risk assessments - practice guidance for mental health social …€¦ · risk assessments –...

Version: 2 FOI Status: Public

Derbyshire County Council Adult Social Care Practice Guidance

Risk Assessments – Practice Guidance for Mental Health Social Workers and Approved Mental Health Professionals

Issued: June 2020 Review Due: June 2022

Once printed this is an uncontrolled document - 1



Name Job Title Date

Authored by: Jacky Ingerson

Service Manager – Mental Health July 2017

Approved by: Quality Assurance Group

Quality Assurance Group July 2017

Change History

Version Date Name Reason

V 1 July 2017 Jacky Ingerson & Chris Smythe

Update and inclusion of Emergency Support Team (EST)

V2 June 2020 Jacky Ingerson Update and Inclusion of further EST information

Derbyshire County Council (DCC) Adult Social Care (ASC) publishes a range of practice guidance documents to support workers managing individual cases. They are written in plain language and give clear and precise guidance detailing how professionals and other relevant parties should respond when dealing with Mental Health Act Assessments (MHAA). This practice guidance has been developed to work alongside statutory guidance and to give greater consistency within Derbyshire. A new risk assessment form is attached as Appendix 1 and checklist as to when to complete the risk assessment attached as Appendix 2.

This practice guidance has been primarily written for approved mental health professional (AMHP) when undertaking Mental Health Act assessments and has arisen from various management reviews and coroners’ findings. This practice guidance should be applied to work undertaken by the Enhanced Support Team (EST). This document will be reviewed on a regular basis – if you would like to make any comments, amendments, additions, etc., please email Phil Robson – Policy and Procedures, [email protected]






Contents

Recording Risk Factors when Undertaking Mental Health Act Assessments ......................... 3

Recording of Risk when Providing Professional Support or Assessing/Creating Support Plans within the Self Directed Support Policies ...................................................................... 5

Assessment and Care and Support Planning ......................................................................... 5

Self-Directed Support .............................................................................................................. 6

Risk Enablement ..................................................................................................................... 6

Appendix 1 – Risk Assessment .............................................................................................. 8

Appendix 1 – Positive Risk Taking ........................................................................................ 13

Appendix 2 - Risk Assessment – Points of Contact Requiring Action .................................. 16






Recording Risk Factors when Undertaking Mental Health Act Assessments

Applies to AMHP’s only. Assessment Process Approved Mental Health Professionals (AMHPs) should carefully consider the use of a second doctor during Section136 assessments (balanced against urgency of the situation, the individual’s human rights and availability of doctors). When working with just one doctor, where there is a difference of opinion, a second doctor must be sought.

Where the two doctors are of the view that the person should be detained and the AMHP does not believe an application is appropriate at this time, the doctors should complete their medical recommendations. In these circumstances the AMHP must retain responsibility for following this assessment through and clearly document their rationale for either not detaining or using the 14 days to monitor the situation.

When decisions are made not to detain a person under the Mental Health Act (MHA), consideration should be given as to whether the person would benefit from a social care assessment and arrangements made accordingly.

Arrangements should also be made to undertake carer’s assessments where appropriate in line with current procedures. Risk Assessment Risk assessment documents must be completed during every MHA assessment.

Where an up-to-date risk assessment (safety plan) completed by a professional who knows the person exists (e.g. a nurse on the ward for inpatients, or a Community Psychiatric Nurse (CPN) for a community patient, a review form can be completed in conjunction with others that know the service receivers.

All risk assessment documentation to be uploaded onto DCC case management system and Derbyshire Healthcare NHS Foundation Trust’s IT system, giving policy and procedure (P&P) copy to nurse in charge with MHA P & P work.

Key risk factors must be included in the AMHP report (reference not just being made to the risk assessment document). Wherever possible new risk assessments should be formulated with the doctors and other professionals involved in the MHA. Otherwise AMHPs should obtain explicit information from the doctors around the risk factors and transfer this into the risk assessment document.

Identification of risk factors must be specific, i.e. what does ‘future on-going risk’ actually mean?

https://staff.derbyshire.gov.uk/working-here/adult-care-information/policies-procedures/fieldwork/fieldwork-policies-and-procedures.aspx






Where different views exist these must be carefully documented.

Risks must include historical and current factors – both to the service receiver and to others.

There needs to be a conversation between all parties to ensure perspectives are shared and where possible agreement reached as to what constitutes a protective factor, i.e. what does this mean in practice? Do they need to be tested out? How does the person respond to being questioned? A child should not be considered a protective factor as a matter of course. Information Gathering All measures should be taken to ensure information is obtained from the service receiver’s GP and local services (in and out of hours) to enable AMHPs to be able to base their decision making on as much available information as possible (the appropriate duty worker could be utilised to assist the AMHP with this where necessary).

Derbyshire Health United (DHU) should also be contacted out of hours to gather information from primary care. It is important during the assessment process to base decisions within a wider context.

Professional judgement must be used when deciding whether to liaise with family members other than the nearest relative. You can override the service receiver’s wishes, if on balance of risk, this is likely to give you information that will support the decision making, again within a wider context. Proportionality and recording your rationale around these decisions are important factors to bear in mind.

Although the interview is a crucial focus of the MHAA, AMHPs need to also look beyond this, especially with regard to the assessment of risk. AMHPs have a responsibility to bring a wider context to the assessment, i.e. to consider what we don’t know and to consider whether the information extracted from the interview gives us enough information to make the decision.

The fact that a MHAA is undertaken out of normal working hours should not prevent the AMHP from attempting to make contact with other professionals to share appropriate information. The AMHP Report The AMHP report should comment briefly on the doctors’ findings, i.e. mental state examination, presenting features and risk factors. Notes can be made during the assessment to capture critical points if appropriate (or immediately after the assessment). Doctors’ findings will inform the decision making.

AMHP reports must be written following all assessments, including Community Treatment Orders (CTO) and Section136’s, whether or not the person is detained. AMHP reports must be sent to all interested parties, both within Derbyshire and to






services where the person originates from, especially the GP or Crisis Resolution Home Treatment team (CRHT). In cases where the person declines to provide any information, all reasonable steps should be undertaken to trace the GP. Telephone contact should be established first before sending confidential information and arrangements to send this in line with the information sharing guidance of both agencies.

Recording of Risk when Providing Professional Support or Assessing/Creating Support Plans within the Self Directed Support

Policies

Applies to AMHP’s and EST For clarification on when to complete a full risk assessment (see Appendix 1) please refer to contact points requiring action as per Appendix 2 embed link checklist. Social workers are required to assess risks throughout their work and there is the SDS Practice Guidance Risk Enablement for guidance. References to risk factors within this documentation can be summarised below.

Assessment and Care and Support Planning

The following points are taken from Derbyshire County Council ‘SDS Practice Guidance – Assessment and Care and Support Planning.’ S.5 The appropriate assessment documentation has been used including

associated risk assessments. S.7.1 In all cases the care and support plan will need to reflect what is important to

and for the person as well as include details of how any risks will be managed. ‘It is not appropriate to sign-off a plan without this information as you will be unable to judge whether the plan is likely to be appropriate and realistic to meet the assessed eligible social care needs; a suitable and legal way to use the budget or that it will keep the person safe and well as possible in the circumstances having regard to their mental capacity.’

S.8.1 Defensible decision making. Our objective is to make sure that wherever possible the outcome of the assessment and care and support plan leaves each person with safe and personalised care and support.









Self-Directed Support

Collective Shared Control The appropriate assessment documentation has been used including associated risk assessments. Senior practitioners or service managers to quality check a sample of assessments. In all cases the care and support plan will need to reflect what is important to and for the person as well as include details of how any risks will be managed. Safeguarding responsibilities require us to demonstrate that the following guiding principles have been utilised in the context of risk management:

a person centred approach has been used to identify good person-centred outcomes

capacity and consent issues have been fully considered; and

defensible decisions are made where the conclusions reached have a clear rationale

Where there are other review systems operating (e.g. care programme approach, safeguarding, continuing care, Care Quality Commission (CQC) reviews, person-centred planning reviews the dates of these reviews should be taken into account and be co-ordinated by the reviewer to reduce duplication. The person should experience as seamless a process as possible. The review process should in all cases include an assessment of whether the needs and circumstances of the individual have changed, to include evaluation of risk, likely changes in need over time, the views of the individual concerned and other professionals/agencies and determination of eligibility.

Risk Enablement

Risk enablement is an approach to the process of decision making which is based on the premise that all people should be supported to make their own choices and take actions in order to improve their quality of life. This may include choices or actions that are considered risky or unwise. Risk enablement does not mean the disregard of potential risks to a client or others and needs to be balanced with safeguarding responsibilities, health and safety procedures and our duty of care for clients and their carers. Risk is part of everyday life and is inherent in everything we do. Positive risk taking can enable people to learn from experience, discover new skills, and develop as a person. It is impossible and undesirable to live in a risk free world. People who use services from Adult Social Care should not have less opportunity than other citizens to strive towards interesting and rewarding lives. Therefore this guidance is written within this context.






Risk can be defined as the uncertainty of outcome, whether positive opportunity or negative threat, of actions and events. The risk has to be assessed in respect of the combination of the likelihood of something happening, and the impact which arises if it does actually happen. A ‘defensible decision’ is one where:

all reasonable steps have been taken to avoid harm

reliable assessment methods have been used

information has been collected and thoroughly evaluated

decisions are recorded and subsequently carried out

policies and procedures have been followed It is possible that a client may present risks associated with their disability/medical condition/mental health but the choices they or their representatives make in terms of how the budget is to be spent present no or minimal risks. In these circumstances a separate risk enablement record will not need to be completed. However, usual departmental risk assessments would still need to be completed to manage risks associated with a client’s disability/medical condition/mental health in line with Policies and Procedures. For further advice see SDS Practice Guidance Risk Enablement







Appendix 1 – Risk Assessment

Risk Incidents History

Service receiver name:

Service receiver date of birth:

Service receiver NHS number:

Date of assessment:

Mosaic ID:

Context and Rationale i.e. is the risk assessment being completed following a MHA assessment, a safeguarding referral or crisis situation, etc. (not exhaustive)

A. Harm to self Active Past History

1. Act with suicidal intent Yes / No / Not known Yes / No / Not known

2. Self-injury or harm (to include ingestion and insertion) Yes / No / Not known Yes / No / Not known

3. Suicidal ideation Yes / No / Not known Yes / No / Not known

4. Self-neglect Yes / No / Not known Yes / No / Not known

5. Other Yes / No / Not known Yes / No / Not known

If you have selected yes for any of the above columns, please give details in the space below.

B. Harm from others Active Past History

1. Risk of neglect Yes / No / Not known Yes / No / Not known

2. Risk of sexual exploitation Yes / No / Not known Yes / No / Not known

3. Risk of emotional psychological abuse including bullying

Yes / No / Not known Yes / No / Not known

4. Risk of unlawful restrictions (e.g. locks on doors, physical)


5. Risk of physical harm Yes / No / Not known Yes / No / Not known

6. Risk of financial abuse Yes / No / Not known Yes / No / Not known

7. Risk caused by medication/services/treatment to include the impact of loss of autonomy


8. Domestic violence Yes / No / Not known Yes / No / Not known

9. Other

Other risk behaviours Active Past History

10. Incidents involving the police Yes / No / Not known Yes / No / Not known

11. Correspondence Yes / No / Not known Yes / No / Not known

12. Phone calls Yes / No / Not known Yes / No / Not known

13. Restricted client Yes / No / Not known Yes / No / Not known

14. MAPPA (Multi Agency Public Protection Agreements) Yes / No / Not known Yes / No / Not known






15. Schedule 1 Yes / No / Not known Yes / No / Not known

16. Absconding/escape Yes / No / Not known Yes / No / Not known

17. Visitors Yes / No / Not known Yes / No / Not known

18. Sex offenders Act 2003 Yes / No / Not known Yes / No / Not known

19. Probation Service involvement Yes / No / Not known Yes / No / Not known

20. Theft Yes / No / Not known Yes / No / Not known

21. Social Media Yes / No / Not known Yes / No / Not known



C. Physical Health Active Past History

1. Long term condition to include Learning Disability, Autism, Brain Injury


2. Medication Yes / No / Not known Yes / No / Not known

3. Pain Management Yes / No / Not known Yes / No / Not known

4. Falls Yes / No / Not known Yes / No / Not known

5. Substance abuse (including smoking and alcohol) Yes / No / Not known Yes / No / Not known

6. Nutrition Yes / No / Not known Yes / No / Not known

7. Pressures sores Yes / No / Not known Yes / No / Not known

8. Venous thromboembolism (VTE) Yes / No / Not known Yes / No / Not known

9. Memory and cognitive impairment Yes / No / Not known Yes / No / Not known

10. Long term conditions Yes / No / Not known Yes / No / Not known

11. Allergies Yes / No / Not known Yes / No / Not known

12. Wellbeing Yes / No / Not known Yes / No / Not known

13. Social situation Yes / No / Not known Yes / No / Not known



D. Harm to others Active Past History

1. Sexual assault (including touching/exposure) Yes / No / Not known Yes / No / Not known

2. Physical violence/aggression/abuse to others Yes / No / Not known Yes / No / Not known

3. Violence towards property and home Yes / No / Not known Yes / No / Not known

4. Verbal assault/aggression Yes / No / Not known Yes / No / Not known

5. Arson Yes / No / Not known Yes / No / Not known

6. Hostage taking Yes / No / Not known Yes / No / Not known

7. Weapons (Inc. those considered ornaments/functional) Yes / No / Not known Yes / No / Not known

8. Risk to children Yes / No / Not known Yes / No / Not known

9. Harm to/or sexual exploitation of animals Yes / No / Not known Yes / No / Not known

10. Is the patient/partner pregnant; are there any children less than one year old in the household who are at risk?


11. Risk to care givers (to include paid support staff) Yes / No / Not known Yes / No / Not known

12. Exploitation of others (e.g. financial, emotional) Yes / No / Not known Yes / No / Not known

13. Stalking Yes / No / Not known Yes / No / Not known

14. Risk to vulnerable adults Yes / No / Not known Yes / No / Not known

15. Coercion or excessive control of others Yes / No / Not known Yes / No / Not known

16. Domestic violence/safeguarding Yes / No / Not known Yes / No / Not known






17. Intimidation Yes / No / Not known Yes / No / Not known



E. Accidents Active Past History

1. Falls Yes / No / Not known Yes / No / Not known

2. Accidental harm outside the house (e.g. wanderings) Yes / No / Not known Yes / No / Not known

3. Unsafe use of medication Yes / No / Not known Yes / No / Not known

4. Driving/road safety Yes / No / Not known Yes / No / Not known

5. Other accidental harm at home Yes / No / Not known Yes / No / Not known



F. Factors affecting risk

The factors to be considered are:

Environmental factor, inc. animals Refusal of services

Substance misuse (e.g. alcohol/drug abuse) Discontinuation of medication

Risk of losing essential services Housing status

Major life event Service receiver is unaware of risk or lacks capacity in relation to specific risks identified (Please record)

Current mental state Service receiver’s care network is unaware of risk

Risk of relapse Risk of acute admission

Service receiver would be unable to summon help

Impact on care givers (to include paid support staff)

Service receiver relationships (at risk of breakdown?)

Ability to adapt to change

Communication factors/barriers (to include ASD)

Chaotic Lifestyle/High impulsive

Rigidity of thought (literal thinking) Perceptual differences (to include ASD, hyper sensitivity to sound/light)

Other

This list is not exhaustive. Where appropriate please refer to the service receivers Tiered Support Plan, Positive Behaviour Support Plan for guidance on key factors/triggers which might affect risk (typically this will apply to EST clients).

F1. Factors increasing risk






F2. Factors reducing risk including support network

Where appropriate please refer to the service receivers Tiered Support Plan, Positive Behaviour Support Plan for guidance on key factors/triggers which might affect risk (typically this will apply to EST clients).

Positive risk taking Yes / No / Not known Yes / No / Not known

Independence & choice Yes / No / Not known Yes / No / Not known

Risk of taking a particular course of action (e.g. hospital or not, why least restrictive or not and risks)


G. Risk Management Plan

AMHPs – please fully complete this section, you should ensure the detail is also recorded in full in the AMPH report (you can cut and paste).

EST – please identify other documents to which you are referring e.g. Tiered Support Plan, HCR 20 (to include the date the document was written).






Assessment Completed by:

Date for Review:






Appendix 1 – Positive Risk Taking Service receiver name:

Service receiver date of birth:

Service receiver NHS Number:

Date of assessment:

Mosaic ID pin number:

Date of assessment and agreed decision:

Details of Positive risk being taken:

Risk being taken: (What has been agreed with the service receiver?)

Describe the known actions or behaviours which may present a risk:

State reasons why it has been agreed clinically appropriate to take the risk:

Detail the Positive benefits/outcomes for the service receivers:

Detail the protective factors in place/strengths of service receivers to support the risk taking:






Details of crisis/contingency plans in place: (This should be completed in collaboration with Derbyshire Health Care Foundation Trust colleagues where appropriate and/or other agencies)

How are these to be managed in this specific risk taking situation:

Outcome of this Positive Risk Taking exercise:

To be reviewed on:

By:

Persons involved in the discussion and agreed decision for this Positive risk-taking: (Collective accountability); (signatures)

Date:

Service receiver signature:






Date:

Carer signature (if applicable):

Date:






Appendix 2 - Risk Assessment – Points of Contact Requiring Action

When Action By whom Mental Health P & P Team – initial referral by NHS Trust

Provision of current Risk Assessment (RA)

Referrer

Mental Health P & P Team – initial referral by other agency of service receiver under NHS Trust

Request current RA from NHS Trust involved with the service receiver

Mental Health P & P Team Duty Worker

Mental Health P & P Team – initial referral of service receiver not under NHS

Contact referring and other involved agencies for background information to create RA

Social Worker allocated for assessment

Mental Health P & P Team – create SDS/Professional Support Plan

Update/create RA for issue to agencies commissioned to support service receiver

Allocated Social Worker

Mental Health P & P Team – referral for MH Enablement

RA to be issues to Enablement Team


Mental Health P & P Team – critical/untoward incident

Update RA and issue to agencies commissioned to support service receiver


Mental Health P & P Team – annual support plan review

Update RA and issue to agencies commissioned to support service receiver


Mental Health P & P Team – Care Programme Approach (CPA) Review

Request updated RA with copy of CPA care plan from Trust


Mental Health P & P Team – hospital discharge

Request updated RA from ward (and update Adult Care RA if necessary, reviewed current)


AMHP – MHA Referral, person already known to NHS Trust/DCC (including CTOs)

Request RA from Trust or locate RA on mosaic. Contact referring and other involved agencies for up to date background information. Start RA following MHA Assessment

Allocated AMHP/Duty Worker

AMHP – MHA Referral, person unknown (including S.136 referrals)

Contact referring and other involved agencies for background information. Complete RA following MHA Assessment


AMHP – MHA Assessment: hospital regrade

Request RA (safety plan) from ward prior to assessment and ensure updated RA is uploaded to mosaic


S.117 discharge meeting Locate RA on mosaic. Request up to date RA from the ward and updated RA on mosaic accordingly, taking into account any additional information discussed during the meeting

Allocated Social Worker for professional support episode

Social Circumstance Report (SCR) for Tribunal

Request up to date RA from ward or Trust prior to completion of SCR

Allocated Social Worker to professional support episode

Community Treatment Order (CTO)

Request up to date RA from ward prior to completion of CTO

Allocated AMHP for professional support episode






CTO Renewal Request up to date RA from Trust prior to completion of CTO Renewal

Allocated AMHP for professional support episode

Guardianship Request RA from Trust or locate RA on mosaic. Contact referring and other involved agencies for up to date background information. Update RA as part of Guardianship application


Safeguarding/VARM (Vulnerable Adult Risk Management) referral – active case

Update RA following strategy meeting and issue to attendees and other relevant agencies

Allocated Social Worker/AMHP

Safeguarding/VARM - referral by NHS Trust

Request RA from NHS Trust involved with service receiver. Update following strategy meeting and issue to attendees and other relevant agencies

Involved Social Worker/AMHP

Safeguarding/VARM – referral by other agency of service receiver under NHS Trust

Request RA from NHS Trust involved with service receiver. Contact other agencies for additional information and create RA following strategy meeting. Issue to attendees and other relevant agencies


Safeguarding/VARM – referral of service receiver not known to Adult Care or NHS

Contact referring and other involved agencies for background information to create RA following strategy meeting. Issue to attendees and other relevant agencies


Discharge from services Send up to date RA to GP and all other involved agencies

Involved Social Worker

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