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Document Title

Positive & Compassionate Management of Self-Harm Policy ( Inpatient settings)

Reference Number CNTW(C) 14

Lead Officer Ron Weddle – Deputy Director Positive & Safe

Author(s) (name and designation)

Ron Weddle – Deputy Director Positive & Safe Rod Bowles – Head of Positive & Safe

Ratified by Business Delivery Group

Date ratified Jan 2020

Implementation Date Jan 2020

Date of full implementation

Jan 2020

Review Date Jan 2023

Version number V02

Review and Amendment

Log

Version Type of change

Date Description of change

This policy supersedes:

Document Number Title

V 01.3 Positive & Compassionate Management of Self-Harm Policy ( Inpatient settings)

Positive & Compassionate Management of Self-Harm Policy

(Inpatient settings)

Section Contents Page No.

1 Introduction 1

2 Purpose 1

3 Duties, Accountability and Responsibilities 1

4 Definition of Terms 2

5 Procedure / Process 3

5.1 NICE Guideline Principles 3

5.2 Associated Mental Health Conditions 4

5.3 Patient Experience 4

5.4 Relatives or Carers 5

5.5 Consent 5

5.6 Mental Capacity 5

5.7 Biopsychosocial Assessment Following Self-Harm 6

5.8 Service Transitions 8

5.9 Staff Support 8

5.10 Care Planning 9

5.11 Positive Risk Taking 9

5.12 Discharge from Inpatient Services 10

5.13 Environmental Considerations 10

5.14 Reporting incidents of self-harm within inpatient services 11

6 Identification of Stakeholders 11

7 Training 11

8 Implementation 11

9 Equality and Diversity 12

10 Fair Blame 12

11 Patient Information Leaflets 12

12 Fraud and Corruption 12

13 Monitoring 12

14 Associated Documents 12

15 References 13

Standard Appendices – attached to policy

A Equality Analysis Screening Toolkit 14

B Training Checklist and Training Needs Analysis 16

C Audit Monitoring Tool 18

D Policy Notification Record Sheet - click here

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

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1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)14-Positive & Compassionate Management of Self-Harm Policy (Inpatient settings)-V02-Jan2020

1 Introduction

1.1 The act of self-harm is not an illness, but a way of managing a distressing state of mind or solving a particular life problem, it should alert clinicians to potential links to underlying problems, or disorders.

1.2 All of the clinical services that CNTW provide may potentially encounter people who have self-harmed, not only mental health services. Self-harm is an issue that has broad spectrum co-morbid diagnostic associations and all clinicians must be aware of the assessment and management guidelines in regards to their contact with this patient group.

1.3 NICE have issued: Clinical guideline No. 16 - the short term management of self-harm (NICE, 2004) followed by Clinical Guideline No. 133: Longer-term management of self-harm (NICE, 2011) and Quality Standard 34 (NICE June 2013). These guidelines form the core basis of this clinical policy.

2 Purpose

2.1 The purpose of this Policy is to provide a compassionate, flexible and reflective approach to the assessment and management of patients who present with previous or current self-harming behaviour within Inpatient Care Services including learning disability services. The Policy supports the implementation of NICE Clinical Guidelines 16, 133 and QS 34.

This guideline is relevant to patients 8 years and older who self-harm, who have been admitted to Inpatient Care Services.

3 Duties, Accountability and Responsibilities

The Policy relates to:

All staff within the Trust.

All patients in receipt of inpatient care and treatment from the Trust. It is relevant to all patients aged 8 years and older who self-harm and it addresses all health and social care professionals who come into contact with them. Where it refers to children and young people, this applies to all people who are between 8 and 18 years inclusive.

3.1 The Board of Directors

The Board of Directors are responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for the positive and compassionate management of self-harm.

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3.2 Chief Executive

The Board of Directors delegates to the Chief Executive the overall responsibility for ensuring the Trust employs a comprehensive strategy to support the management of risk, including clinical risks associated with patient care.

3.3 Associate Director / Clinical Managers

Associate Director and Clinical Managers are responsible for:

The dissemination of this Policy to their staff.

Identifying the training needs of their staff in relation to this Policy.

Releasing staff to attend for training.

Supporting staff who care for patients that Self-harm.

3.4 All Clinical Staff

All staff that have contact with people who have self-harmed should be adequately trained to assess mental capacity and to make decisions about when treatment and care can be given without consent.

Staff should give full information in a form that is accessible to the person and make all efforts necessary to allow someone who has self-harmed the opportunity to make decisions in a consensual and informed way.

Staff working with those who have self-harmed should understand when and how the Mental Health Act can be used to treat the physical consequences of self-harm.

Staff who have emergency contact with children and young people who have self-harmed must understand how issues of capacity and consent apply to this group.

The clinical staff must also be aware of other guidance, including:

The Mental Health Act (1983, amended 2007).

The Children Act (1989).

The Human Rights Act (1998, amended 2005).

The Mental Capacity Act (2005).

The Code of Practice (2015)

4 Definition of Terms

4.1 This policy sets forward the means that all services can contribute to the care of such individuals by providing a comprehensive and research based approach to care.

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4.2 This policy uses the following definition of self-harm:

“Any act which was intended to and may have resulted in actual or potential physical harm to the body. The most common types of self-harm in this context are cutting, burning, self-poisoning, swallowing or inserting objects, tying ligatures around the throat to limit breathing, not managing physical health conditions whilst having the capacity to do so, excessive consumption of alcohol or recreational drugs, starvation and severe self-neglect. Self-harm is often associated with a wide range of other symptoms and disorders, such as Borderline Personality Disorder, Impulse Control Disorders, Anxiety Disorders, Post-traumatic Stress Disorder, Major depressive disorder, Obsessive- Compulsive Disorder, Eating disorder (Anorexia, bulimia), Substance use disorders, Dissociative Disorders)”.

4.3 Suicide

“Self-harm acts may or may not be associated with an intention to complete suicide. Suicide intent should be assessed and discussed as a separate but related issue with the client. Sometimes, self-harm may be a way of preventing and managing thoughts or urges relating to suicide. It should not be assumed that any acts intending to but do not result in death are in any way failures, but the act and intentions always have a communicative message behind them”.

It has been generally accepted that the words “deliberate” or “intentional” to pre- fix self-harm and “commit” to pre-fix suicide have a negative effect and are not acceptable to patients and in view of this these words should be avoided by staff.

5 Procedure / Process

5.1 NICE Guideline Principles

People who self-harm need to be treated with the compassion, respect and understanding given to others who use the health service, taking account of their physical and emotional distress; their needs for support and information; and their right to be properly involved in clinical decision-making.

All healthcare professionals must be able to understand and assess mental capacity and ensure that someone who has self-harmed is given the opportunity to give properly informed consent before any treatment is initiated.

Everyone who has self-harmed should have a comprehensive assessment of needs and risk. The assessment outcome should form a collaboratively agreed plan of care with the patient which may include relatives or carers which should include a crisis and contingency plan.

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The key aims and objectives for short-term management of initial assessment and treatment of self-harm are defined by NICE (2004) as:

Rapid assessment of physical and psychological need, irrespective of the venue.

Effective engagement of the patient.

Effective measures to minimise pain and discomfort.

Timely initiation of treatment.

Harm reduction.

Rapid and supportive psychosocial interventions.

Prompt and effective psychological and psychiatric treatment where indicated.

An integrated and planned approach to the persons problems.

The expanded aims and objectives for long-term management of assessment and treatment of self-harm(NICE 2011) are:

Aim to develop a trusting, supportive and engaging relationship with them.

Be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health service and adopt a non-discriminatory approach.

Ensure that people are fully involved in decision-making about their treatment and care.

Aim to foster people’s autonomy and independence wherever possible.

Maintain continuity of therapeutic relationships wherever possible.

Ensure that information about episodes of self-harm is communicated sensitively to other team members.

Specific focus must then be provided to:

Biopsychosocial assessment and intervention.

Risk assessment and management.

Ensure person centred approaches are provided to tailor idiosyncratic care planning and reduce stigma.

5.2 Associated Mental Health Conditions

NICE recommend that psychological, pharmacological and psychosocial interventions for any associated conditions, must consider the most appropriate NICE guideline (examples would concern: NICE 90 – Depression, NICE 82 – Schizophrenia and NICE 78: Borderline Personality Disorder).

5.3 Patient Experience

People who have self-harmed should be treated with compassion, care, respect. In addition, healthcare professionals should take full account of the likely distress associated with self-harm and or the ceasing of such behaviours.

Providing treatment and care for people who have self-harmed is emotionally

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demanding and requires a high level of communication skills. Therefore it is imperative that all staff working in this field have regular clinical supervision to allow them the opportunity to reflect on their practice, as defined in the CNTW Clinical and Management Supervision Policy for clinical staff.

Wherever possible, people who have self-harmed should be offered the choice of male or female worker. When this is not possible, the reasons should be explained and recorded in the patient records.

When caring for people who repeatedly self-harm, staff should be aware that the individual’s reason for self-harming may be different on each occasion and therefore each episode needs to be treated in its own right.

Staff should involve people who self-harm in all discussions and decision making about their treatment and subsequent care. Staff should ensure that the person is provided with comprehensive information about the different treatment options available.

5.4 Relatives or Carers

People who self-harm should be allowed, if they wish, to be accompanied by a member of their family, friend or advocate during assessment and treatment.

Staff should also be ready to offer support and help to the relatives/carers of people who have self-harmed as they may also be experiencing high levels of distress and anxiety.

Staff should recognise and incorporate into the care plan the vital role carers and relatives can play in formulation, maintaining safety and promoting recovery.

5.5 Consent

Staff often face difficult decisions about whether they should intervene to provide treatment and care to a person who has self-harmed and then refuses help. Not only are these decisions difficult but they can provoke disagreements between staff who may interpret differently the legal framework that underpins them.

Consent may pertain to emergency treatment of self-harm (as defined by NICE, 2004), or may pertain to longer term care options provided by services. Assessment of Capacity and Consent should be assessed at each point of contact with patients whom self-harm.

5.6 Mental Capacity

The concept of mental capacity is central to determining whether treatment and care can be given to a person who refuses it. The Mental Capacity Act (2005) gives clear definition of capacity and “best interests”, how to measure and record decisions and will not be dealt with explicitly within this policy. Staff should refer to the Mental Capacity Act 2005 Code of Practice for guidance.

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A person may lack capacity to make the decision in question because of either long-term mental disability or because of temporary factors such as unconsciousness, confusion or the effects of fatigue, shock, pain, anxiety, anger, alcohol or drugs.

If a person has capacity to make the decision, then this decision must be respected; even if a refusal may risk permanent injury or death to that person.

Compulsory treatment can include medical and surgical treatment for the physical consequences of self-poisoning or self-injury if the self-poisoning or self-injury can be categorised as either the consequence of or a symptom of a patients mental disorder, providing it can be shown (and recorded) that the person lacks capacity and that the treatment satisfies the conditions of best interests as defined by the Mental Capacity Act (2005).

Treatment and care should take into account patients’ needs and preferences. People who self-harm should have the opportunity to make informed decisions about their care and treatment, in partnership with health and social care professionals. If patients do not have the capacity to make decisions, health and social care professionals should follow the guidance in the Code of Practice that accompanies the Mental Capacity Act.

If the patient is under 16, health and social care professionals should follow the guidelines in ‘Seeking consent: working with children’.

5.7 Biopsychosocial Assessment Following Self-Harm

It is the case that Health and Social Care policy advises those who present to services following an episode of self-harm should receive a Biopsychosocial assessment, the most important components of which are an assessment of needs and an assessment of risks and ultimately safety. Within the Trust there is approved risk assessment documentation in place, on which staff are to document the outcome of their assessment.

When undertaking a full Biopsychosocial assessment following an act of self- harm the following is to be included:

Social situation (including living arrangements, work and debt).

Personal relationships (including recent breakdown of significant relationships).

Recent life events and current difficulties

Psychiatric history and mental state examination, including any history of

previous self-harm and alcohol or drug use.

Protective factors.

Physical illness, learning disability, medication etc.

Spiritual and Religious needs.

Enduring psychological characteristics that are known to be associated with self-harm:

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Motivation for the act.

Long-term vulnerability factors.

Short-term vulnerability factors.

Precipitating factors.

The assessment needs to be clearly recorded in the patient’s clinical records and conveyed to others involved in the care of the individual.

In respect of patients who are not previously known to the service it is recognised that there may only be limited information available. However, it is the responsibility of the staff member completing the assessment to gain as much information as possible from the available sources to aid in the recognition and management of any risk of self-harm.

Whenever possible, any assessments made should be shared with the patient and carer to encourage joint clinical decision-making.

All people who have self-harmed should be assessed for risk, including the identification of the main clinical and demographic features known to be associated with the risk of further self-harm and/or suicide, in particular, depression, hopelessness and suicidal intent.

Patients who repeatedly self-harm should not be treated in any way that could infer punishment for their actions.

5.7.1 Psychological, Pharmacological and Psychosocial Interventions for the Management of Self-Harm

Following psychosocial assessment for people who have self-harmed, the decision about referral for further treatment and help should be based upon a comprehensive psychiatric, psychological and social assessment, including the assessment of risk and should not be determined solely on the basis of having self-harmed. A clear plan of care should then be developed (or amended).

Within Inpatient Care Service: Assessment of needs should include:

Skills, strengths and assets.

Coping strategies.

Physical health problems or disorders.

Social circumstances and problems.

Psychosocial and occupational functioning and vulnerabilities.

Recent and current life difficulties, including personal and financial problems.

The need for psychological intervention, social care and support, occupational rehabilitation and also drug treatment for any associated conditions.

The needs of any dependent children.

NICE recommend that drug treatment should not be offered as a specific intervention to reduce self-harm. They suggest that 3-12 sessions of

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psychological interventions be offered to patients dependent upon needs.

No specific psychotherapeutic model is defined in regards to this care delivery but it is suggested that, cognitive behavioural, psychodynamic or problem solving approaches are suitable.

5.8 Service Transitions

Transitions

This section should be read in conjunction with:-

Access to Acute Wards for CNTW Patients Policy- CNTW (C) 15

CYPS - LD Health Nurse Team – CNTW (C) 48

Transitions CC/CPA PGN – CNTW (C) 20

Self-harm research and NICE Guidance emphasise the risks posed when patients who self-harm undertake transitions within healthcare services. Core transition points within the services that CNTW provide include:

Primary Care to Specialist Care Services.

CYPS or other Children’s Services or to Adult Care Services.

Adult to Older Adult Services.

Inpatient to Community health Services.

Community to Inpatient Services.

Transition from any Service.

Risk assessment, risk management, therapeutic support planning and crisis and contingency planning must be considered in preparation for any transition for a patient with a history of or current self-harm. This is specifically essential to minimise risk and maintain safety proactively intervening with patients who may resort to self-harm at periods of high stress. Substance Misuse

Substance misuse is strongly associated with a range of mental health problems including self-harm. It is important that assessments identify this dual diagnosis and services plan appropriately.

Mental health services should consider referral to substance misuse services or seek advice from substance misuse services where they identify significant substance misuse in self harming patients

5.9 Staff Support

Dealing with those that self-harm is often stressful and distressing. Consequently, staff need appropriate supervision and support arrangements, (see Supervision Clinical Policy CNTW (C) 31.)

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Staff also need to recognise:

Addictive / compulsive nature of self-harm and be prepared to discuss this with the client.

Understand that patients who self-harm may very quickly become distressed or volatile during consultations and be able to support and manage these types of encounters.

Staff members and services involved with people who self-harm need to adopt a consistent approach across all disciplines involved in care, with clear, unambiguous care plans that are negotiated collaboratively with the patient and carer where appropriate to ensure maximum involvement and ownership. Complex case discussions and multi-disciplinary across agency working is therefore essential to support patients and ensure consistency.

In the inpatient setting, engagement and observation of the patient may be required. It is important for staff to recognise that this is a therapeutic intervention that should involve the patient. It should not be carried out in a way that could be considered punitive (Engagement and Observation Policy (C) 19).

5.10 Care Planning

The assessment and management of self-harm is an on-going part of the care planning process which is incorporated into the Trust Care Programme Approach (CPA) Policy for patients engaged within services. Ongoing regular evaluation of the plan should also include the patient and cares actively within the process.

For all patients who have been assessed as a risk of self-harming behaviour there will be an agreed management plan in place as to how this behaviour is to be managed in both the short and long term.

When developing this management plan consideration will be given to any advance directives which the patient may have in place.

Prior to the discharge of any patient from inpatient services there should be a pre-discharge CPA meeting held at which a discharge care plan will be agreed which will include contingency and crisis plans ( Care Coordination –CPA policy CNTW (C) 20) .

Crisis planning must be considered for all patients who self-harm. These must consider self-management strategies and how to access services if self- management fails. Crisis plans should be in place for all patients receiving services and should be considered within Wellness Recovery Action Planning on discharge where appropriate across all inpatient services.

5.11 Positive Risk Taking

A positive risk-taking approach is person centered and focuses on developing a patient’s strengths and supporting them to take a higher level of control over the situation.

In relation to patients who self-harm positive risk taking could involve effective

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use of the Trust engagement and observation policy or making a decision to not admit someone to an inpatient ward, or to discharge a patient who has had recent episodes of self-harm, because the risks of them being on a ward (eg. an escalation in their self-harming) outweigh the risks posed if they are treated in the community. In these circumstances effective management of the short term risks could lead to longer term gains for the patient.

Due to the potential risks of such an approach any decision to proceed must be based on the patient having the capacity to engage in the agreed plan of care and a detailed knowledge of:

The patients past history.

Their current self-harming behaviour.

The patient’s ability to develop alternative coping mechanisms.

In such cases the multidisciplinary team (including CNTW and non-CNTW services), patient and their carers (subject to consent) should be involved in the decision and in agreement with the plan of care.

All discussion which take place is to be documented in the clinical records along with the details of who was involved. This also includes documenting any phone discussions which take place.

5.12 Discharge from Inpatient Services

When a patient who self-harms is discharged from the inpatient services, staff are to follow the local discharge procedures see Policy (Care Coordination – CPA CNTW (C) 20)

5.13 Environmental Considerations

Whilst it is difficult to eliminate all risks from inpatient areas, the Trust endeavours to minimise the potential risk of patients harming themselves whilst receiving inpatient care by having in place the following measures within high risk areas.

Clinical Environment Risk Assessment (CERA).

Anti-ligature considerations in environmental assessments.

Collapsible curtain tracking.

Non barricade doors.

Observation panels in doors.

Controlled access/egress systems.

All staff are aware of individual and environmental risks associated with the ward environment and or the patient.

These measures are also supported by policies previously mentioned and the following Trust Policies and Procedures:

Clinical Risk Strategy and associated PGN’s.

Young People requiring admission to hospital CNTW (C) 08.

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Search Policy CNTW (C) 11

5.14 Reporting incidents of self-harm within inpatient services

Within inpatient services all incidents of self-harm are to be reported using the Trusts electronic reporting system. The information provided on these reports will assist the clinical team in:

Reviewing the risk management plan.

Identifying any triggers to the self-harming behaviour.

Identifying any trends in relation to self-harming behaviour.

Reviewing ward and team practice.

6 Identification of stakeholders

North Locality Care Group

Central Locality Care Group

South Locality Care Group

North Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

7 Training implications

There are no specific staff training needs identified in relation to the use of this policy. Staff will be made aware of the policy contents in the following ways:

The issue of the policy will be included in the Trust Weekly News Bulletin, discussion at Team Ward meetings.

Use of the policy during clinical supervision if staff have any issues/concerns re a service user which fall under this policy.

8 Implementation

How the policy will be implemented and if appropriate an action plan to achieve this.

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9 Equality and Diversity

In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. (See Appendix A)

10 Fair Blame

The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

11 Patient Information Leaflets

Any information given to patients needs to be in an accessible format, accurate and ‘branded’ correctly. Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) follows the process around production of this information as outline in the Trust’s, CNTW(O)03 – Accessible Information for Patients, Carers and Public Policy.

Patient Information leaflets will be reviewed every 3 years with the exception of those documents which are reviewed on an annual basis. However, should there be any changes in legislation or practice; all documents will be reviewed immediately irrespective of review date.

12 Fraud and Corruption

In accordance with the Trust’s policy CNTW(O)23 – Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

13 Monitoring

A short statement about key elements within the policy that require monitoring and/or audit; referenced to Appendix C

14 Associated documents

Any resources used to formulate the document must be acknowledged within this section, this may include other CNTW Trust policies that provide associated guidance. Polices should be referenced by policy number and full title e.g. CNTW(O)18 Impact assessment - A reference guide

Clinical Policies should always consider the links to Safeguarding

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15 References

Clinical guideline No. 16 - the short term management of self-harm (NICE, 2004)

Clinical Guideline No. 133: Longer-term management of self-harm (NICE, 2011)

Quality Standard 34 (NICE June 2013)

NICE 90 – Depression,

NICE 82 – Schizophrenia and

NICE 78: Borderline Personality Disorder

The Mental Health Act (1983, amended 2007).

The Children Act (1989).

The Human Rights Act (1998, amended 2005).

The Mental Capacity Act (2005).

The Code of Practice (2015)

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C

o

n

Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Chris Rowlands Equality and Diversity Lead

Jan 2020 Jan 2023 Trustwide

Policy to be analysed Is this policy new or existing?

Positive and Compassionate Management of Self- Harm Policy (Inpatient Setting)

V02

What are the intended outcomes of this work? Include outline of objectives and function aims

Improved understanding of self harm within in patient settings

Who will be affected? e.g. staff, service users, carers, wider public etc

All of the above

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Consider and detail any evidence on attitudinal, physical and social barriers.

Sex Consider and detail any evidence on men and women (potential to link to carers below).

Race Consider and detail any evidence on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers.

Age Consider and detail any evidence across age ranges on old and younger people. This can include safeguarding, consent and child welfare.

Gender reassignment

(including transgender)

Consider and detail any evidence on transgender and transsexual people. This can include issues such as privacy of data and harassment.

Sexual orientation. Consider and detail any evidence on heterosexual people as well as lesbian, gay and bi-sexual people

Religion or belief Consider and detail any evidence on people with different religions, beliefs or no belief.

Marriage and Civil Partnership

Consider and detail any evidence on working arrangements

Pregnancy and maternity Consider and detail any evidence on working arrangements, part-time working, infant caring responsibilities.

Carers Consider and detail any evidence on part-time working, shift-patterns, general caring responsibilities.

Other identified groups Consider and detail other groups experiencing disadvantage and barriers to access.

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Consul

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard Trust Policy process

How have you engaged stakeholders in testing the policy or programme proposals?


For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:


Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

There is no anticipated negative impact

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

It is anticipated that the policy will support effective understanding of self harm and therefore reduce any potential for discrimination

Advance equality of opportunity See above

Promote good relations between groups See above

What is the overall impact? To improve staff’s understanding of self harm and to reduce ineffective strategies regarding self harm.

Addressing the impact on equalities None anticipated

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Chris Rowlands Date: Jan 2020

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Appendix B Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

New

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

N/A

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Solutions etc.

Please identify the risks if training does not occur.

There are no specific staff training needs identified in relation to the use of this policy. Staff will be made aware of the policy contents in the following ways:

The issue of the policy will be included in the Trust Weekly News Bulletin, discussion at Team Ward meetings.


Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

N/A

Is there a staff group that should be prioritised for this training / awareness?

N/A

Please outline how the training will be delivered. Include who will deliver it and by what method.

The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned

Local Induction Training

Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session

E Learning

N/A

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

N/A

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of training

Duration of

Training

Frequency of Training


There are no specific staff training needs identified in relation to the use of this policy.

N/A N/A

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y

Statement

Monitoring Tool

Appendix C

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

Positive & Compassionate Management of Self-Harm Policy- Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any Associate Action plan will be reported to implemented and monitored; (this will usually be via the relevant Governance Group).

1. Each Locality Group will establish their own monitoring arrangements, to ensure compliance or otherwise, with the standards outlined in the Policy.

Ongoing within appropriate Quality and assurance programmes.

The Positive and Safe Implementation Group.

2.

3.

4.

5.

6.

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.