Ligature Risk Management for Mental Health, Justice Health ...



Canberra Health Services Operational ProcedureLigature Risk Management for Mental Health, Justice Health and Alcohol & Drug Services Inpatient Mental Health UnitsContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc31621439 \h 1Purpose PAGEREF _Toc31621440 \h 2Alerts PAGEREF _Toc31621441 \h 2Scope PAGEREF _Toc31621442 \h 3Section 1- Components of the MHJHADS Ligature Risk Management System PAGEREF _Toc31621443 \h 4Section 2-Staff Responsibilities PAGEREF _Toc31621444 \h 5Section 3 – Risk Dynamics and Risk Zoning PAGEREF _Toc31621445 \h 8Section 4 – Collateral Risk Assessment Factors PAGEREF _Toc31621446 \h 12Section 5 – Environmental Safety Checks PAGEREF _Toc31621447 \h 13Section 6 – Ligature and Ligature Point Assessment Audit (LLPAA) PAGEREF _Toc31621448 \h 14Section 7 – Risk Assessment and Reduction Action Plans PAGEREF _Toc31621449 \h 18Section 8 – Staff Training PAGEREF _Toc31621450 \h 19Implementation PAGEREF _Toc31621451 \h 19Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc31621452 \h 20References PAGEREF _Toc31621453 \h 21Definition of Terms PAGEREF _Toc31621454 \h 22Search Terms PAGEREF _Toc31621455 \h 24Attachments PAGEREF _Toc31621456 \h 24Attachment 1 – Floor Plan Risk Map Zoned Example PAGEREF _Toc31621457 \h 25Attachment 2 – Enviornmental Safety Check PAGEREF _Toc31621458 \h 26Attachment 3 – Ligature and Ligature Point Assessment Audit Tool Checklist (LLPAA) PAGEREF _Toc31621459 \h 29Attachment 4 - Canberra Health Services Risk Assessment Template PAGEREF _Toc31621460 \h 39Attachment 5 – Canberra Health Services Risk Reduction Action Plans PAGEREF _Toc31621461 \h 42PurposeMental Health Justice Health and Alcohol & Drug Services (MHJHADS) aims to provide a safe and therapeutic environment for people admitted for care and treatment. This includes ensuring that the environment is as free as possible from ligatures and ligature points.This procedure is to be seen as an integral part of an overall strategy to reduce the risk of self-harm and suicide and will be used in collaboration with assessment of mental state, medication prescription, participation in therapy, clinical risk assessment, observation and engagement of mentally ill persons admitted to inpatient units. Accordingly, this procedure outlines the responsibilities and operational requirements for the implementation of a mental inpatient ligature risk management system. This procedure has been developed in support of the Australian Commission on Safety and Quality in Health Care’s National Standards for Mental Health Services 2010, where the priority is “the optimal safety and wellbeing of the consumer in all mental health settings” (Standard 2.1).This procedure primarily addresses environmental risks within the inpatient setting that, if not identified and/or managed, could contribute to attempts or completion of acts of self-harm or suicide by hanging.This procedure aims to:Guide the provision of a safe and therapeutic environment for people with mental health disorders;Reduce risks associated with ligatures and ligature points that may enable or provide a person in distress with an opportunity to act upon their thoughts and feelings of self-harm;Provide a procedural framework to enable staff to effectively identify, assess and reduce environmental risks; Provide operational guidance for staff that ensures a coordinated approach to the prevention of self-harm from ligatures and ligature points, consistent with other related clinical, physical, procedural and relational security strategies used in delivering quality care to admitted persons ensuring their safety and wellbeing.Back to Table of ContentsAlertsA significant proportion of the cases of people who have died by suicide are believed to have occurred through impulsive acts using the first means to hand and without time for reflection, whilst others are a result of a well-planned and considered approach to self-harm. The most common method of suicide in hospitals and in the general community is self-strangulation by hanging.Due to human ingenuity and/or a lack of a technical solution, it is not possible for all potential ligatures and ligature points to be eliminated without setting aside a person’s human rights. Therefore a clinical judgement has to be made about the likelihood of something being used as a ligature and or a ligature point.Where identification of ligature or a ligature point risk is evident, direct, timely action ensuring the safety and welfare of people accessing an inpatient unit should occur as part of the overall clinical risk assessment. An anti-ligature or reduced ligature fitting or fixture does not automatically eliminate risk.Back to Table of ContentsScopeThis procedure applies to all persons providing services and those visiting and supporting admitted persons to MHJHADS inpatient mental health units including: Nursing, Medical, Visiting Medical Officers, Registrars, Locums, Allied Health, Administrative, Agency and Casual staffStudents on placement under the supervision of MHJHADS Nursing, Medical and Allied Health staffVolunteersIn-scope inpatient MHJHADS facilities include: Adult Mental Health Unit (AHMU) – Building 25, Canberra Hospital campusExtended Care Unit (ECU) - Mary Potter Circuit, BruceAdult Mental Health Rehabilitation Unit (AMHRU) - University of Canberra Hospital (UCH) campusMental Health Short Stay Unit (MHSSU) - Level 2, Emergency Department, Canberra Hospital campusDhulwa Mental Health Unit (DMHU) – Symonston.Note: This procedure does not cover the risk factors associated with the clinical assessment, treatment and management of mental state or managing a person’s behaviour associated with self-harm and suicide. These strategies are undertaken as part of the clinical risk assessment process, the allocation of risk categories and the associated levels of observation required for individuals being assessed or admitted for treatment and care.Back to Table of ContentsSection 1- Components of the MHJHADS Ligature Risk Management SystemThe key components of the MHJHADS Ligature Risk Management System are: 1.1Floor Plan Risk Map (FPRM) Floor Plan Risk Maps are to be used as a means of raising staff awareness of areas within an inpatient unit identified or zoned as high, medium or low risk. FPRMs (Attachment 1) must be developed and regularly updated for each inpatient unit, including display in prominent location(s) within the unit. FPRMs are to be colour coded to ensure quick reference and identification of higher risk areas are highlighted to staff.FPRMs are also used to assist in the clinical handover process and are to be included as part of the orientation and training of all staff working in MHJHADS inpatient units.Refer to Section 3 of this document for more detailed content on FPRMs.1.2Environmental Safety Checklists (ESC)An Environmental Safety Checklist (Attachment 2) must be completed at the beginning or change of every shift. The purpose of the ESC is to observe for ligatures, ligature points, environmental risks and the presence of prohibited items and follow-up action taken to reduce risk.The ESC supports work practices aimed at ensuring all people are as safe as possible from harm, and to ensure that risks are effectively managed. ESCs are undertaken as it is reasonably practicable to do so without infringing on a person’s human rights. Refer to Canberra Health Services Searching of a Consumer’s Person or Property Policy for further information.Refer to Section 5 of this document for more detailed content on ESCs.1.3Ligature and Ligature Point Assessment Audit ToolA formal Ligature and Ligature Point Assessment Audit Tool (LLPAA) (Attachment 3) is used to identify the presence of ligatures and ligature points.The LLPAA is incorporated into the MHJHADS Clinical Audit Schedule as part of the integrated system for ligature and ligature point management and must be conducted every six months at minimum, or more frequently where indicated.Where a change to the environment is proposed (eg. room refurbishment or change in purpose), a full ligature assessment review will be required.Refer to Sections 6 and 7 of this document for more detailed content on LLPAAs.1.4Risk Assessment and Risk Reduction Action Plan (RRAP)All high-risk ligatures and/or ligature points identified in the LLPAA audit are subject to a further formal detailed risk assessment using the Canberra Health Services Risk Assessment Tool (Attachment 4). Identified risks must then be addressed through the development of a RRAP (Attachment 5).Once completed by the ADON, the RRAP is to be provided to the Operational Director for identified action. Where reduction or removal of a ligature or ligature point requires significant investment of funds by the service, the Operational Director is required to report this to the MHJHADS Executive Director for further action.Refer to Section 7 of this document for more detailed content on the RRAP.1.5RiskmanRiskman is the Canberra Health Services risk reporting system. All staff are required to report incidents involving near misses, damage, tampering to fittings, maintenance issues or other risks that have the potential to increase opportunity or means for self-harm. Riskman incidents are to be followed up promptly by the responsible manager and issues escalated in accordance with policy and procedures and acted upon without delay. Back to Table of ContentsSection 2-Staff Responsibilities2.1MHJHADS Divisional ExecutiveMHJHADS executive inclusive of the Executive Director and Chief Psychiatrist are responsible for ensuring policies, procedures and standards comply with legislative requirements inclusive of those that relate to the identification, mitigation and where possible elimination of ligatures and ligature points within inpatient mental health units.2.2Operational Directors Operational Directors are responsible for ensuring implementation of the MHJHADS Ligature Risk Management System and local governance and reporting requirements in their respective mental health inpatient units.Where reduction or removal of a ligature or ligature point requires significant financial investment, the Operational Director is required to report and make recommendations to the MHJHADS Executive Director for further action.2.3Clinical Directors Clinical Directors are to ensure that medical officers as part of their orientation are familiar with the Ligature Risk Management System and the procedures required for implementation.2.4Assistant Directors of NursingAssistant Directors of Nursing (ADON) are to ensure completion of and compliance with the following:Floor Plan Risk Maps are developed, displayed and updated in each inpatient unit, and communicated to staff through Clinical Nurse Consultants (CNC) and Shift Team Leaders.Environmental Safety Checklists (ESC) are completed each shift.Ligature and Ligature Point Assessment Audits, using the LLPAA are conducted at a minimum of six monthly intervals.Canberra Health Services Risk Assessment Tool is completed for all identified risks and Risk Reduction Action Plans developed to address and manage these risks.Once completed by the ADON, the action plan is provided to the Operational Director to action and monitor.All staff receive orientation and training that includes the work practices that support the Ligature Risk Management System, ESC and the LLPAA.Ensure that tradespersons, contractors, cleaning staff do not bring high risk ligature items into clinical areas. In the case where tradesperson and contractors do bring in materials that represent a ligature risk, these items must remain under the direct control of the personal who are operating with these materials. An example list of ligatures is provided in Section 6.Ligature and ligature point assessment audit findings and the actions being taken are to be reported by the ADON through to the inpatient Work Health Safety Committee and Clinical Governance Committees.All minor works and the addition of fixtures and fittings are to be subject to a LLPAA assessment and an approval process.Reporting to the relevant Operational Director occurs, ligature risk issues are identified, and documentation is made in Riskman.Implementation of strategies that reduce the risk of self-harm, suicide and prevention of serious incidents through audits and risk reduction action plans.Keeping all records associated with the implementation of the Ligature Risk Management System as set out in the Procedure for Mental Health Inpatient Units.2.5 Clinical Nurse Consultant and Nurse in Charge of ShiftEnsure the completion of ESCs for every shift and that the reporting of identified risks occurs. Ensure searching of consumers on admission and on return from leave of admitted persons consistent with approved Canberra Health Services search policy and procedures.Ensure that staff receive training in Ligature Risk Management System and emergency response measures and that they are aware of and are able to complete all relevant documentation.Ensure staff are vigilant that visitors/carers do not bring ligatures and high risk items into clinical areas (see examples Section 6).2.6Multidisciplinary team (MDT) responsibilities All MDT members of each inpatient unit are responsible for the following:Attending orientation and training that includes the Ligature Risk Management System, use of the ESC and the LLPAACommunicating both at clinical handover and at other times risk issues associated with the management of ligatures, ligature points and risks for self-harm or possible harm from prohibited itemsEnsuring that individual work practices are supportive of managing environmental risk including supporting Operational Directors, ADONs and CNCs to meet their responsibilities to implement the Ligature Risk Management SystemDesignated Nursing staff are to complete ESCs on each shiftReporting ligature risk issues to their line manager and utilising the Riskman and SAIR reporting system to document clinical risks inclusive of electronic medical record systemFamiliarising themselves with the Ligature Risk Management System as well as the Clinical Risk Assessment (CRA) and At Risk Category (ARC) procedures, completion of the Suicide Vulnerability Assessment Tool (SVAT) and other related policies, procedures and guidelines through their orientation and each units line supervision requirements.2.7 Tradespersons & ContractorsThe management of tradespersons & contractors who enter the clinical environment is also integral to an effective approach to the identification and reduction of ligature risks. CHS staff who allow building access for the tradespersons and contractors will discuss safeguarding their materials and tools and will provide them with a copy of this document if requested or if required.Tradespersons and contractors may be required to bring tools, materials and other items that represent a ligature risk into an inpatient environment. On these occasions’ communication between inpatient unit staff and the visiting tradespersons and contractors is essential, where the priority is to ensure a high level of cooperation occurs, especially in maintaining vigilance for the identified risk items and for managing and reducing all identified risks that pertain to them.Tradespersons and contractors are responsible for the safekeeping of all tools, materials and items that they bring into an inpatient environment and they are expected to take all reasonable measures to prevent access of these items by consumers. Tradespersons and contractors are required to collaborate with Nursing staff and to follow their direction, in as far as the management of identified ligature risks is concerned.Tradespersons and contractors are required to take responsibility for the safety and vigilant management precautions prior to entry into inpatient mental health units:Safe and vigilant management of sharp cutting implements, tools and equipment including security of electrical cords, tool bags and liquids;Cords contained in clothing, shoes, shoelaces, personal items containing elastic and other items that represent a potential ligature risk such as plastic bags.Where co-operation in regard to these items cannot be achieved staff are to report any ligature risk issues to the CNC/ADON/Nurse In Charge of Shift.Tradespersons and contractors are expected to engage in behavior and work practices that does not compromise the provision of a safe and therapeutic environment and they must at all times comply with relevant policy and procedures. 2.7 Visitors & CarersThe management of visitors and carers who enter the clinical environment is also integral to an effective approach to the identification and reduction of ligature risk. Nursing staff are responsible for monitoring items that are brought into the inpatient unit by visitors and carers and for providing education and raising awareness of prohibited items with them when appropriate. This requires proactive local communication in order to ensure a high level of cooperation occurs, especially in the vigilance for prohibited items.Visitors and carers are required to take responsibility for the following prior to entry to inpatient mental health units requiring the safe and vigilant management:Cords contained in clothing, shoes, shoelaces, personal items containing elastic and other items that represent a potential ligature risk such as plastic bagsComply with direction from Nursing staff that certain prohibited items cannot be brought into the clinical environment due to their associated risks such as scissors, glass bottles and knifes.Where co-operation in regard to these items cannot be achieved staff are to report any ligature risk issues to the CNC/ADON/Nurse In Charge of Shift.Visitors and carers must not engage in behavior or work practices that compromise the provision of a safe and therapeutic environment and they must adhere to the direction of Nursing staff, in as far as the management of identified ligature risks is concerned. Visitors and carers must comply with all relevant policy and procedures. Staff should provide information to the persons who require it and escalate any risks due to the behavior of visitors to the Nurse in Charge who will follow normal CHS procedure, including calling a Code Black if required, reporting to the CNC/ADON/After hours ADON, management, ensuring security is maintained and completing a Riskman if a reportable incident occurs. Back to Table of ContentsSection 3 – Risk Dynamics and Risk ZoningWithin inpatient mental health units there are known areas that present the potential for a greater risk of self-harm and suicide.Risk zoning is based on recognising the opportunity that a person could have access to a ligature and a ligature point. Areas are zoned according to the amount of time most people will spend in an area without direct supervision or observation from staff.Note: Bedrooms, ensuite bathrooms, doors, showers, toilets and isolated areas within all mental health inpatient units are the least directly supervised spaces and present the highest potential risk.Three salient risks that must always be actively managed by staff include:Means (ligatures and ligature points)Motive (mental state)Opportunity (the time and the means to act based on mental state)While privacy and dignity are to be afforded to people at all times, a person’s safety and welfare must not be put in jeopardy due to staff not asserting themselves in situations where a risk for self-harm has been assessed and identified. This requires that the necessary clinical judgment is exercised to keep people safe from harm.Three further pillars of safety and security are also part of the way in which risk is assessed and responded to are:Physical SafetyRelational SafetyProcedural Safety Physical safety Physical safety requirements are determined through good design aimed at minimisation of ligature points, the presence of ligatures and the likelihood of unauthorised entry and exit to gain possession of prohibited at risk items. This includes those items brought into clinical areas by staff, visitors and contractors.Relational safetyRelational security is the knowledge and understanding that staff have gained about a person directly or have had provided to them by way of collateral information. This process informs the basis of a therapeutic relationship with a person and their carers and facilitates the translation of this information into appropriate interventions that assist in keeping the person safe while supporting their treatment, care and recovery.Procedural safety Procedural safety relates to the diligent application of a range of procedures, policy, work systems and work practices designed to keep people safe from harm. A comprehensive range of effective procedures anchors the application of therapeutic activity through structure, processes and clinical routines. The routine application of endorsed procedures ensures that staff are able to quickly and efficiently establish clear boundaries and enables safe practices to be embedded and applied in a consistent way. The line supervision of staff is an essential element of a procedural safety system.Examples include searching the belongings of a person or the person themselves (subject to searching requirements being met – refer to Searching of a Consumer’s Person or Property Policy) who is being assessed or admitted for treatment and care and or is on their return from leave. Removal of prohibited or at-risk items requires clinical judgment, and clinical leadership to act in circumstances where the risk of self-harm has been identified and a proportionate response is required.Note: Similarly, entry to bedrooms, ensuites and toilets by staff should not, under all circumstances, be considered as an intrusion or a breach of a person’s human rights or of their privacy and dignity.Entry must be approached based on achieving a balance between a person’s privacy and dignity, and their right to be treated and kept safe by assertively managing the risk of self-harm and paying close attention to assessed risk levels.Although it is not possible at all times to individualise the allocation of bedrooms due to movement of persons within and between services, those assessed as having higher clinical risk should be accommodated where possible, in bedrooms closer to the staff station to facilitate increased opportunities for direct clinical observation.Risk ZoningFloor Plan Risk Maps (FPRM) are to be used to map and identify risk areas. FPRM are to be used to assist the clinical handover process by specifically indicating the location of persons in need of higher levels of observational vigilance particularly in circumstances where ESCs have identified prohibited risk items. FPRM are also to be included in the orientation of new staff to inpatient areas and updated in the event of changes to the physical floor plan or any change in the use of these spaces.To focus the attention of staff on these areas, a FPRM is to be displayed on each unit and used as a visual prompt to increase staff awareness for specific risk areas. Areas are zoned and colour-coded to indicate Red (High), Amber (Medium) and Green (Low) risk. An example of a FPRM can be viewed at Attachment 1.For the purposes of this procedure the following approach to risk zoning is to apply:Red Zone - High RiskPlaces where people receiving treatment and care are alone and away from direct observation and other persons for extended periods. This includes all bedrooms, shower/toilet ensuites, toilets located in common areas, and isolated external areas adjacent to the unit. These areas are to be zoned high risk and colour-coded red.Amber Zone - Medium RiskAreas where people receiving treatment and care may be unsupervised for periods of time but are within the unit or department environment. Contact with other persons or staff may be occasional, dependent on number of people on the unit and staff duties.Examples may include therapy areas, activity rooms, lounges, kitchens, quiet areas, spiritual rooms, courtyards and gardens etc.Green Zone - Low RiskCommon areas where people receiving treatment and care are regularly supervised and/or are regularly in the company of other persons e.g. dining rooms, main corridors, reception areas, etc.RED ZONE High RiskAMBER ZONEMedium RiskGREEN ZONELow RiskAreas where most people receiving treatment and care spend long periods of time, in private, without direct supervision of staffAreas where people spend periods of time with minimum direct supervision of staff and are usually in the company of peersAreas where there is a regular staff presence and other persons moving freely with good lines of sightAll bedroomsCommon Lounge AreasGeneral circulation spacesEnsuite toilet/shower areasDining rooms/areasCorridorsToilets in general ward areas Therapy, recreation, gym and spiritual spaces where staff are not in constant attendanceInterview rooms where staff are in constant attendanceIsolated rooms without good line of sight such as unisex toilets and recreation roomsSitting rooms without good line of sightFamily rooms when family are presentUnlocked Laundry areas where staff are not in constant attendanceRecreation AreasTherapy rooms where staff are in constant attendanceIsolated external areas adjacent to or near the unitNote: While areas can be categorised and zoned according to the level of risk, unpredictable and opportunistic risks will arise within any environment and vigilance is required particularly at night where areas zoned and assessed as low risk. In day light areas assume a higher level of risk at night.Back to Table of ContentsSection 4 – Collateral Risk Assessment FactorsPeople being assessed or admitted for mental illness, mental disorders and associated co-morbidities are at greater risk of self-harm and suicide than the general population. Within this group certain clinical presentations are more vulnerable and susceptible to self-harm and suicide risk than others.As inpatient mental health units cater for a range of clinical presentations, individuals are assessed using a combination of static and dynamic risk factors. These factors need to be taken into consideration when CRAs are undertaken and the required ARC observation level is determined or adjusted at clinical meetings or following adverse incidents. SVATs should also be utilized to assist in the assessment of self-harm and suicide.When clinical risk is being assessed, staff awareness for ligatures and ligature point risks must also be factored into the risks associated with managing the person and their interaction with the physical environment. Staff orientation and training are essential elements in developing staff awareness for these risks.Note: This is especially important for a person with a known previous history of self-harm and suicide attempts as this is an indicator of a higher risk for future self-harm.Collateral factors can both decrease and increase risk despite inpatient units in areas zoned as having, low, medium or high potential risk areas for self-harm and suicide.For example, a person receiving unfavorable news, experiencing circumstances where a family visit does not proceed well, or receiving rejection of a period of leave may increase the potential for self-harm with an associated shift in mental state. Periods spent alone in their bedroom, even though in a known high risk staffed red zone, will require greater levels of vigilance from staff.Specific reference to these factors must be included in clinical handovers for the purpose of considering whether a person previously assessed as being a low risk for self-harm may need to have their observation level reviewed and increased.This may also necessitate a person specific ligature risk assessment process as part of the CRA review and this includes the risk presented by personal items that can be used as potential ligatures.Personal items include such things as mobile phones, phone chargers, hair dryers, belts, shoelaces, string ties for hoodies and tracksuit pants, under wear, leisure wear clothing makeup, jewelry, nail polish bottles, aerosol cans and soft drink glass bottles, cans and plastic carry bags. In these circumstances personal items may need to be removed as assessed on a person by person basis in order to reduce risk.There are also situations, for example when 1:1 continuous observation (Specialling) is used, that reduces the risk of self-harm in bedroom and ensuite areas which have been zoned as red. At these times, the area of high risk is temporarily under constant observation making it less likely that a ligature or ligature point could be used.When an ARC observation rating is reduced the need for vigilance still remains high. A person who has had their ARC observation reduced, subsequent to an episode of self-harm and who is later in a low risk green zone area after hours, would still require staff to exercise a higher level of vigilance when undertaking their regular ARC observations; particularly during known high risk periods such as clinical handover and during night shift.MHJHADS also recognises that inpatient units provide services to older people and that there is a need to balance reducing the risk of ligatures and ligature points against maintaining some fixtures and fittings such as aids to daily living for this group.Managers need to consider other collateral issues such as staffing levels, staff skill mix, the use of specialling and the level of acuity being experienced on a mental health unit at any time.Back to Table of ContentsSection 5 – Environmental Safety ChecksThis procedure incorporates the completion of an ESC (Attachment 2) on all mental health inpatient units to ensure that risks are managed by staff on a shift to shift basis. These checks support the overall intention to keep people as safe as possible from harm.The purpose of these checks is for staff to observe for any items that could lead to self-harm. As well as prohibited items these checks also assess for ligatures and or ligature points and items such as torn articles of clothing, torn linen/blankets/towels, sharp objects, non-prescription and illicit drugs, drug paraphernalia, cigarettes, tobacco, alcohol, cigarette lighters, knives, plastic bags, glass objects, razor blades and any damage, tampering to fittings and changes in the immediate environment that may increase potential for self-harm and suicide attempt.While ESCs are completed on each shift, there will arise occasions where opportunistic actions are taken by staff in order to manage items that can be used for self-harm. All additional checks need to be well integrated within the overall patient safety, clinical risk and Risk Management pleted ESCs are to be used at clinical handover as part of the ISBAR staff communication system. They are also an appropriate source of collateral information to inform the Clinical Risk Assessment process and the review of ARC observation levels.Any risks identified are to be notified to the CNC or the Nurse-In-Charge Shift (NICS), documented in Riskman and in the medical record, and include documentation of action(s) taken to reduce the risk of harm. Information in ESCs needs to be collated by the CNC and used as part of the Unit’s clinical governance and risk reporting systems and staff line management system.ESCs do not replace or compete with Ligature Risk Management Assessment Audits. Where an environmental check has identified an item(s) that requires an extensive ligature and ligature point assessment, the LLPAA is then used.The outcome of ESCs as documented over each six month period should be included in the process to identify the risks to be included in the development of the RRAP.Back to Table of ContentsSection 6 – Ligature and Ligature Point Assessment Audit (LLPAA)The approach taken to LLPAA is that they are undertaken by senior members of the management team including the ADON, Clinical Director (CD), Clinical Nurse Consultant (CNC), Health and Safety Representative (HSR) and any other person relevant to the process. LLPAA must be completed using the endorsed LLPAA Tool Checklist included in Attachment 3.The Operational Director and ADON must ensure that an LLPAA is undertaken every six (6) months as a minimum requirement. The audit procedure requires that the audit team physically visits all areas of the unit (both internal and external) accessible by admitted persons. The areas to be audited include all bedrooms, therapy rooms, activity and recreation rooms, toilets, bathrooms, gardens, courtyards and adjacent public or private areas to which a person may have access. Further, adjacent external areas to the inpatient unit including walking routes and areas where a local search would occur if an ‘at risk person’ was found to be missing are included. Identified risks are to be rated as high, medium or low risk with the outcome of the assessment being an analysis of the risks identified and agreed upon by the assessment team.6.1Ligatures The following examples of ligatures are intended to assist staff and the ligature assessment audit team in the identification of risks.A ligature can be defined as anything a person can use to constrict blood flow to an area of the body or used to compromise an airway so as to self-strangulate. Ligatures are used either by suspending fully or partially their body for the purpose of suicide by hanging or the constriction of blood flow to a body part. A ligature can be made from anything that can be used to form a noose that may be tied around the person leading to the closure of an airway or the constriction of blood supply to any part of the body. This includes the use of a ligature such as a rubber band to secure a plastic bag over a person’s head to occlude their airway to achieve asphyxiation. Plastic bags can also be used separately or in combination to form a noose.An effective ligature does not need to entirely support a person’s full body weight to be effective. It must be noted that the following list of examples is not exhaustive and some of these items can be readily repurposed by a person as a means to effect self-harm and suicide.Examples of ligatures include:Linen – sheets, pillow cases, blankets, towelsCurtains – shower curtains, window curtains, cubicle curtainsClothing – shirts, blouses, t-shirts, trousers, leisure wearClothing accessories - belts, laces, braces, underwear, garment elastic, neck ties, scarfsCords – curtain pull cords, cord from curtains, draw cord on linen bags, vertical/venetian blind pull cords or chains, draw cords on gown cords, hoodies, tracksuit pants and dressing gownsPlastic bags – carrier bags, rubbish bags, clinical waste bagsShoe and boot lacesMedical products - theraband, compression stockings, bandages, tubingVinyl bed coversElectrical leads (washers, dryers), telephone cable, mobile phone charger leads, head phone leads, hair dryers, electric bed control cablesCoat hangers, cable ties, masking tape, duct tape, string, woolSticky tape, Duct tape, Surgical tapeToilet paper plaited into a ropeRubber strips from fire doors, rubber dust stripsTumble drier ductingGarden hose.6.2Ligature PointsA ligature point is anything that would support a person’s body weight either fully or partially allowing the attachment of items from the list of ligatures above to be used for the purposes of constricting a person’s airway and or blood vessels. It should be noted that a well formed knot or well-crafted noose is not required to achieve the constriction of an airway or a blood vessel.While it is also commonly thought that a ligature point requires a minimum height, the actual height needed can be as little as a few centimeters allowing the person to slump forward or sideways from an almost seated or even prone or supine position. Such a point may include an anchor at floor level (such as a drain cover in a shower area) allowing for a rolling self-strangulation to occur. It must be noted that the following is not an exhaustive list of examples that can be used for the purposes of self-harm and suicide.Examples of ligature points include:Doors – trapping a ligature between door and frame, particularly at the top; or attaching a ligature from the top edge of an open door (including wardrobe doors); and door self-closing mechanismsDoor hinges – either from the hinge itself or that part of a hinge that protrudes from the door frame Handles/hand rails – bedroom and bathroom door handles, ensuite shower door handles, wardrobe door handles, towel rails, disability rails/grab bars, stair railsCeiling fittings – false ceilings, lights, air vents, diffusers, smoke detectors, extractor grillsCeiling/wall - maintenance access hatch/panelCurtain tracks and rails, cubical tracking, widow trackingWindows – trapping a ligature between window and frames, window closer handles, window opening restrictors, window locksPipes – hot and cold water pipes, radiator pipes Taps, shower roses, sinks, toilets, shower recess floor gratesWall fittings – fire alarm bells, soap dispensers, paper towel and soap dispensers, shelves, fire alarm call points, coat hooks, pictures and paintings, mirrors, magnetic locksDoor hold-backs hold-open devices, wall mounted televisions, wall lights, nurse call pointsBeds - bed head/headboard, beds upended or propped up on their end/against the wall, electric beds where the frame or actuating mechanism may be used; Cupboard shelving, coat hooks, clothes racks, drawers; External areas - trees, fencing, gazebos, covered walkways, fire escapes, guttering, rain-water down pipes, storm water grates; and Walking sticks.Additional examples of ligatures and ligature points are provided in the LLPAA (Attachment 3).Note: For inpatient areas, ADONs are to maintain a list of those items deemed unsafe that are prohibited and which are not to be brought into the unit by either visitors, contractors or staff. This list is to be posted at the entrance to the Unit in full public view and is to be updated as required. The list is to be reviewed when instances of self-harm or a suicide attempt has occurred, as part of the incident investigation process.This list is also to be used to inform reviews of the ESCs completed on a shift by shift basis.Any immediate concerns arising from the audit where there are inconsistencies with current policy and procedure; such as the presence of prohibited items; are to be assertively managed by the ADON and the CNC in collaboration with staff (both clinical and non-clinical), the results of which are then communicated at staff meetings and in clinical handovers.Where concerns for safety are identified this should act as the basis for that persons CRA to be reviewed and a more thorough ligature risk assessment is to be undertaken using the LLPAA. Note: As part of this process the SVAT should also be completed (refer to Initial Management, Assessment and Intervention for People Vulnerable to Suicide Procedure).The risk presented by any ligatures and/or ligature points must be considered in the context of clinical risk assessment procedures and in the case of an individual’s personal items, these should be removed to a secure environment if they present an unacceptable risk.The removal of personal items must be based on sound clinical judgement with direct reference to the LLPAA together with clinical risk assessment and search procedures informing the decision. Any removal of personal items needs to be done with due sensitivity and transparency when communicating the decision to a person and their carers and is to be done consistent with search requirements.LLPAAs must be completed every six months. The ligature assessment audit should also be carried out on all new equipment or items purchased or introduced into the care and treatment environment or where the environment or use of an area changes or after any incident of self-harm that identified an emerging or actual ligature or ligature point risk.Back to Table of ContentsSection 7 – Risk Assessment and Reduction Action PlansAny ligatures and ligature points identified during the LLPAA and rated as high by the audit team are to undergo a risk analysis which is to be documented on the Canberra Health Services Risk Assessment Template included on Attachment 4.Based on an analysis of identified individual and grouped risks, appropriate risk control and mitigation measures are to be included. The ADON and Operational Director will ensure that once the audit is completed, all agreed high risks are documented and addressed through development of a RRAP included on Attachment 5-13.These plans are developed for identified risks and used to track the completion of the risk reduction strategies adopted within agreed timeframes at unit level. ADONs must escalate any identified risks that are unable to be adequately mitigated and managed on the unit to the respective Operational Director and as circumstances dictate to the Clinical Director and Executive Director, to ensure that the risk is managed and appropriate preventative action is taken, monitored and reviewed.Where structural alterations to the environment have been made since the last audit or changes to the clinical environment have occurred, the LLPAA audit criteria can be revised and the necessary changes made to the FPRM and ESCs.When completed, the RRAP and the measures to be implemented are to be communicated to all staff (not just clinical staff) working at the unit during staff meetings and clinical handovers. This information should include progress on meeting necessary risk reduction requirements.It is important to note that while all risks cannot be completely eliminated, appropriate steps can be taken through the RRAP to reduce the impact of the risks identified in the clinical environment, to the point that the risk can be made safer by collaboration between all those involved in a person’s treatment and care. The following approach to clinical risk is to be adopted in the development of RRAPs: RemoveThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed, despite having no suitable alternative, as the benefit of having its continued use is outweighed by its potential risk. The surface finishes are made safe following the items removal. Remove and ReplaceThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed and replaced with a specifically designed similar ligature minimised piece of equipment or materials.Remove and RenewThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed and new alternative equipment or materials are installed.ProtectProvide and install materials that hide and protect a person from a potential ligature point.ManageThe ligature is assessed and it is agreed that it is impractical or unnecessary to remove’ or there are no other technical solutions’ or it needs to be kept because other risks are even more significant such as the use of a hi-low bed to avoid patient falls.Back to Table of Contents Section 8 – Staff TrainingClinical staff will be provided with training in the MHJHADS Ligature Risk Management System, including the use of FPRMs, the completion of the ESCs and the use of the LLPAA.Training in the use of this procedure will be facilitated through the appropriate CNC in each unit and training records kept.Back to Table of ContentsImplementation Implementation of this procedure will occur within each mental health inpatient unit, inclusive of CRA and ARC systems, respective policies and procedures, and the work practice and line supervision systems that support them. The Executive Director together with the Chief Psychiatrist and other relevant members of the MHJHADS Executive are responsible for the development of relevant policies and procedures to ensure that the MHJHADS division complies with relevant standards for the management of ligatures, ligature points and also the management and reduction of ligature risk.This procedure is to be implemented in conjunction with the operational procedure for the safe removal of a ligature including ligature cutter use for inpatient mental health units as outlined in the CHS Ligature use in Inpatient Mental Health Units Response and Management Clinical Procedure. Both procedures are to be communicated to all staff by the ADON and CNC. New staff will be informed of these procedures during local orientation to the clinical work area and through participation in mental health inpatient in-service programs.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationHuman Rights Act 2004Work Health and Safety Act 2011Mental Health Act 2015Mental Health (Secure Facilities) Act 2016Children and Young People Act 2008Public Advocate Act 2005Guardian and Management of Property Act 1991Information Privacy Act 2014Carers Recognition Act 2010StandardsAustralian Charter of Health Care Rights 2019Department of Health National Suicide Prevention Strategy 2015National Aboriginal and Torres Strait Islander Suicide Prevention Strategy May 2013National Standards for Mental Health Services 2010National Safety and Quality Health Service Standards (Second Edition) 2017National Practice Standards for the Mental Health Workforce 2013PolicyACT Health Policy Incident Management ACT Health Policy Work Health and Safety ACT Health Risk Management PolicyCanberra Health Services Operational Policy Dhulwa Mental Health Unit (DMHU) – SearchingCanberra Health Services Operational Policy Searching of a Consumer’s Person or Property Canberra Health Services Policy Restraint of a Person – Adults Only Canberra Health Services Clinical Policy Dhulwa Mental Health Unit (DMHU) - Use of Force by Authorised Health Practitioners, Security Officers, Court Security Officers and Escort Officers Canberra Health Services Clinical Policy Patient Identification and Procedure Matching Canberra Health Services Dhulwa Mental Health Unit: Security Policy and Procedures ProcedureCanberra Health Services Procedure Incident Management Canberra Health Services Operational Procedure Dhulwa Mental Health Unit (DMHU): Valuables, Property and Access to MailCanberra Health Services Clinical Procedure Ligature use in Inpatient Mental Health Units: Response and ManagementCanberra Health Services Operational Procedure - Initial Management, Assessment and Intervention for People Vulnerable to SuicideCanberra Health Services Operational Procedure - Clinical Handover – Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS) Handover Canberra Health Services Clinical Procedure Spinal Injury Management of the AdultCanberra Health Services Clinical Procedure Seclusion of Persons with Mental Illness or Mental Disorder Detained under the Mental Health Act 2015 Canberra Health Services Operational Procedure Incidents Reportable to the Executive Director and Intervention Following the Death of a Person – Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS) Canberra Health Services -Operational Procedures Adult Mental Health Unit Canberra Health Services Procedure Emergency Response Plans – Code Blue Medical EmergencyCanberra Health Services Operational Procedure Transport of People Admitted to Mental Health, Justice Health and Drug and Alcohol Services (MHJHADS) Bed Based Units across the Canberra Hospital Campus Canberra Health Services Clinical Procedure Dhulwa Mental Health Unit (DMHU) - Use of Force by Authorised Health Practitioners, Security Officers, Court Security Officers and Escort Officers Canberra Health Services Operational Procedure Mental Health Act 2015 - Notification and Consultation Responsibilities in relation to the Public Advocate of the ACT Canberra Health Services Operational Procedure Death and DyingCanberra Health Services Operational Procedure Risk escalation and closure Canberra Health Services Operational Procedure Justice Health Services (JHS): Duress Alarm and Emergency Response Canberra Health Services Dhulwa Mental Health Unit: Security Policy and Procedures GuidelineACT Health Risk Management Guidelines Canberra Health Services - Emergency Department and Mental Health Interface [17/052]Canberra Health Services - Dhulwa Mental Health Unit (DMHU): Consumer Observation Canberra Health Services-Initial Management, Assessment and Intervention for People Vulnerable to Suicide Canberra Health Services - Dhulwa Mental Health Unit; Prohibited and Restricted Items and Items Requiring ApprovalBack to Table of ContentsReferencesWest London Mental Health Trust – Ligature Risk Reduction Policy January 2016.Rotherham, Doncaster and South Humber NHS Trust – Suicide Prevention Policy July 2016.South West Yorkshire Partnership NHS Foundation Trust Ligature and Suicide Risk: Environmental Assessment and Management Policy and Procedure November 2015. HYPERLINK \l "Contents" Back to Table of ContentsDefinition of Terms Clinical Risk AssessmentClinical Risk Assessment involves assessing the needs of the person receiving care and treatment based on static and dynamic risk factors inclusive of information about current mental state, history of mental illness, self-harm, substance and alcohol use, personal history, inter personal relationships, recent losses, trauma experienced in their lives, employment, housing issues, their family and social supports. The collation of information and analysis of this information assists in the identification of potential for self-harming behaviours through the identification of specific risk factors of relevance to an individual and the context in which they may occur.This process links historical information to current circumstances, to predict the possibility of future behaviour. Clinical Risk Assessment is a dynamic and ongoing process and should be reviewed on a regular basis, particularly after significant events and prior to changes in the person’s care and treatment plan.Clinical Risk FormulationClinical Risk Formulation is a process in which the clinical team determines how static and dynamic risk factors might be triggered or become acute. It identifies historical as well as presenting risks and describes predisposing, precipitating, perpetuating, protective and prognostic factors, as well as how these interact to produce risk. This will assist in the development of an individualised risk management plan as detailed within the person’s treatment and recovery plan. Risk formulation is informed by tools such as the SVAT.Clinical Risk ManagementClinical Risk Management is the development of one or more flexible strategies based on a thorough assessment with the aim of preventing an adverse event from occurring or minimising future harm. This also includes the development of an action plan which identifies strategies to be implemented and a date for review. It is also the process within the care planning framework that ensures that risks and vulnerabilities for each person are identified to manage and mitigate the risks identified through the clinical risk assessment.Floor Plan Risk MapA Floor Plan Risk Map is a visual representation of the workplace that identifies hazard areas. These areas are colour-coded as Red (high), Amber (medium) and Green (low) hazard risk. The Floor Plan Risk Map is developed in collaboration with the Ligature Risk and Ligature Point Audit conducted by the ADON and senior clinicians on the unit. The map is posted for staff to increase awareness for specific risks areas for each inpatient unit. An example of the colour-coded floor plan with corresponding risk zones can be viewed at Attachment 1.LigatureA ligature can be defined as anything a person can use to form into a noose or tied into a knot for the purpose of closing off the persons airway or blood vessels so as to self-strangulate either by suspending themselves fully or partially or using their body weight either fully or partially for the purpose of self-strangulation suicide by hanging. Note an effective ligature does not need to be able to entirely support a person’s full body weight to be effective. A ligature can also be used to wrap around any part of the body to constrict blood flow and compromise the circulation the point whereby the death of tissue can result.Ligature point or anchor pointA ligature point is any fixture or fitting which is load bearing either entirely or partially that can be used to tie or secure a cord, sheet or other tether that can then be used as a means of self-harm through self-strangulation and in extreme circumstances resulting in death by suicide.While it is commonly thought that a ligature point requires a minimum height the actual height needed can be as little as a few centimeters allowing the person to be able to slump forward or sideways from an almost seated or even prone or supine position. Such a point can also include an anchor at floor level such as a drain cover in a shower area.Anti-Ligature Fittings also known as Reduced Ligature Fittings and Collapsible FittingsThe term means any fitting that is designed in such a way as to prevent a ligature being attached to it or to collapse under load however this does not mean it is not a risk, it is a reduced risk.Some items of furniture and other devices manufactured to reduce risk are often called or referred to as anti-ligature.Anti-ligature fittings may not necessarily collapse under all loads and an anti-ligature or reduced ligature fitting does not automatically mean no risk.Anti-ligature devices are to be considered as reduced risk ligature devices. An anti-ligature fitting should cause a ligature to slip off, or the fitting itself should break away from its mount when placed under pressure of weight.When approved for use, anti-ligature curtain tracking for example should either be the collapsible magnetic type or an approved curtain rail track tested to break away at 15kg or less in accordance with manufacturer’s instructions.Operational Directors and ADONs should consult with Health Infrastructure and or the Business Support Services team to establish the full range of anti-ligature devices available on the market for any specific need.As part of unit management responsibility all anti/reduced ligature, devices/equipment must be regularly checked and tested as part of the ligature risk management procedure audit on a six monthly basis.Self-StrangulationAn attempt by an individual to restrict the flow of oxygen to a body part, to cause injury or death to self, by the application of a ligature.Unexpected DeathThis is a death that is not expected due to a terminal condition or physical illness.Back to Table of ContentsSearch Terms Ligature, ligature audit, ligature management, ligature points, self-harm, self-strangulation, suicide, hangingAttachmentsAttachment 1. Floor Plan Risk Map ExampleAttachment 2. Environmental Safety Check Inpatient Attachment 3. Ligature and Ligature Point Assessment Audit ChecklistAttachment 4. Canberra Health Services Risk Assessment TemplateAttachment 5. Risk Reduction Action PlansDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 29/01/2020Complete ReviewKaren Grace, ED MHJHADSCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS18/188Ligature Risk Management for Mental Health, Justice Health and Alcohol & Drug Services Inpatient Mental Health UnitsAttachment 1 – Floor Plan Risk Map Zoned ExampleLow Risk Medium Risk High Risk Attachment 2 – Enviornmental Safety CheckMental Health Justice Health and Alcohol & Drug ServicesEnvironmental Safety Check - Mental Health Inpatient Units Mental Health Justice Health and Alcohol & Drug Services (MHJHADS) aims to provide a safe and therapeutic environment that is as free as possible of items that could be used to self-harm or harm others. Due to human ingenuity and/or a lack of a technical solution, it is not possible for all potential items to be eliminated. While all risks cannot be completely eliminated, appropriate steps can and must be taken to reduce the impact of the risks identified in the clinical environment, so that it can be made safer working collaboratively with all involved each person’s treatment and care.Self-harm and death by suicide have been associated impulsive acts among people using the first means to hand without time for reflection, while other people have a well-planned and considered approach to deliberate self-harm and in extreme circumstances taking their own life. The most common methods of suicide in health facilities are hanging, suffocation, jumping from heights and overdosing on prescribed medication.The purpose of these checks is to observe for any items that could lead to self-harm and require diligent assessment and screening on a shift to shift basis.As well as ligatures and or ligature points these checks also assess for items such as sharp objects, non-prescription and illicit drugs, drug paraphernalia, cigarettes, tobacco, alcohol, cigarette lighters, knives, plastic bags, glass objects, razor blades and any tampering to fittings damage and changes in the immediate environment that could increase an opportunity for a person to self-harm and attempt suicideChecks are to be documented for each shift and used as part of the shift ISBAR handover. Any risks identified are to be notified to the Clinical Nurse Consultant (CNC) or the Nurse In Charge of Shift (NICS) and documented in Riskman as well as in the person’s medical record and the action taken to reduce the risk of harm.It is the responsibility of the Nurse In Charge of Shift to ensure that an Environmental Safety Check is completed on each Shift and reported on in the Shift Handover. Completed Checks are to be retained on the Unit for future use and Ligature Management Audit Purposes*Morning Shift:Afternoon Shift:Night Shift:Details of any risks found and who this was reported to:Riskman documentation completed: Yes / No / NA Riskman Number:Immediate Action taken to manage and mitigate risk:Requires CNC post shift follow-up: Yes / No If Yes CNC action taken by CNC/NICS Yes / No Maintenance request required: Yes / No If yes CNC action taken by CNC/NICS Yes / No Print Name and Designation Nurse completing Check:Date Environmental Safety Check Completed: / / Print Name of CNC or out of hours Nurse In Charge Shift:*Please note all checks are to include vigilance for Unit specific prohibited items and potential ligatures.Page 1 of 2Internal Areas: Date of Last Fire & Emergency Monthly Alarm Testing / /Please tickIf YES or If No or write N/A if not relevant to your work areaGeneral/social areas:1. Duress alarm systems are accessible and date of last working test has been recorded. 2. Bathrooms and toilets nurse call buttons tested and working each shift.3. Shared bathrooms remain unlocked 4. All interview, treatment, store rooms, cupboards, kitchens secured & locked5. Dirty utility room to remain unlocked6. Courtyard gates secured & locked when not in use7. Airlock & Fire Door to remain locked8. All furniture checked for prohibited items9. Social areas/courtyards clean, clear of excess clutter, infection control risks & property damage10. De-escalation & courtyard lock/unlock functions working11. No missing electrical/data cables from TVs, phones, washing machines & gym equipment12. Other issues identifiedAll Bedrooms and isolated areas are high risk for self-harm:1. All bedrooms visually scanned for prohibited items, property damage and tampering (apply search policy if searching is required) and appropriate action taken2. Visual scan for torn clothing, sheets, pillow cases, blankets, towels, clothing cords, stockings, cables, elastic bands, potential ligatures and appropriate action taken3. Bedrooms and ensuite nurse call bells and door alarms tested monthly and working4. Bathroom call bells checked each shift5. Bedrooms and ensuites clean and free from excess linen and clutter6. Other issues identifiedDe-escalation and Seclusion Suite: (AMHU/DMHU)1. De-escalation area is clean & clear of excess clutter (including courtyard)2. All access & egress doors are locked & secure3. Seclusion rooms & ensuites clean & ready for use (mattress, non-tear linen)4. Seclusion rooms internal doors checked & in working order (lock/unlock functions)5. Laundry rooms locked, clean & clear of linen bags – cleared by previous shift6. Other issues identifiedEnvironmental Safety Check - Mental Health Inpatient UnitsName of Unit: ____________________________________________________________Area of Unit where Check Conducted: _________________________________________Date: / / Prohibited Items (unless permitted based on risk assessment for items 8, 9, 10, 11)Please tickIf YES or If No or write N/A if not relevant to your work area1. No cigarettes/tobacco - including lighters, matches, e-cigarettes and vaporisers2. No drugs, alcohol and or related paraphernalia3. No sharp objects (including razors, scissors, cans, cutlery, glass or porcelain, bottles)4. No pornography or offensive materials5. No plastics – bin liners, plastic bags, bubble wrap 6. No heavy duty boots are worn7. No jewellery assessed as unsafe8. No phones, earphones/headphones, internet enabled electronic devices 9. No phone chargers/electronic device chargers and or cords10. No shoes laces, belts, cords, pantyhose 11. No other ligature material not otherwise previously specified12. Other issues identified*Please note all checks are to include vigilance for Unit specific prohibited items and potential ligatures. Page 2 of 2Attachment 3 – Ligature and Ligature Point Assessment Audit Tool Checklist (LLPAA)LLPAA completed by:Name:Position:ADONDate:Name:Position:CNCDate:Name:Position:HSRDate:Name:Position:Date:Name:Position:Date:Name:Position:Date:Name:Position:Date:LLPAAMental Health Inpatient Units??Date: ____________ Unit: _________________________________ Room Number: _________________LIGATURES - General / Social Areas ? Y = Yes, N= No, H= High, M = Medium, L = Low? ClothingY/NH/M/L Y/NH/M/LBelt/Cord (dressing gown)? Socks? Belt (trousers)? Stockings / Pantyhose? Bra (Straps)? Shoe / Boot Laces? Elastic Braces? Neck Ties? Cords (hoodies, trackpants, pyjamas)? Elastics in garments? Compliant with restricted items policy?????Other:?????Comments:???Personal EffectsY/NH/M/L Y/NH/M/LBaby Wipes ?Hair Bands? Bandages ?Headphone leads? Wash Bag Cords ?Game console leads? Elastic Bands ?Mobile / Electric chargers? Hand luggage straps ?Hairdryers? Compliant with restricted items policy??Walking sticks (can be utilised to hold a ligature)??Other:??Nail polish, makeup bottles, aerosol deodorant ??Comments:???Bedrooms / EnsuitesY/NH/M/L Y/NH/M/LPillow cases ? Towels ? Sheets ??Window Curtains??Blankets??Mattress covers??Other??Shower curtains??Comments: ???MiscellaneousY/NH/M/L Y/NH/M/LSticky tape? Knitting wool? Packaging tape / Packing string? Plastic aprons? Musical Instrument Strings? TV DVD cable / leads? Telephone cables? Window or door seals? Plastic bags? Garden vine runners? Cling wrap film??Garden hose??Other:? ?Garden twine / plastic ties? Comments:???Bedrooms / EnsuitesY/NH/M/L Y/NH/M/LBeds are of the approved ligature reduction type??High / Low electronic hospital beds used only with approval??Bed head / foot board / bed rails ? Shelves and shelf fittings??Bed (can the bed be up-ended)? Shower hose brackets / shower hoses??Clothes hooks / rail? Shower head and taps??Door closers? Shower rails and fittings??Door handles? Shower doors??Bed rails / cot sides ? Sink fittings (taps, plug)??Floor waste / drain cover??Towel rails??Door jams? Bathroom / shower ventilation extractor grill? Door hinges? Wall buffers / grab rails? Doors wardrobe? Wall mounted mirrors / pictures? Bathroom / Shower floor waste grills / drain covers? Window opening / locking points? Overhead bed lights? Window latches? Pipes plumbing and electrical? Window curtain rails? False ceilings? Radiators / Heaters and pipe work? Smoke detectors ? Radiator / Heater covers? Other:? Alarm detectors? ?? Bathroom / Shower curtain rails? Comments: ???Therapy /Recreation AreasY/NH/M/L Y/NH/M/LBath and Bathroom sinks, taps and hose fittings? Telephone Kiosks / Nooks? Light fittings? Fuse boxes and Electrical conduit feeds? False ceilings? Wall mounted pictures / Singage? Sink, taps and hose fittings? Sky lights? Laundry washing machine electrical flex? Laundry exhaust ventilation grill? Laundry floor waste/ drain covers??Computers / Audio visual equipment, cords / cables ??Other:??Floor power boxes?????Gym equipment and cords / cables??Comments:???Communal AreasY/NH/M/L Y/NH/M/LBath and Bathroom sink, taps and hose fittings? Telephone Kiosks? Light fittings? Wall mounted pictures? Laundry exhaust ventilation grill? Free standing furniture? Laundry sink, taps and hose fittings? TV and game console cables? Laundry washing machine electrical flex / cables / cords? TV wall mounting brackets? Laundry floor waste/ drain covers??False ceilings??Drop down ironing boards??Electric Irons (cable / flex)??Other: ??Sky lights??Comments:???LIGATURES – Seclusion Suites? ? ClothingY/NH/M/L Y/NH/M/LBelt / cord (dressing gown)? Socks? Belt (trousers)? Pantyhose / Stockings? Bra (Straps)? Shoe / Boot Laces? Elastic Braces? Neck Ties? Cords (hoodies, track pants, pyjamas)? Elastic in garments? Is the area compliant with restricted items policy?????Other:?????Comments:?????Seclusion Suites (Anti - Tear) Y/NH/M/L Y/NH/M/LPillow cases ? Towels ? Sheets ??Curtains??Blankets??Mattress covers, integrity intact??Other:?????Comments:???LIGATURE POINTS? ? Seclusions Suites Y/NH/M/L Y/NH/M/LNo bed in place? Shower head and taps? Clothes hooks / rail? Shower fittings (taps)? Door closers? Sink fittings (taps, plug holes)? Door handles? Collapsible towel / clothing hooks? Floor waste / drain cover??Shower ventilation extractor grill??Door jams - no purchase point? Wall mounted mirrors? Door hinges - no purchase point? Window opening / locking points? Bathroom / Shower floor waste grills/drain covers??Window latches? Overhead lights? Alarm detectors? Access to pipes and electrical cables? Bathroom / Shower exhaust ventilation grills? Smoke detectors ? ?? Other:?????Comments:???External AreasY/NH/M/L Y/NH/M/LAccess to unit roof structures? Garden trellis? Fire Escapes / Access ladders? Trees / tree limbs? Down pipes? Seating benches (can they be up-ended)? Light fittings? Courtyard garden gates? Fences??Lighting / illumination is sufficient??Other:?????Comments:?????Adjacent External AreasY/NH/M/L Y/NH/M/LAccess to adjacent heights and roof structures? Fences? Fire escapes / Access ladders? Tree limbs? Down pipes? Seating benches (can they be up-ended)? Light fittings? Multi story car parks? Perimeter fences?????Other:?????Comments:?????ENVIRONMENTAL ISSUESY/NH/M/L Y/NH/M/LAll staff have access to all keys to all rooms and locking mechanisms? Observation levels maintained by clinical staff? Electronic communications triggering group code alerts in place for all staff? Staff unimpeded access and egress by both manual key and electronic swipe / fob? Environmental Shift Checks completed on a shift by shift basis and used for ISBAR handovers? Open or unsecured storerooms/ linen stores? Lack of appropriate furniture? Overcrowded areas (People / Staff)? Lack of therapeutic activities? Poor Lighting? Lack of social facilities? Privacy for admitted persons? Line of sight blind spots? Privacy (Interview rooms)? Other: ?????Comments:?????CLINICAL MANAGEMENT ISSUESY/NH/M/L Y/NH/M/LBed pressures and acuity inform judgments about safe staffing levels? Previous risk assessments are utilised as well as alerts posted on Mhajicer? Quality Standards Audits and Reviews undertaken??Risk assessments are of a high standard??Staff communication on self-harm issues are a standing item on staff meeting agenda? Staff breaks are managed to ensure ARC system integrity is maintained? Handovers use ISBAR to address self-harm risk? Lack of allocated training time? Timely investigations of incidents conducted? Related Policies and Procedures followed? Staff have attended risk assessment training? Lack of support staff? ARC Observation and SVAT completion is adhered to? Risk Audits and Reviews undertaken? Learnings from self-harm incidents shared with staff??Regular clinical reviews occur for persons at risk of self-harm??Engagement with carers following day leave and overnight leave used to inform risk assessment??Regular clinical reviews occur for persons at risk of self-harm out of hours??Staff have access and receive updates on the latest Unit Ligature and Ligature Point Assessment and Action Plan??Persons returning from absent without leave are reviewed and the risk of self-harm assessed.??The Unit Floor Plan Risk Map is mounted in a prominent staff location and used as part of ISBAR during Clinical Handover??Ligature Risk Management and Ligature Cutter Use Procedures and training are included in the Orientation of new staff??Other:?????Comments:?????????Attachment 4 - Canberra Health Services Risk Assessment TemplateNotified byContact DetailsDivision/GroupProgram/Service/UnitDateSTEP 1 - ESTABLISH THE CONTEXT: Establishing the context takes into consideration the circumstances in which the team, division, group or organisation as a whole is operating. Things to consider may be: ? What objectives are to be achieved & how do they influence your team / project / program? ? How are you planning to achieve the objective & at what tier? ? When should it be finished, what resources are available & what other limitations exist? ? Who may be influenced; how and why? ? How do the objectives influence the division, the group, ACT Health, the public and other stakeholders? Risk Category - select only one option and delete others (Register can only select one)- refer to consequence tablePEOPLE (Staff, patients, Clients, contractors and Work Health and Safety)CLINICALPROPERTY AND SERVICES (Business Services and continuity)FINANCE AND PERFORMANCEBUSINESS SYSTEMS AND PROCESSESREPUTATIONENVIRONMENTINFORMATION / RECORDS MANAGEMENTSTEP 2 - RISK IDENTIFICATIONTitle (What is the risk?)Cause(Why is it a risk? Why can something go wrong? How does it happen?Consequence(What could happen if this risk eventuated?)STEP 3 - RISK ANALYSISCurrent controls (What is currently in place to reduce/mitigate the risk?)For example education, processes, investigation/data analysis, interventionsCurrent Level of Risk - The current level of risk with all existing controls taken into consideration but before any treatment or management. (Refer to Risk Matrix & apply objective measures when possible)Likelihood= Consequence=(Always use the most likely level of consequence not the most extreme. If it is possible to link the consequence wordings in the Risk Assessment Template to consequence definitions in the guidelines.) Risk Rating= Target Level of Risk -The level of risk that ACT Health would ideally and realistically like to reduce the rating to, for the risk to become acceptable. (Refer to Risk Matrix, What would the risk rating have to be for the risk to be deemed acceptable?)Likelihood= Consequence=Risk Rating= STEP 4 – RISK EVALUATIONThis risk is (select only one option and delete others): (Is this risk effectively managed/ controlled/ prevented from occurring?)A totally risk free environment is unrealistic. Risk evaluation should recognise that it is not usually possible to eliminate all risk and question whether the current level of risk is acceptable. Select only one option and delete the other:ACCEPTABLE - the risk, in context and in consideration of the tolerance that must be applied is acceptable & the risk can be closed. UNACCEPTABLE - Risk treatments should be considered. STEP 5 – RISK TREATMENTRISK TREATMENT ACTION PLAN Possible Risk Treatment Actions(Should be listed in order of priority)Advantages of this actionDisadvantages of this action Action Accepted (Yes/No) Position responsible for completing actionEstimated completion date Other comments Risk Management resources; including the Action and Response Timeframe, Risk Matrix and Consequence Definition and Likelihood Definition tables can be found on the Intranet Policy Register.Attachment 5 – Canberra Health Services Risk Reduction Action Plans1.0 Bathroom & Shower Fixtures & Fittings1.1 Bedroom Linen1.2 Door Fittings1.3 Permanent External Fixtures1.4 Personal Belongings1.5 Ceiling Fixtures1.6 Furniture1.7 Wall Fixtures & Fittings1.8 Curtain Fittings1.9 Temporary Construction Works1.10 Laundry1.11 Audio, Visual, Technological & Electrical Equipment1.12 Therapy Group Equipment1.13 Miscellaneous1.0 Risk Reduction and Action Plan (RRAP) - Bathroom & Shower Fixtures & FittingsUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.1 Risk Reduction and Action Plan (RRAP) – Bedroom LinenUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.2 Risk Reduction and Action Plan (RRAP) – Door FittingsUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.3 Risk Reduction and Action Plan (RRAP) – Permanent External FixturesUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.4 Risk Reduction and Action Plan (RRAP) – Personal BelongingsUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.5 Risk Reduction and Action Plan (RRAP) – Ceiling FixturesUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.6 Risk Reduction and Action Plan (RRAP) – FurnitureUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.7 Risk Reduction and Action Plan (RRAP) – Wall Fixtures & FittingsUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.8 Risk Reduction and Action Plan (RRAP) – Curtain FittingsUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.9 Risk Reduction and Action Plan (RRAP) – Temporary Construction WorksUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.10 Risk Reduction and Action Plan (RRAP) – LaundryUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.11 Risk Reduction and Action Plan (RRAP) – Audio, Visual, Technological & Electrical EquipmentUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.12 Risk Reduction and Action Plan (RRAP) – Therapy Group EquipmentUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate1.13 Risk Reduction and Action Plan (RRAP) – MiscellaneousUnit Risk No.Plan Developed from Ligature & Ligature Risk Assessment completed on: / / ImageNameDesignation / SignatureADONCNCWHSRRiskLocationRiskRating Description of Risk Action/s required(state if action requires immediate OD escalation)Action OfficerByWhenStatusHave risks requiring Operational Director escalation been escalated:YES / NOHave risks requiring Facilities Management escalation been escalated:YES / NOIf YES, date of notification: / / If YES, date of notification: / / Assistant Director of Nursing ConfirmationI can confirm that that a Ligature and Ligature Point Risk Assessment Audit has been completed by the Assessment Team and finalised with the Operational Director. The Risk Reduction Action Plan has identified appropriate actions arising from the completed Ligature and Ligature Point Risk Assessment and that these risks have been included on the Unit Risk Register. Risks have also been recorded on Riskman. The Unit HSR and Unit staff have been advised of the risk reduction strategies by the CNC and responsibilities assigned within the Risk Reduction Action Plan to manage and reduce the risk identified. Where further follow-up action or immediate escalation is required these items have been referred separately to the Operational Director.Submitted: / / Received / / ADON Operational DirectorSignedSignedDateDate ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download