities alert re potential ligature risk of rubber/ PVC weatherproof seals DH (2006 – 07) Estates and Facilities alert re use of doors - and potentially windows as ligature points. Issued:18th October 2006 Gateway Ref: 7208 DH (2006 - 05) Shower heads NHSE (2004 - 10) Bed cubicle rails, shower curtains NHSE (2004 - 08) Cubical Tracking, PVC used a potential ligature garrotte. NHSE (2004 - 05) Suspended ceilings, ligature point NHSE (2004 - 03) G Rail 2301, Window curtain tracking NHSE SN (2002 - 01) Cubical rail suspension system with load release support systems NHSE HN (1998 - 04) Curtain Tracks, potential ligature points


12.0 Monitoring Statement

Aspects of the policy to be monitored

Monitoring method

Individual/Team responsible for monitoring

Frequency Findings: Group/Committee that will receive the findings/monitoring report

Action: Group/Committee responsible for ensuring actions are completed

Assessment and management of environmental suicide risks and ligature points

Completion of the Environmental Suicide and Ligature Point Risk Assessment and Audit Tool

Service Managers

Annual Service Governance sub-Committee

Audit and Risk Committee Service Governance sub-Committee

Circulation of and action taken on the Safety Alerts and Bulletins (SABs)

Discussion/review of SABs at meeting


Quarterly SABs reviewed by Service Governance sub-Committee


NB: All incidents relating to suicide, attempted suicide and self harm in in-patient and other environments managed by the Trust will be reported and reviewed appropriate to the severity of the incident, to identify any environmental safety concerns requiring action. This will be monitored monthly through the Incident Management Support Group and quarterly via the Service Governance sub-Committee who will raise any significant risks with the Executive Directors. All Trust staff are encouraged to report any adverse incident or near miss (See Q20: Accident and Incident Reporting). Each incident should be reviewed locally to ensure any actions are taken to improve safety and prevent recurrence. More serious incidents will be the subject of an internal review using root cause analysis principles to identify any learning (See Q11: Serious Incidents Requiring Investigation). All recorded incidents are aggregated, analysed and reviewed through the appropriate Trust groups.


Appendix 1

Assessing and Removing Personal Items which could potentially be used as a Ligature

Protocol to Support Good Practice

Introduction Personal items such as clothing can be used as a ligature for hanging or self strangulation. This protocol describes the Trust’s approach to assessing and managing the potential risk of self harm or suicide from personal items including clothing, such as belts, cords and laces, in inpatient environments. This includes when it will be appropriate to remove items from the person to manage the risk. It is obviously a delicate matter to remove someone’s possessions. This will only be done after careful assessment and if this is to be done, it should normally be with the consent of patients and their full understanding. Purpose The Trust recognises the need to balance effective clinical risk management against issues of privacy, dignity and the need to take positive therapeutic risk. This protocol is intended to clarify practice in relation to assessing and managing the risks presented by personal items. It will be considered in conjunction with related policies and procedures, and in particular:

• C36: Observation and Engagement with Service Users

• C35: Searching Patients including Rooms

• C82: Clinical Risk Assessment and Management Context Clinical risk assessment involves assessment of the risks an individual presents in the context of their environment. The environment includes the buildings and fittings, other people, and the clothing and personal items the person has access to. There is no way of creating a completely ligature free environment that does not involve removing every potential ligature from every inpatient (or even visitor) to an inpatient unit. Attempting to ensure that all individual service users are completely “ligature free” would, in theory, require many items of clothing to be given up. This is completely unrealistic and undesirable for wide application and would adversely impact on other key principles of providing mental health care including privacy and dignity, recovery and positive risk taking. There may be rare occasions where a clear and present clinical risk is evidenced, where it may be appropriate to remove identified ligatures from individuals e.g. where they have a clear history (or expressed intention) of using particular ligatures or personal items or have a history of using belts as weapons etc. However, the Trust recognises that staff will need to consider and balance clinical risk management against issues of privacy, dignity and the need to take positive therapeutic risk. The organisation continues to identify, remove and manage potential ligature points, supported by the Health and Safety Audits and Modern Matrons Environment Audit processes. The Trust also continues to review and improve its policies and procedures in relation to the management of clinical risk. In mental health services consideration We also recognise that in mental health no environment is entirely risk free and that no risk assessment or risk decision-making process can be guaranteed to be 100% accurate. Definition of a Ligature The notion of what constituted a ligature in this context has been considered. Whilst concern was raised specifically about belts, cords and laces, individuals could cite many examples of other items of clothing being utilised as ligatures, including underwear.


Principles for Assessing and Managing Ligature Risks from Personal Items The Trust recognises the need to balance clinical risk management against issues of privacy, dignity and the need to take positive therapeutic risk. The Trust does not routinely remove potential ligatures such as belts/laces from individuals admitted to its inpatient areas. There may be rare occasions where a clear clinical risk is evidenced, where it may be appropriate to remove particular ligatures from an individual e.g. where he or she has a clear history (or expressed intention) of using particular ligatures or personal items or a history of using belts as weapons etc. The key to decision-making about these potential risks is effective clinical risk assessment, formulation and management Each individual will have an assessment of risk which will inform decisions about what items they will have access to; this will include ligatures. This will include reference to the Trust’s banned items policy. Where risk assessment indicates a high risk of self harm, individuals should be considered for ‘within eyesight’/’within arms length’ in accordance with the Trust’s observation policy. Staff should continue to be aware that the observation policy outlines the criteria for changes to levels of observation. The Trust’s observation policy recommends that levels of observation should only be reduced when the individual has met specific pre-determined criteria, and reinforced the importance of Multi Disciplinary Team decisions on managing therapeutic risk. The Trust will continue to identify and reduce potential ligature points through Health & Safety and Environmental Audit processes. Service Users and their families should be involved, wherever practicable, in managing risks. NSFT recognises that balancing the rights to privacy, choice and dignity against the need to maintain safe therapeutic care is extremely complex and carries inescapable levels of risk for clinicians. Staff will need to consider and balance clinical risk management against issues of privacy, dignity (see C54: Privacy, Safety and Dignity policy). The Use of Observation and Therapeutic Risk-taking Generally speaking, if an individual was assessed as being a significant self harm risk, they would be managed under the observation policy (C36: Observation and Engagement of Service Users). These levels of management should negate the need to remove ligatures as the individual would be under appropriate levels of supervision by staff. The removal of personal ligatures would not completely rule out access to ligatures, as they are likely to be present amongst the general ward population. Where individuals have been assessed as having reduced the risk of self harm, clinical teams will at some point have to consider reducing (using a risk assessment tool) the levels of observations. By definition, this is taking a therapeutic risk which will always carry a degree of uncertainty. There is no obvious alternative because there is no clinical risk assessment or clinical risk assessment tool which can predict with absolute certainty when an individual is recovered significantly enough to have their level of observations reduced. Involvement of Service Users and Carers in Managing Risk The ongoing involvement and experience of service users and carers in the management of their own (or relatives) levels of risk is also crucial to effective partnerships in care delivery, and the Trust continues to develop systems to support this e.g. MDT, identification of events, safety plans etc.


Appendix 2

Environmental Suicide and Ligature Point Risk Assessment and Audit Tool - Guidance

For use in in-patient, day care, residential wards or units and other areas operated by the Trust accessed by service users who may be at risk of suicide

The assessment should be undertaken by a group of at least 2 or 3 people, including the

ward/unit manager (or another delegated experienced member of staff from the unit), a senior member of staff from another unit who can bring objectivity to the assessment and another

person. Introduction and Background Information The purpose of this assessment and audit process is to reduce the risk of suicide and self harm in in-patient units and other areas managed by the Trust. Most suicides in inpatient areas occur by hanging. Removing the means of hanging (ligature point and ligature) is the most important step towards prevention. Risks of self-strangulation - where the ligature point can be virtually any fixed or heavy structure – indicates the need to remove ligatures. The assessment is for use in in-patient, day care, residential wards or units, and other areas operated by the Trust accessed by service users who may be at risk of suicide. It should be used with reference to the Trust Policy for environmental assessment and management of ligature and suicide risk. The built environment is only one factor to be continually assessed and managed in efforts to minimise suicide risks, and it should not be viewed in isolation from other clinical risk management measures such as observation and engagement, access to items that may be a risk e.g. clothing such as belts being used as a ligature, therapeutic activity for service users, staffing levels and skill mix. (Even when staffing levels and skill mix are adequate, there may be particular times when the risks are heightened e.g. during ward round, handovers or during violent or other incidents.) Any risk assessment is only truly valid for a point in time or for a long as the risk factors remain the same:

• All staff should be alert to identifying new risks

• Repeat the assessment if changes are made to the environment Risk will change and vary depending on the circumstances. For example, public areas such as corridors and circulation space may be considered to be low risk during the day, when there are lots of people around, but at night present more of a risk when staffing levels are reduced and there is less activity.

Definitions

A ligature is anything that binds or ties - which could include a range of items such as bedding, clothing, belt, cord, rope or other material.

A ligature point is anything that could be used to attach a ligature for the purpose of strangulation or hanging. This could include shower rails, coat-hooks, water pipes window frames, hinges and closures – but other potential ligature points should be considered.

As well as ligature points at high level used for hanging ligature points could be at low level, with service users using other means eg twisting their bodies, to achieve the same effect.


Undertaking inspection and risk assessment Risk assessments will be undertaken at least annually.

Additional assessments will be undertaken:

• If changes are made to the environment (including structural work, change of room use or change to furnishings). The assessment and safety alerts should be considered both as part of the planning process and when the work is completed.

• If a new safety alert relating to suicide risks in Trust premises is received. The assessment will focus on the new risk identified with an awareness of other potential risks. Following assessment identified risks will be identified to the relevant service manager for action according to the timescales defined in the safety alert. The outcome of the assessment will be communicated to the Trust’s safety alerts officer within the timescale defined by the alert.

Assessments will be carried out by groups of at least 2 including:

• The ward or unit manager (or another delegated experienced member of staff from the unit)

• A senior member of staff from another unit - who can assess with a ‘fresh’ pair of eyes

• Someone with experience of the process (including Risk or Estates team) Inspection and risk assessment will:

• Use the Environmental Suicide and Ligature Point Risk Assessment Tool (Appendix 3)

• Cover all internal floor space accessible to service users, including corridors/circulation space.

• Cover any external unit areas and the immediate external environment

• Fully floor-walk each internal and external area and note any items which they consider to be a risk.

Although no special training is required to spot hazards, anyone undertaking the assessment should be briefed on the process. Identifying hazards will become easier the more experience is gained. Risk Factors to Consider This is not a definitive list, but highlights some of the more hazardous/obvious risk factors to consider:

• Issues identified in safety alerts

• Height of potential ligature points - any protuberance or device at higher levels eg above 5 feet or 1.5 metres from the floor that is easily reachable.

• Weight bearing capacity of potential ligature points – most adults weigh well above 30kg (4½ stones). Note: service users with eating disorders may be at greater risk (account may need to be taken of a lower body weight in considering the weight-bearing capacity of a potential ligature).

• Isolation of area such as single bedrooms, toilets, bathrooms and showers tend to be higher risk than more public areas such as lounges, reception areas or corridors.

• Obstructions to observation such as corridors, single bedrooms and some external garden areas Following the Assessment The Environmental Suicide & Ligature Point Risk Assessment Tool form should be completed in full

• Section A - Assessment

• Section B - Management confirmation (by responsible manager

• Section C - Identified risks which could result in self harm/suicide

• Section D - Environmental audit action plan

This should then be sent to the identified Service Manager and copied to the areas Clinical Team Leader/Ward manager and Modern Matron. On completion the Service Manager will sign off the risk assessment, adding their comments as necessary. Managing identified risks The purpose of risk assessment is to identify, assess and evaluate a risk or hazard as objectively as possible to inform decisions and actions to remove or reduce risk.


Every effort should be made to reduce and manage environmental risk - by removing or making safe the most hazardous and obvious risks e.g. ligature points. However it is extremely difficult to completely eliminate environmental risk, and this may not be achievable or desirable - in some areas there will be positive reasons why some risks are taken and managed in a different way e.g. through individual clinical risk assessment and management, or through observation and engagement. Next steps - decisions and actions Decisions about action will be taken at a senior management level, i.e. Service Manager or above, may be considered by the Estates Phased Project, and will be communicated back to staff at ward level, with an explanation as to why action will/will not be taken The risk of suicide by ligature has to be weighed up against other factors and risks. This includes balancing the risk against costs and benefits (such as the intended length of occupancy of the premises) and the availability of funding. Recommended actions will not necessarily be taken, particularly if the costs balanced against the level of risk are prohibitive.

Potential Ligatures/Ligature Points Risk Control/Comments

Bedsteads Should be appropriate to the environment

Brackets, picture rails, etc Consider brackets and fixings – remove, box in or chase into the wall

Coat hooks Remove all hooks including behind doors, in wardrobes etc - and consider alternatives

Curtain rails for:

• Beds

• Windows or doors

• Baths and showers

Must be collapsible and have a low weight bearing capacity. Avoid beams and vertical stabilisers

Curtain tracking Avoid gaps in fixed tracking Fit tracking flush to walls/ceilings

Curtain wires for nets Avoid the use of curtain wires - consider alternatives

Doors Door closers Door handles

Consider design, handles, hooks, hinges, any gap between door and frame Protruding door handles - consider alternative design Closers should be mounted on the outside of doors on the public or staff-controlled side

Electrical conduits/wiring Should be ‘chased’ into walls, or fitted flush to wall Exposed pipe work and fixing Consider height and accessibility Hinges – doors, wardrobes, cupboards Consider type of hinge and any gap between door and frame (eg

consider piano hinge) Should not be nylon cord Consider solid pull cords Consider infra-red automatic switches

Light switch cords

Consider shortening length of cord Patient’s lockers/wardrobes Consider hinges and removal of hanging rails Radiators Consider boxing in if appropriate to the environment Shelving and fixing brackets Consider the risks Wardrobes Consider design, handles, internal hooks, door closing, hinges and

any gap created between Windows and window openings Design appropriate for the environment – consider handles, trickle

vents, hinges hooks and closers etc. Window and door weatherproof seals Consider risk of use as a ligature on both existing, and when

installing new, windows and doors.


Other environmental risks to consider Although hanging or strangulation is the most common method of in-patient suicide there may be other risks for suicide or self harm present in the environment, which the risk assessment needs to consider. Heights Such as stair wells, access to opening windows or roof tops. Fires/burns/scalds Examples are paper items, aerosols, waste materials, ignition sources, alcohol based hand rubs Hazardous substances Examples are adhesives, cleaning materials, batteries, clinical waste, self administered medication, building maintenance materials. Potential asphyxiants Examples of these are plastic bags, aprons, bin liners and wrapping materials. Sharps Examples are glass/glazing, knives, needles, razors, Formica, scissors and items which can be shaped to a point eg plastic toothbrushes, plastic picture coverings etc Any other risks identified in safety alerts Although risks identified in safety alerts have been included in this checklist new risks may be identified and should be taken into account. Anti-ligature equipment There may be items i.e. coat hooks and curtain tracking that is specifically designed to ‘release’ under set pressures, if unsure you should consult your Estates lead to establish the environmental equipment sufficient to the client in-patient risk.


Appendix 3

Environmental Suicide and Ligature Point Risk Assessment and Audit Tool A. Assessment 1. Name of care area/ward/unit: 2. Name/s of assessors: 3. Completed on (date): 4. Type of care area: 5. The risk potential for the service user group in this area is considered to be: High / Medium / Low (Circle or delete) 6. The area(s) covered by this assessment is/are (tick one box only):

All corridors Patient bedrooms

Laundry rooms Clinics

Lounge/Dining rooms Shower/bathrooms

External recreation areas Kitchens/Beverage bays

Hairdressing salon Therapy areas

Sluice/Cleaners store Toilet accommodation

Other/s (describe):

7. The reference room or area used to start this assessment is: 8. If the reference area is a room - does it have a viewing panel? (Circle or delete) Yes / No /Not applicable 9. Are all the comparable rooms in the assessment area designed to this same specification or standards? (eg all individual service user bedrooms, treatment or therapy rooms)

Yes

No

Comments:


10. Reference room or area accessed by service users: tick one box from each column Unlocked Patient access Unlocked some of the time Escorted patient access Locked at all times No Patient access

B. Management Confirmation The risk assessment documentation has been completed and appropriate actions and responsibilities have been identified on the attached clinical risk assessment sheet(s)

Date of assessment: Review date for assessment: Signed (Service Manager): Name/Designation: C. Identified risks which could result in self harm/suicide

Description

Control code (see overleaf)

Rooms covered by standard reference assessment

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16


Control Codes for Use with This Assessment/Audit To meet the needs of the whole client group as safely as possible risks identified through the environmental assessments/audits may need managed differently. The list below provides codes and examples for the different risk management approaches (or risk controls) that can be applied to each identified environmental risk - to remove, reduce or manage the identified risk. CP: Individual care planning

• Clinical risk assessment and management including care planning

• Observation of service users, including appropriately sited vision panels

• Control of individual service user access eg to identified rooms such as kitchen BM: Buildings management controls

• Locking areas with potential risks for self harm - such as laundry, kitchen, clinics, cleaning and maintenance areas

• Secure storage of substances eg cleaning materials

• Fixtures with low weight bearing potential eg curtain and shower rails

• Emergency lock over-rides eg bathrooms

• Outward opening doors

• Secure fitting of covers

• Security of voids, service ducts, cellars etc

• Window restraints at all levels

• Solid ceilings where necessary

• Limit number of exit routes from building (compliant with Fire Regulations)

• Fire exits with fail-safe locking systems

• Fire detection in all areas including bathrooms and toilets

• Fire fighting equipment

• Control of water temperatures

• Use of non breakable glazing and anti-shatter films

SA: Staff awareness • Staff awareness and training re emergency procedures

• Resuscitation training and equipment

MC: Managerial Controls • Removal of obvious hazards

• Safe disposal of packing materials and waste

• COSHH information availability in case of ingestion or exposure of products

• Instruction & supervision of contractors, domestic & estates staff

• Control & supervision of people likely to bring harmful substances onto premises

• Control of lighters and matches

• Fire retardant textiles and furnishings provided by the Trust comply with HTM 87

• Where sleepwear is provided by the Trust it should comply with BS5722

• Safe and secure use, storage and disposal of sharps, tools etc

• Control of issue of knives & sharp tools

• Use of ‘shadow boards’ for tools/items in high risk areas – so it is clear when an object is not in its place


D. Environmental audit action plan

Area(s) inspected

Date inspected

Inspected by: PRINT NAME (s) Signature (s)

Date due for next inspection: Copied to (Name of responsible manager):

Location of hazard/risk

Description of hazard/risk Comments Action required/ recommendations

Who By when

Estimate of any costs

When complete send to Service Manager with a copy to Clinical Team Leader/Ward Manger and Modern Matron