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Controlled circulation not for publication 1 HBN 03-03 Patient safety and the prevention of self-harm in healthcare environments February 2020 Health Building Note 03-03: Patient safety and the prevention of self-harm in healthcare environments [Provisional title – comments requested. This is a working draft of a new Technical Standard prepared for technical engagement and wider consultation February 2020] Version 1.0 February 2020
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1 HBN 03-03 Patient safety and the prevention of self-harm in healthcare environments February 2020
Health Building Note 03-03:
Patient safety and the
prevention of self-harm in
healthcare environments
[Provisional title – comments requested.
This is a working draft of a new Technical Standard prepared for technical engagement and wider
consultation February 2020]
Version 1.0 February 2020
Controlled circulation not for publication
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HBN 03-03 Patient safety and the prevention of self-harm in healthcare environments February 2020
Version
history/revisions
Date Author Changes
Version 1.0 14 February 2020 Jenny Gill, Sue Holding Created skeleton draft from the structure of the 2018 scoping
document (option 2). Draft developed incorporating comments from
the working group meeting and review of draft by policy lead (Michael
Rope).
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HBN 03-03 Patient safety and the prevention of self-harm in healthcare environments February 2020
Introduction to NHS Technical
Standards
Prelim text to be inserted when finalised
Health Building Notes (HBNs)
Health Building Notes give best practice guidance on the design and planning of new healthcare
buildings and on the adaptation or extension of existing facilities. The Health Building Notes have
been organised into a suite of core subjects. Care-group-based Health Building Notes provide
information about a specific care group or pathway but cross-refer to Health Building Notes on
generic (clinical) activities or support systems as appropriate. Core subjects are subdivided into
specific topics and classified by a two-digit suffix (-01, -02 etc), and may be further subdivided into
Supplements A, B etc. They provide information to support the briefing and design processes for
individual projects in the NHS building programme.
Where there is an opportunity to build a new department/ facility or refurbish an existing one, it
provides the opportunity to design a modern department that inspires and intuitively supports safe,
effective and efficient patient care, with the flexibility to meet future developments in healthcare,
technology and patient needs.
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HBN 03-03 Patient safety and the prevention of self-harm in healthcare environments February 2020
Contents
Introduction to NHS Technical Standards ............................................................................................... 3
Health Building Notes (HBNs) ............................................................................................................. 3
Glossary ................................................................................................................................................... 6
Terminology ............................................................................................................................................ 7
Executive summary ................................................................................................................................. 8
Acknowledgements ................................................................................................................................. 8
1.0 Introduction to HBN 03-03 ................................................................................................................ 9
Policy and regulatory overview........................................................................................................... 9
Patient safety alerts .......................................................................................................................... 10
Background ....................................................................................................................................... 10
2.0 Scope and status of this document ................................................................................................. 14
Ensuring that building component are fit for purpose ..................................................................... 14
Therapeutic environment versus safety ........................................................................................... 15
3.0 General principles ........................................................................................................................... 16
4.0 Design guidance .............................................................................................................................. 17
Ligature anchor points ...................................................................................................................... 18
Doors ............................................................................................................................................. 18
Windows ....................................................................................................................................... 18
Tracking ......................................................................................................................................... 19
Height ............................................................................................................................................ 19
Lockable Cupboards and rooms .................................................................................................... 20
Observation ....................................................................................................................................... 20
Aggression and violence ................................................................................................................... 21
Infection control ............................................................................................................................... 21
Cleaning and hygiene .................................................................................................................... 21
Accident and emergency dedicated facilities ................................................................................... 22
Mixed sex accommodation ............................................................................................................... 23
Access to internet services................................................................................................................ 23
5.0 Risk assessment ........................................................................................................................ 25
6.0 Fitting and maintenance ................................................................................................................. 28
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Fitting ................................................................................................................................................ 28
Maintenance ..................................................................................................................................... 28
Appendices ............................................................................................................................................ 29
References ............................................................................................................................................ 30
ACTS AND REGULATIONS .................................................................................................................. 30
TECHNICAL STANDARDS ................................................................................................................... 30
BRITISH STANDARDS ......................................................................................................................... 30
End notes .............................................................................................................................................. 31
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Glossary 1
A&E Accident and Emergency BS British Standard BRE Building Research Establishment CAMHS Child and Adolescent Mental Health Services CAS Central Alerting System CCGs Clinical commissioning groups CCTV Closed circuit television CDM Construction, Design and Management COSSH Control of substances hazardous to health CQC Care Quality Commission DiMHN Design in Mental Health Network DQI Design Quality Indicator EFA Estates and Facilities alerts FGI Facilities Guidelines Institute GIRFT Getting It Right First Time programme HSE Health and Safety Executive HTM Health Technical Memoranda HBN Health Building Note ISO International Organisation for Standardisation MHFAE Mental Health First Aid England MHSIP Mental Health Safety Improvement Programme NCISH The National Confidential Inquiry into Suicide and Safety in Mental Health NCCMH Collaborating Centre for Mental Health NHS National Health Service PAS Publicly Available Specification PLAN Psychiatric Liaison Accreditation Network PSIRF Patient Safety Response Framework RCN Royal College of Nursing RCPsych Royal College of Psychiatrists WHO World Health Organisation
2
3
4
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Terminology 5
In this HBN the following definitions apply: 6
7
Patient safety The avoidance of unintended or unexpected harm occurring to patients during treatment.
Ligature anchor point Anything that can be used (usually a fixture or fitting) to attach an item such as cord, rope or other material for the purpose of self-strangulation.
Ligature An iem which binds or ties and can be used to attach to a ligature anchor point.
Self-harm Intentional damages or injury by a person to their body.
Reduced ligature Fixture or fitting designed to reduce the opportunity to attach a ligature or which will not hold anything over a specified weight. (Also commonly referred to by manufacturers and others as “anti-ligature.)
Private space Single bedrooms/en-suites, rooms where observation is intermittent.
Semi-public space Areas such as lounges where observation is generally ongoing.
Public space Areas of a facility accessible by the general public
8
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Executive summary 9
This guidance is a new topic in the Technical Standards series of Health Building Notes. It is 10
applicable to all sectors with mental health facilities whether NHS, independent or third sector. 11
Whilst it is principally for use for in-patient mental health facilities, there may be other areas in both 12
primary and acute healthcare settings which are specially adapted for mental health provision or 13
where it is beneficial to have an understanding of how the environment can be designed to reduce 14
the likelihood of opportunities to self-harm. 15
It is intended for use by all those involved in the development of new or refurbishment of existing 16
healthcare facilities (whether mental health or not) and also for people working in those 17
environments. It will raise awareness of the issues to be tackled when balancing the needs of staff, 18
visitors and patients – taking care of patients’ therapeutic needs while providing a safe environment 19
for them. 20
21
22
23
24
25
Acknowledgements 26
[To be inserted] 27
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1.0 Introduction to HBN 03-03 28
1.1 This guidance is a new topic in the Technical Standards series of Health Building Notes. It is 29 applicable to all sectors with mental health facilities whether NHS, independent or third 30 sector. Whilst this is principally for use in in-patient mental health facilities, there may be 31 other areas in both primary and acute healthcare settings which are specially adapted for 32 mental health provision or where it is beneficial to have an understanding of how the 33 environment can be designed to reduce the likelihood of opportunities to self-harm. 34
1.2 It is intended for use by all those involved in the development of new or refurbishment of 35 existing healthcare facilities (whether mental health or not) and also for people working in 36 those environments. It will raise awareness of the issues to be tackled when balancing the 37 needs of staff, visitors and patients – taking care of patients’ therapeutic needs while 38 providing a safe environment for them. 39
1.3 The emphasis of this document is on safety and prevention of self-harm – keeping people safe 40 within the built environment. Whilst the focus is on patient safety and self-harm, many of the 41 things highlighted in the document will help to keep visitors, professionals and others safe. 42
1.4 This is not a comprehensive list of dos and don’ts on patient safety, the aim is to raise the level 43 of knowledge and understanding of various aspects of self-harm and keeping patients safe. It 44 is important to have realistic expectations about what can be achieved within and by the 45 environment. 46
1.5 It is not possible for any room to be totally ligature free and it should not be anticipated that 47 a room where ligature anchor points have been reduced to a minimum is totally safe. Best 48 practice together with local safety and operational policies should always be adhered to. 49
1.6 Many products are labelled anti-ligature which can be misleading as this does not mean that 50 they are completely ligature free, a more accurate way of describing them would be reduced 51 ligature and this term will be used throughout this document. 52
53
Policy and regulatory overview 54
55
1.7 See Appendix 1 for a policy checklist compiled for this HBN. The policy and regulatory context 56 includes the following: 57
The Health and Social Care Act 2008 - Code of Practice on the prevention and control of 58
infections and related guidance Infection control: 59
https://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents 60
Care Quality Commission (CQC): 61
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-62
providers-managers 63
Never events: 64
https://improvement.nhs.uk/documents/2266/Never_Events_list_2018_FINAL_v5.pdf 65
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Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12: 66
https://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents 67
68
Patient safety alerts 69
70
1.8 It can be helpful for commissioners and design teams to view recent patient safety alerts in 71 order to inform the developing design. These are available on the Central Alerting System 72 and include Estates and Facilities alerts. These can be accessed at: 73
England: 74
https://www.cas.mhra.gov.uk/Home.aspx 75
Wales: 76
http://www.nwssp.wales.nhs.uk/estates-and-facilities-alerts-efa- 77
Northern Ireland: 78
https://www.health-ni.gov.uk/articles/niaic-estates-and-facilities-alerts 79
Scotland: 80
http://www.hfs.scot.nhs.uk/publications-/iric-safety-alerts/?show=20&set=2 81
82
1.9 A new Patient Safety Response Framework (PSIRF) is being developed to replace the current 83 Serious Incident Framework and is due to roll out in 2021. More information is available on 84 the NHS Improvement websitei 85
1.10 Information on patient safety alerts can be found at: 86
https://improvement.nhs.uk/resources/patient-safety-alerts/. 87
There is also a useful video on the NHS National Patient Safety Alerting System on the site. 88
89
Background 90
91
1.11 The World Health Organisation (WHO) defines patient safety as “the absence of preventable 92 harm to a patient and reduction of risk of unnecessary harm associated with health care to an 93 acceptable minimum”.ii 94
1.12 The National Confidential Inquiry Suicide and Safety in Mental Health (NCISH) - Annual Report 95 2018iii reported that the downward trend of reductions in suicide by people in in-patient care 96 had slowed from 31% in 2006-2010 to 11% in 2011-2016iv. The Annual Report for 2019v 97 reported a continued reduction in 2017. 98
1.13 The report’s clinical messages identify nine key areas where measures could be taken to 99 reduce suicide risk. Amongst these, those which are particularly about the environment are: 100
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Safer wards, including the removal of low-lying ligature points. 101
Internet use: ensuring staff are aware of suicide methods associated with and as a result 102 of information available online. This is a risk not only for younger age groups but 103 potentially for all age groups. 104
1.14 The Care Quality Commission (CQC) has, amongst other responsibilities, that of monitoring 105 and inspecting health and care services to see that they are safe, effective, caring, responsive 106 and well-led. The publication ‘Opening the door to change NHS safety culture and the need 107 for transformation,’ December 2018vi identified safety culture as a key concern from their 108 inspections of NHS Trusts. 109
1.15 In the State of Health care and adult social care in England 2018/19vii the importance of wards 110 including the layout, the safety of fixtures and fittings and the provision of same-sex 111 accommodation and single en-suite bedrooms was emphasised for mental health facilities in 112 the strengthening of regulations for mental health inpatient care. 113
1.16 The NHS Patient Safety Strategy Safer culture, safer systems, safer patients - July 2019 viii 114 states: “Patient safety is about maximising the things that go right and minimising the things 115 that go wrong for people experiencing healthcare.” 116
1.17 In terms of self-harm, Mental Health First Aid England (MHFAE)ix reports that the UK has one 117 of the highest rates in Europe. 118
1.18 The NHSx definition of self-harm is: 119
“Self-harm is when somebody intentionally damages or injures their body. It’s usually a way 120 of coping with or expressing overwhelming emotional distress: It also indicates that more than 121 half of those people who die by suicide have a history of self-harm. Self-harm is often not a 122 failed suicide attempt, but it can lead to unintentional suicide.” 123
124
125
Self-harm is usually a way of coping with or expressing overwhelming emotional distress 126
127
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1.15 Further information for medical professionals on Suicide Risk Assessment and Threats of 128 Suicide is available on Patient Infoxi 129
1.16 The Office for National Statistics: Statistical bulletin Suicides in the UK: 2018xii registrations 130 report that the most common method of suicide in the UK was by hanging. 131
1.17 The National patient safety incident report of 25 September 2019xiii identifies the proportion 132 of incidents across England (from April 2018 to September 2019) including those of self-harm 133 which is identified at 5% overall. However, in mental health services this rises to 28% of all 134 incidents (see table below). 135
136
137
138
1.18 Reference should be made to the section of this document on ligature for more detailed 139 information on ligature points, ligatures and angles for ligature, the Design in Mental Health 140 Network (DiMHN) and British Research Establishment (BRE) document “Informed Choices 141 Testing Guidance for Products in Mental Health Facilities" (2020)xiv. 142
1.19 Guidance is available to assist in working to reduce the occurrence of hanging in the 143 community setting through Public Health England1 who offer resources and assistance for 144 local authorities, public healthcare professionals, police forces, and others to prevent suicides 145 in their areas. 146
1.20 This document will focus primarily on the mental health in-patient environment, but some of 147 the information contained within it may translate to the acute non-mental health and 148 community settings and be of assistance to all involved in patient safety with regard to self-149 harm. 150
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151
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2.0 Scope and status of this document 152
2.1 This guidance is applicable to all sectors with mental health facilities whether NHS, 153 independent or third sector. Whilst this is principally for use in in-patient mental health 154 facilities, there may be other areas in both primary and acute healthcare settings which are 155 specially adapted for mental health provision or where it is beneficial to have an 156 understanding of how the environment can be designed to reduce the likelihood of 157 opportunities to self-harm. 158
2.2 Whilst reducing episodes of self-harm by, for example, limiting ligature anchor points is the 159 main focus in the mental health in-patient environment for this document, this is not the only 160 means of self-harm. There are many others typically encountered, which include: 161
Poisoning 162
Hitting or burning 163
Cutting 164
2.3 The CQC “Brief guide for Inspection teams – Ligature points” gives context and requirements 165 for inspection teamsxv. This document also states: 166
“There are no specific requirements over the management of ligature risks in hospital facilities 167 outside of the mental health sector, although services that may deal with mentally disordered 168 patients (such as A&E departments) should be aware of the risks and have management 169 plans to meet them.” 170
2.4 Whilst the focus of the document is on mental health facilities it is helpful for staff in non-171 mental health services (particularly A&E, where patients who have self-harmed, may first 172 attend) to be aware of what a ligature point entails and how it may be used. This can be 173 helpful to inform observations and to understand risk and thus to mitigate against possible 174 self-harm. 175
2.5 The DiMHN/BRE document “Informed Choices Testing Guidance for Products in Mental Health 176 Facilities" (2020) gives useful information on possible anchor points, tools potentially available 177 to use as a ligature and other information to further knowledge. 178
179
Ensuring that building component are fit for 180
purpose 181
182
2.6 This HBN was prepared for publication in March 2020. The main sources of data used in the 183 preparation of this HBN are listed in the references section. It is essential that readers ensure 184 that they use the latest or new editions of all relevant references, including building 185 legislation, British Standards and any other standards and guidance, which may post-date the 186 publication of this document. 187
2.7 The content of this HBN does not diminish either the manufacturer’s responsibility for fitness 188 for purpose of products or the design team’s responsibility for selection and application of 189 products to meet project requirements. 190
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2.8 Design teams are reminded of their obligations under the Construction, Design and 191 Management (CDM) Regulations 2015xvi to ensure safe construction, maintenance and repair. 192
2.9 First preference should be given to products and services from sources which have been 193 registered under ISO 9000 quality assurance system procedures or other certification 194 schemes. 195
2.10 Suppliers offering products other than to British Standards should provide evidence to show 196 that their products are at least equal to such standards. 197
198
Therapeutic environment versus safety 199
200
Patient safety will need to be balanced with the therapeutic environment and patient satisfaction 201
2.11 The environment can have a negative or positive effect on us all, it can assist or hinder 202 recovery. It is therefore very important to ensure that facilities have a positive environment. 203 This is equally important for the staff who work there as for the patients. It can be challenging 204 on occasions to balance the therapeutic environment against the requirements for safety. 205
2.12 The Design in Mental Health Network has issued a series of books entitled ‘Design with People 206 in Mind.’xvii The first of these covers general design and contains researched information on 207 the characteristics required within the mental health environment to create a therapeutic and 208 safe environment. 209
2.13 “Whilst spatial tensions exist between the mitigation of risk and the creation of de-210 institutionalised environments, the literature suggests that facilitating a balance between 211 achieving the required levels of safety and creating homely non-sterile spaces should be a key 212 consideration in mental healthcare design” (Shepley et al., 2016)xviii. 213
2.14 A guest blog by Dr Colin Dale, Chief Executive, Caring Solutions (UK) Ltd on the Star wardsxix 214 website offers some useful suggestions on “ensuring the safety of service users, staff and 215 visitors” and summarises: 216
“A safe environment for care should be seen as a partnership between service users, their 217 families and staff. What units should strive for is a balance between the measures available 218 to ensure that the environment is as least restrictive as possible whilst offering appropriate 219 levels of safety and security for all.” 220
2.15 HBN 00-01 – General Design Guidance for Healthcare buildings (2014)xx offers guidance for 221 creating a therapeutic and safe environment. 222
223
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3.0 General principles 224
“Patient safety is the absence of preventable harm to a patient and reduction of risk of unnecessary 225 harm associated with health care to an acceptable minimum. An acceptable minimum refers to the 226
collective notions of given current knowledge, resources available and the context in which care was 227 delivered weighed against the risk of non-treatment or other treatment.” 228
229 The World Health Organisationxxi 230
231
3.1 Patient safety is the basis of this HBN and is part of the culture of the NHS. NHS 232 Improvementxxii define it as: “Patient safety is the avoidance of unintended or unexpected 233 harm to people during the provision of health care.” 234
3.2 All providers of care who are inspected by the CQC must comply with regulation 12 of the 235 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014xxiii the intention of 236 which is: “to prevent people from receiving unsafe care and treatment and prevent avoidable 237 harm or risk of harm.” This includes ensuring that the environment in which people are 238 treated is as safe as possible for their needs. 239
3.3 Several quality improvement programmes around mental health patient safety are run by the 240 National Collaborating Centre for Mental Health (NCCMH) (a collaboration between the Royal 241 College of Psychiatrists and University College, London). The Mental Health Safety 242 Improvement Programme (MHSIP) established by NHSi in partnership with the CQC has an 243 overall aim that every NHS Trust providing core mental health services in England should 244 understand their safety priorities and begin to work towards making measurable 245 improvements in at least one key area of mental health safety. 246
3.4 The NHS Patient Safety Strategyxxiv describes how the NHS will continuously improve patient 247 safety, building on the foundations of a safer culture and safer systems. 248
3.5 The Royal College of Nursingxxv describes patient safety as an essential part of nursing care 249 and the Royal College of Physiciansxxvi state: “ We believe there must be a shift in the NHS 250 from a place where there is an assumption that care is safe until something goes wrong, to a 251 team working environment that minimises the chances of harm, builds in safety to daily 252 practice, and is open, supportive and facilitates learning when error occurs”. 253
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4.0 Design guidance 254
4.1 Good design requires good dialogue. It should be based on informed decisions, best practice 255 and good understanding of the environment. The client is always the decision maker and it 256 is important that the designer identify potential safety issues from their perspective, as well 257 as understanding the client’s issues and concerns, and work with the client to ensure that the 258 environment is as safe as possible. It is important to ensure that all stakeholders, staff, 259 patients, visitors and others who may use the building, are involved in the decision making. 260
4.2 NHS Englandxxvii publication Patient Engagement in Patient Safety: A Framework for the NHS 261 will assist in the engagement process as the design process takes place. 262
4.3 To assist in the design process and to ensure that patient safety needs are understood, the 263 data from previous incidents should be gathered. This can assist in understanding where 264 previous incidents have occurred and inform the design process and product selection. 265
4.4 The NHS Safety Thermometerxxviii gives up to date information for several specialties, including 266 maternity, medication, Children and Young People and mental health and measures various 267 safety issues. 268
4.5 The section on mental health gives up to date information on the proportion of patients across 269 the country who have self-harmed, feel safe, have been a victim of violence and aggression 270 and had an omission of medication in the last 72 hours. 271
4.6 Hospital episode data sets are available through NHS Digitalxxix. 272
4.7 Local data on the location of incidents of self-harm may prove helpful to the design process. 273
4.8 The design must meet the requirements of the CQC, and other bodies as identified in the 274 Policy and Regulatory overview above. 275
4.9 There needs to be a holistic approach to the briefing process. Solutions should be appropriate, 276 and needs driven. Consideration of the location (multi-disciplinary estates), the building 277 users, the environment within the building and the clinical needs should all be considered. 278 Other considerations such as fire safety, infection control and appropriateness for 279 characteristics in the location, for example humidity in wet areas, will all need to be 280 understood and will impact on decisions made by the commissioners and design teams. 281
4.10 Product selection may vary depending on where it is to be fitted and alternatives of many 282 products may be required. Likewise, location of fixture and fittings will need to consider the 283 service area, the type of walls and ceilings to which they are to be fitted. 284
4.11 Suspended ceilings should not be used in a mental health environment accessible to patients 285 as they offer the opportunity for anchor points for ligature. See HBN 03-01 section 10.65 286 which states: “Grid-type suspended ceilings should not be designed into service user-287 accessible areas” and 10.66 “Removable suspended ceiling panels should not be used, as they 288 provide spaces for the concealment of prohibited objects and are sometimes constructed with 289 materials that can be used for self-injury”. 290
4.12 The Design in Mental Health Network series of books ‘Design with People in Mind’xxx also 291 includes books on acoustics and nature. Whilst the third in the series is the Stakeholder 292 Engagement Toolkit, which assists commissioners, design teams and Trusts to ensure 293 involvement of all parties at the appropriate times. 294
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4.13 The design process can often come up with innovative solutions to problems and it is 295 important that these can develop. Product manufacturers continue to improve and innovate 296 moving their products to the next level, particularly in the area of mental health, where 297 products are becoming both safer and more aesthetically pleasing which helps to improve the 298 therapeutic environment and outcomes for patients. 299
300
Ligature anchor points 301
302
4.14 The reduction of ligature anchor points within the built environment, particularly in areas 303 designed for mental health care, is important to continue reducing this method of self-harm. 304
4.15 The 2019 Annual report by The National Confidential Inquiry into Suicide and Safety in Mental 305 Health (NCISH) xxxi reported that between 2007-2017 there were approximately 20-30 deaths 306 per year by hanging / strangulation on the ward. Most of these incidents took place in private 307 areas such as single bedrooms, toilet / bathroom areas. 308
309
Doors 310
4.16 The most common ligature anchor points identified in the 2019 NCISH Annual Report was 311 doors, with 47% of the 2007-2017 suicides using this method. 312
4.17 Manufacturers have responded to these reports by producing a range of reduced ligature 313 products to assist in tackling this issue. There are also doors available with alarms which will 314 sound when any weight is put on to them. 315
4.18 Anti-barricade doors allow the opening of a door which has been barricaded to allow a fast 316 response by staff. 317
318
Windows 319
4.19 The second most common ligature point is windows. There is also the risk of falls from 320 unrestricted windows in areas other than mental health units. 321
4.20 The Health & Safety Executive (HSE)xxxii offers information and a leaflet on the Risk of Falling 322 from windows for those people using health and social care premises, particularly where there 323 may be an element of confusion. 324
4.21 The HSE guidance is supplemented by HBN 00-10 Part D: Windows and associated hardware. 325 The recommendation is that windows should be restricted to 100 mm, however following a 326 number of falls from high windows following the restrictors being forced open, it is 327 recommended that the correct testing recommendations are followed and that window 328 restrictors are included on planned preventative maintenance and monitoring schedules. 329
4.22 There are now several products available which, whilst allowing natural air to flow into the 330 room, do not leave an opening through which a person could fall and have reduced ligature 331 particularly in comparison to standard windows. These are now used extensively in mental 332 health facilities and could be considered for the acute setting in rooms on high floors. 333
334
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Tracking 335
4.23 Never Events Provisional data from April 2019 to November 2019 published by NHSi xxxiii 336 records one incident of “Failure to install functional collapsible shower or curtain rails”. For 337 information on the safe installation and maintenance of curtain rails, reference should be 338 made to HBN 00-10-part E – Tracking (ref to location required) which also includes a risk 339 assessment checklist for tracking and curtains. 340
4.24 The Design in Mental Health Network (DiMHN) and the Building Research Establishment (BRE) 341 document: “Informed Choices Testing Guidance for Products in Mental Health Facilities" 342 (2020) (ref to online location to be added) states: “Ligature Anchor Point: A ligature point is 343 anything that could be used to attach (i.e. immobilise at one end) a cord, rope or other 344 material for the purpose of strangulation”. 345
346
Height 347
4.25 The DiMHN/BRE document goes on to say: “Ligature points can be both high and low. The 348 loading pattern will differ depending on the anchor point height and direction of body 349 lean/fall”. 350
351
Ligature points can be both high and low (illustration courtesy DiMHN/BRE, ‘Design Guide for 352
Products’) 353
4.26 The term anti-ligature has been used for several years but can give false assurance as this does 354 not mean that it is totally safe. The DiMHN and BRE document uses the term reduced ligature 355 device, stating: 356
“Reduced ligature device sometimes referred to as “Anti-ligature”: An “anti-ligature” or 357 reduced ligature fitting is any fitting that is designed in such a way as to minimise the risk of it 358 being used as a ligature attachment point or limit the consequences from attachment (e.g. 359 load release devices), that could cause death however this does not mean it is not a risk, it is 360 reduced risk.” 361
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4.27 The design of products categorised as reduced ligature does not replace or substitute the 362 need for necessary supervision of those who may be at risk, or for other necessary 363 protective measures to be taken in the specific circumstances of usage. 364
4.28 Guidance on ligature points is available from the CQC in the document “Brief guide for 365 inspection teams – Ligature points”.xxxiv 366
367
Lockable Cupboards and rooms 368
4.29 To assist in the avoidance of self-harm by poisoning, it is important that rooms such as 369 cleaning stores are fitted with lockable cupboard and COSSH cupboards. These should be 370 utilised for the storage of cleaning fluids and other toxic products. The cupboards in these 371 rooms and the doors to the rooms should always be kept locked. All keys should be kept in a 372 secure key safe. 373
4.30 Locked storage should also be available in ward areas to store those items risk assessed by 374 staff as allowing only restricted access by patients, this may include such things as blades and 375 cigarette lighters, matches etc. 376
377
Observation 378
379
4.31 Observation together with a good understanding of risk plays an important part in keeping 380 people safe. Observation is an integral part of care in the mental health environment and the 381 acute sector are now building on this learning. 382
4.32 In 2018 the Enhanced Observation and Care Collaborative was set up by NHSi xxxv. The remit 383 for this is: 384
“There has always been a need for one-to-one nursing care, also known as ‘special 385 observation’ or ‘specialling’, for critically ill or vulnerable patients in hospital. Definitions of 386 enhanced care come largely from mental health nursing, with different levels of observation 387 defined by the proximity of staff to the patient needing enhanced care. Studies on enhanced 388 care in acute settings have built on this, with a driver to move from ‘passive watching’ to an 389 engaged person-centred relationship with the patient and their family or carers”. 390
4.33 In the acute sector there may be a requirement to have an interview /assessment room, 391 where discussions with possibly aggressive or vulnerable people can take place and offer staff 392 a space which is a little more safe and secure. This can be achieved with a vision panel into 393 the corridor area where staff may check the room, a staff alarm call system including push 394 buttons in strategic places around the room. The room should include only minimal furniture 395 which should be immovable and placed so that staff members have clear access to the door 396 with no obstacles, ideally there will be two doors to the room on opposite sides. Further 397 information can be found at Psychiatric Liaison Accreditation Network (PLAN) document 398 Quality Standards for Liaison Psychiatry Services, Sixth Editionxxxvi Standard 168 (see also 399 section on A&E). 400
4.34 An operational policy should be in place to guide staff and to identify where a response should 401 come from should the alarm bells be activated. Ideally the room will have two rooms to allow 402 for additional staff security. 403
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4.35 CCTV can also assist in keeping people safe within NHS premises. This should be operated in 404 line with national and local policies on data protection. 405
4.36 Car parks and outdoor areas should be well lit at night and covered by CCTV to ensure the 406 safety of all visiting the facility. 407
408
Aggression and violence 409
410
4.37 Aggression and violence can occur in any setting. It can be traumatic, frightening and cause 411 damage and harm to the environment and other people. 412
4.38 The ‘Manchester risk assessment template’ offers a starting point to judge the vulnerability of 413 a patient and to gain an understanding of where problems may appear. This can be found at 414 https://www.nice.org.uk/media/default/sharedlearning/364_364_MMHandSCTOfficialform.415 pdfxxxvii 416
4.39 If a situation is escalating towards violence it is helpful to have a room, such as described in 417 the observation section above, which can be used by staff to reduce the escalation. 418
4.40 Strategically placed mirrors, particularly in reception areas, can also assist in reducing the 419 escalation of violence when the person becoming violent can see themselves. 420
4.41 In mental health particularly it is as important to reduce the opportunity for fixtures and 421 fittings to be used as weapons as it is to reduce ligature anchor points. Items which can be 422 used as a weapon against others can also be used to self-harm. 423
424
Infection control 425
426
4.42 Infection control is an important area in keeping patients safe, and in 2004 the Department of 427 Health Policy Research Programme commissioned a research team from the RCN Institute and 428 the University of Sheffieldxxxviii to investigate the role of the Modern Matron across a sample 429 of NHS Trusts. One of the key areas identified was that of cleanliness in the patient 430 environment, with the modern matron involved in the development and monitoring of 431 cleaning specifications. See https://www.nursingtimes.net/clinical-archive/infection-432 control/the-role-of-modern-matrons-in-raising-standards-of-infection-control-29-06-2004/ 433
434
Cleaning and hygiene 435
4.43 Patient safety is a vital aspect of the role of the ward leader, this includes ensuring the 436 cleanliness of the environment in which care is being given. The Ward Leader’s Handbookxxxix 437 includes a section on safety. 438
4.44 The design, materials and workmanship of a system should be such that when installed it will 439 not generate dust or dirt. The construction should be capable of withstanding the cleaning 440 regimes in use by the organisation and in accordance with the requirements identified in PAS 441 5748:2014xl and in the Health and Social Care Act 2008 (Regulated activities) Regulations 2014: 442 Regulations 15: Premises and equipment. 443
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4.45 PAS 5748:2014 is a “model cleaning contract” for hospitals and has three key elements: 444
the National Standards of Cleanliness (introduces measures for HCAI cleaning and 445 disinfection); 446
the NHS Cleaning Manual (sets out best practice methods for cleaning); 447
cleaning frequencies (these should be determined to address the element of risk 448 identified in accordance with the National Standards of Cleanliness and taking into 449 account any further advice and guidance in the model cleaning contract and the NHS 450 Cleaning Manual). 451
452
Accident and emergency dedicated facilities 453
454
4.46 A lack of beds in mental health trusts can result in long waits in accident and emergency (A&E) 455 for patients suffering mental health problems. A report and audit carried out in August 2019 456 commissioned by London healthcare providers and supported by NHS England and NHS 457 Improvementxli identified that, depending on local circumstances, there may be need for 458 dedicated space for mental health patients in accident and emergency departments. The key 459 recommendation was that there should be at least three dedicated mental health spaces 460 within every London A&E. 461
4.47 Whilst it is not possible to make an A&E department safe and remove ligature points and other 462 means for patients to harm themselves, a dedicated space for treating mental health patients 463 can help, particularly if that space can offer an environment that feels safe and therapeutic. 464
4.48 Reference should be made to the Psychiatric Liaison Accreditation Network (PLAN) document 465 Quality Standards for Liaison Psychiatry Services, Sixth Editionxlii Standard 168 recommends 466 the following that: 467
“The liaison team has access to assessment rooms suitable for conducting high risk 468 assessments. Facilities should: 469
Be located within the main emergency department; 470
Have at least one door which opens outwards and is not lockable from the inside; 471
Have an observation panel or window which allows staff from outside the room to check 472 on the patient or staff member but which still provides a sufficient degree of privacy; 473
Have a panic button or alarm system (unless staff carry alarms at all times); 474
Only include furniture, fittings and equipment which are unlikely to be used to cause harm 475 or injury to the patient or staff member. For example, sinks, sharp edged furniture, 476 lightweight chairs, tables, cables, televisions or anything else that could be used to cause 477 harm or as a missile are not permitted; 478
Be appropriately decorated to provide a sense of calmness; 479
Have a ceiling which has been risk assessed. 480
Not have any ligature points.” 481
482
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NB. PLAN also recommends that assessment facilities have two doors to provide additional 483 security. All new assessment rooms must be designed with two doors. 484
4.49 For those patients awaiting transfer to another facility a waiting area based on the same 485 standards as applied to the assessment room could be provided. 486
4.50 It is important that there is good observation of patients who may be deemed to be at risk of 487 self-harm and by having a dedicated space with dedicated staffing to that area, observation 488 can be improved, thus reducing risk. 489
4.51 Operational policies should include details of how risks can be reduced within the department. 490
491
Mixed sex accommodation 492
493
4.52 In 2018 the final report of the independent review of the Mental Health Act 1983xliii identified 494 several recommendations required to improve the ward environment, making it safer for 495 patients and to reduce incidents of sexual assault and harassment. One recommendation 496 stated: 497
“The definition of single sex accommodation should be tightened up to ensure a genuinely 498 single sex environment with separate access to any shared daytime space” 499
4.53 A report in January 2020 in the Health Service Journal identified that between April 2017 and 500 October 2019 there had been 1,019 sexual assaults reported by male and female patients on 501 mixed sex wards, compared with 286 reported in the same period on single sex wards. A total 502 of 491 attacks were so serious they required safeguarding action, with 104 incidents reported 503 to police. 504
4.54 Commissioners should consider carefully how single sex ward accommodation can be 505 achieved in current buildings. Designers and commissioners should specify single sex ward 506 for all new build projects. 507
Access to internet services 508
509
4.55 Reports have highlighted the dangers of some internet sites related to suicide, particularly for 510 those who are particularly vulnerable to suicidal suggestions. 511
4.56 The National Confidential Inquiry into Suicide and Safety in Mental Health (2019)xliv reports 512 that there were 65 suicides in patients known to have used the internet in ways that were 513 suicide related and this is one of 9 key areas identified where measures could be taken to 514 reduce suicide risk. 515
4.57 HBN 03-02 - Facilities for child and adolescent mental health services (CAMHS)xlv states at 516 section 6.50 that the Mental Health Act Code of Practice recognises that blanket restrictions 517 on access via the internet, access to (or banning) mobile phones is inappropriate. 518
4.58 The CQC document brief guide: the use of ‘blanket restrictions’ in mental health wardsxlvi has 519 at Appendix 1: Normative expectations regarding blanket restrictions at different levels of 520 security and includes in this access to mobile phones and the internet. 521
4.59 Local operational policies on this issue should be available. 522
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523
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5.0 Risk assessment 524
5.1 Risk assessment is a very important process within all health services and should be carried 525 out on a regular basis. However, it should not be restricted to the ‘live’ ward environment 526 but should commence at the beginning of the briefing process for new and refurbished 527 facilities and continue throughout the design and construction process. When undertaking 528 risk assessment reference should be made to local operational policies on risk management 529 and patient safety which can be amended and changed to incorporate any new issues which 530 arise throughout the design process. 531
5.2 Whilst in the non-mental health environment there are more opportunities for vulnerable 532 patients to self-harm it is also valuable to identify rooms where there is a high level of risk to 533 vulnerable patients and those rooms which offer a safer environment. This information can 534 then be used to inform operational policies to ensure a safer experience for patients and to 535 deter the opportunity for self-harm to take place. 536
5.3 If potential risk is identified from the start then it may be possible through design to minimise 537 some risks, if that is not possible it can be clearly documented so that it is identified and inform 538 future risk assessments. 539
5.4 The Design Quality Indicator (DQI)xlvii is a process for evaluating and improving the design and 540 construction of new buildings and the refurbishment of existing ones. It should include all 541 stakeholders in the process. It looks at Functionality, Build Quality and Impact of the building 542 and included in this is patient safety. There are five stages when DQI workshops should be 543 undertaken. These are when the process is at the following stages: 544
1. Briefing 545 2. Concept Design 546 3. Detailed Design 547 4. Ready for Occupation 548 5. In-Use 549
550
5.5 Guidelines issued by the Facilities Guidelines Institute (FGI) in the USA state that “all health 551 care facility projects shall be designed and constructed to facilitate the safe delivery of care. 552 To support this goal, an interdisciplinary team shall develop a safety risk assessment.” 553
5.6 In response to this, the Center for Health Design have created a useful safety risk assessment 554 toolxlviii online which can be found at: https://www.healthdesign.org/sra/about/intent. The 555 aim of the tool is to provide guidance in considering the underlying conditions which can lead 556 to harm. 557
5.7 This toolkit is designed to be used from the beginning of the design process, gathering 558 information from all stakeholders to help and assist the process. 559
5.8 The Royal College of Psychiatrists, CPD on-line module Patient Safety in Mental Healthxlix 560 states: “Ensuring that patients are safe involves risk assessment, the identification and 561 management of patient-related risk, and the reporting and analysis of incidents. It also 562 requires the capacity to learn from and follow up on incidents, and to implement solutions to 563 minimise the risk of them reoccurring”. 564
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565
566
5.9 The ‘Serious Incident Framework’ published by NHS Englandl defines patient safety as “the 567 process by which an organisation makes patient care safer. This should involve: 568
risk assessment 569
identification and management of patient-related risks 570
reporting and analysis of incidents 571
the capacity to learn from and follow up on incidents and implement solutions to 572
minimise the risk of them recurring.” 573
5.10 The National Confidential Inquiry into Suicide and Safety in Mental Health ‘The assessment of 574 clinical risk in mental health services – October 2018’li and Safer Services : A toolkit for 575 specialist mental health and primary carelii should be consulted, whilst this covers the clinical 576 aspects of risk, it offers some important information on the tools used to undertake an 577 assessment. 578
5.11 The Ward Leader’s handbook emphasises the importance of good leadership skills in reducing 579 safety incidents on the ward: 580
“Where nurses demonstrate and use their transformational leadership skills, wards have 581 fewer safety incidents, less staff absence and lower turnover (Hay Group 2006). As the NHS 582 develops more complex systems, it is essential that ward leaders can operate in that changing 583 environment, enabling and sustaining excellent performance (Castillo and James 2013).”liii 584
5.12 It also identifies the importance of ensuring that risk assessments are carried out regularly 585 and are up to date. 586
5.13 Reference should be made to the national Patient Safety Programmes identified by NHS 587 Improvementliv 588
5.14 In 2013 the Yorkshire and Humber Patient Safety Collaborative piloted the Huddle Up for Safer 589 Healthcare (HUSH) programmelv. A safety huddle is a short multidisciplinary briefing, held at 590 a predictable time and place, and focused on the patients most at risk. This programme can 591 used in the community, acute or mental health setting and has demonstrated a reduction in 592 patient harmlvi. 593
Identify the risk
Analyse the risk
Evaluate the risk
Identify and implement a
solution
Monitor and review
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5.15 It is important that there is knowledge of the compliance requirements for all regulators and 594 stakeholders such as the Care Quality Commission (CQC), NHS England and Improvement and 595 Clinical Commissioning Groups (CCGs). 596
5.16 Reference should be made to Section 12 CQC Safe care and treatment: 597 https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-12-safe-598 care-treatment#guidance-linkslvii 599
5.17 Acknowledged by NICE as a useful template for local use is the Manchester Mental Health 600 and Social Care Trust Health and Safety Risk Assessment / Clinical risk assessment: see 601 Appendix 2 for details. 602
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6.0 Fitting and maintenance 603
Fitting 604
605
6.1 It is essential that all fixtures and fittings are installed in accordance with manufacturers’ 606 guidance, by installers trained and accredited by the manufacturer. 607
6.2 Correct fixings must be used according to the location of the fixture, for example tamperproof 608 screws should be used in a mental health environment and in other areas if risk assessment 609 of the area deems it necessary. 610
6.3 HBN 00-10 part E – Trackinglviii offers advice on the correct installation and maintenance of 611 tracking. 612
Maintenance 613
614
6.4 Damage to products – particularly in mental health facilities – can occur frequently and it is 615 therefore important that: 616
maintenance schedules and facility service level agreements include a rapid response 617
rooms do not have to be closed 618
rooms do not become dangerous to occupants. 619
6.5 Regular replacement schedules should be in place for all fixtures and fittings. Wear and tear 620 can lead to fixtures and fittings becoming dangerous or increasing ligature anchor points, 621 therefore regular inspection should take place. 622
6.6 Care should be taken to ensure that components have not become redundant or unsafe and 623 remain fit for purpose. 624
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Appendices
Appendix 1 Policy checklist Designed for local use (Excel file)
Appendix 2 Manchester Mental Health and Social Care Trust Health
and Safety Risk Assessment / Clinical risk assessment Exemplar (PDF)
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References
ACTS AND REGULATIONS
(The) Building Regulations 2000 (SI 2000: 2531) and subsequent amendments
http://www.legislation.gov.uk/uksi/2000/2531/contents/made
(The) Construction (Design and Management) [CDM] Regulations 2015 and subsequent
amendments http://www.legislation.gov.uk/uksi/2015/51/contents/made
TECHNICAL STANDARDS Health Building Notes https://www.gov.uk/government/collections/health-building-notes-core-
elements
Health Technical Memoranda https://www.gov.uk/government/collections/health-technical-
memorandum-disinfection-and-sterilization
ProCure 21+ Repeatable Rooms http://www.procure21plus.nhs.uk/standardisation/
PAS 5748:2014 Specification for the planning, application, measurement and review of cleanliness
services in hospitals https://shop.bsigroup.com/ProductDetail/?pid=000000000030292594
BRITISH STANDARDS
BS 476-4:1970 Fire tests on building materials and structures. Non-combustibility test for
materials. British Standards Institution, 1970 (current, under review)
https://shop.bsigroup.com/ProductDetail/?pid=000000000030296640&_ga=2.233608734.14328435
7.1565281661-1937188718.1565281661
BS 5438-1:1976 Methods of test for flammability of vertically oriented textile fabrics and fabric
assemblies subjected to a small igniting flame. British Standards Institution, 1976.
https://www.thenbs.com/PublicationIndex/documents/details?Pub=BSI&DocID=17764
https://www.gov.uk/government/collections/health-technical-memorandum-disinfection-and-sterilization
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End notes
i Patient Safety Incident Response Framework - https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/
ii World Health Organisation - https://www.who.int/patientsafety/about/en/
iii The National Confidential Inquiry Suicide and Safety in Mental Health Annual Report 2018
http://documents.manchester.ac.uk/display.aspx?DocID=38469
iv Annual report 2018: England, Northern Ireland, Scotland and Wales – Key messages
https://sites.manchester.ac.uk/ncish/reports/annual-report-2018-england-northern-ireland-scotland-and-wales/
v The National Confidential Inquiry Suicide and Safety in Mental Health Annual Report 2019 https://sites.manchester.ac.uk/ncish/reports/annual-report-2019-england-northern-ireland-scotland-and-wales/
vi CQC - Opening the door to change NHS safety culture and the need for transformation (December 2018) https://www.cqc.org.uk/sites/default/files/20181224_openingthedoor_report.pdf
vii CQC – The state of health care and adult social care in England 2018/19 (October 2019) https://www.cqc.org.uk/sites/default/files/20191015b_stateofcare1819_fullreport.pdf
viii The NHS Patient Safety Strategy Safer culture, safer systems, safer patients - July 2019
https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf
ix Mental Health First Aid England (MHFAE)
https://mhfaengland.org/mhfa-centre/research-and-evaluation/mental-health-statistics/#self-harm
x NHS - https://www.nhs.uk/conditions/self-harm/
xi Suicide Risk assessment and Threats of Suicide - https://patient.info/doctor/suicide-risk-assessment-and-threats-of-suicide
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xii The Office for National Statistics: Statistical bulletin Suicides in the UK: 2018
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicide
sintheunitedkingdom/2018registrations#suicide-methods
xiii NHSi – National Patient Safety – Incident reports https://improvement.nhs.uk/resources/national-patient-safety-incident-reports-25-september-2019/
xiv DiMHN and BRE document – Informed Choices Testing Guidance for Products in Mental Health
Facilities" (2020)
https://www.dimhn.org/wp-content/uploads/2016/11/DIMHN-Design-Guide-for-consultation-05jun19.pdf
[re-check URL before publication]
xv CQC Brief guide for Inspection teams
https://www.cqc.org.uk/sites/default/files/20150328%20CQC%20mental%20health%20brief%20guide%20-
%20Ligature%20points.pdf
xviThe Construction (Design and Management) Regulations 2015 - HSE
http://www.hse.gov.uk/construction/cdm/2015/index.htm
xvii Design with people in mind – DiMHN – www.dimhn.org
xviii Mental and behavioral health environments: critical considerations for facility design - Shepley, M. M.,
Watson, A., Pitts, F., Garrity, A., Spelman, E., Kelkar, J., & Fronsman, A. (2016). General Hospital Psychiatry, 42,
15–21. doi:10.1016/j. genhosppsych.2016.06.003
https://www.researchgate.net/publication/304491197_Mental_and_Behavioral_Health_Environments_Critica
l_Considerations_for_Facility_Design
xix Star wards https://www.starwards.org.uk/ensuring-safety-service-users-staff-visitors/
xx HBN 00-01 – General Design Guidance for Healthcare buildings (2014) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/316247/HBN_00-01-2.pdf
xxi World Health Organisation - https://www.who.int/patientsafety/about/en/
xxii NHS Improvement - https://improvement.nhs.uk/improvement-hub/patient-safety/
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xxiii CQC - Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - regulation 12
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-12-safe-care-treatment
xxiv The NHS Patient Strategy - https://improvement.nhs.uk/resources/patient-safety-strategy/
xxv The Royal College of Nursing – Patient safety and human factors - https://www.rcn.org.uk/clinical-topics/patient-safety-and-human-factors
xxvi Royal College of Physicians, Patient Safety - https://www.rcplondon.ac.uk/projects/rcp-policy-patient-safety
xxvii NHS England - Patient Engagement in Patient Safety: A Framework for the NHS (2016) https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2016/05/pe-ps-framwrk-apr-16.pdf
xxviii NHS Safety Thermometer- https://www.safetythermometer.nhs.uk/
xxix NHS Digital - https://digital.nhs.uk/
xxx Design with people in mind – DiMHN – www.dimhn.org
xxxi The National Confidential Inquiry into Suicide and Safety in Mental Health (2019) -
http://documents.manchester.ac.uk/display.aspx?DocID=46558
xxxii Health & Safety Executive – Risk of Falling from windows https://www.hse.gov.uk/healthservices/falls-windows.htm
xxxiii Never Events - https://improvement.nhs.uk/documents/6283/Provisional_publication_-_NE_1_April_-_30_November_2019.pdf
xxxiv CQC Brief Guide for inspection teams – Ligature Points -
https://www.cqc.org.uk/sites/default/files/20150328%20CQC%20mental%20health%20brief%20guide%20-
%20Ligature%20points.pdf
xxxv Enhanced observation and care collaborative – NHS Improvement
https://improvement.nhs.uk/resources/enhanced-observation-and-care-collaborative/
xxxvi Royal College of Psychiatry – Liaison Quality Standards for Liaison Psychiatry Services, Sixth Edition https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/psychiatric-liaison-
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services-plan/quality-standards-for-liaison-psychiatry-services---sixth-edition-20209b6be47cb0f249f697850e1222d6b6e1.pdf?sfvrsn=1ddd53f2_0
xxxvii Manchester Risk Assessment https://www.nice.org.uk/media/default/sharedlearning/364_364_MMHandSCTOfficialform.pdf
xxxviii Evaluation of the modern matron role in a sample of NHS trusts (2004) – Royal College of Nursing
https://www.rcn.org.uk/professional-development/publications/pub-003197
xxxix The Ward Leader’s Handbook – October 2018 – NHSi https://improvement.nhs.uk/documents/3359/Ward_leaders_handbook.pdf
xl PAS 5748:2014 - Specification for the planning, application, measurement and review of
cleanliness services in hospitals
https://shop.bsigroup.com/ProductDetail/?pid=000000000030292594
xli https://www.hsj.co.uk/quality-and-performance/trusts-told-to-create-dedicated-aande-space-for-mental-health-patients/7026587.article The report was written by Judith Fairweather, deputy director of contracting for North and East London Commissioning Support Unit, and led by Matthew Trainer, chief executive of Oxleas Foundation Trust. The audit analysis and preliminary results were provided by NHSI’s emergency care programme improvement lead, Emma Bagshaw, and Geraldine Strathdee, former national director for mental health.
xlii Royal College of Psychiatry – Liaison Quality Standards for Liaison Psychiatry Services, Sixth Edition https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/psychiatric-liaison-services-plan/quality-standards-for-liaison-psychiatry-services---sixth-edition-20209b6be47cb0f249f697850e1222d6b6e1.pdf?sfvrsn=1ddd53f2_0
xliii Modernising the Mental Health Act Increasing choice, reducing compulsion Final report of the Independent Review of the Mental Health Act 1983 December 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/778897/Modernising_the_Mental_Health_Act_-_increasing_choice__reducing_compulsion.pdf
xliv The National Confidential Inquiry into Suicide and Safety in Mental Health 2019 https://www.hqip.org.uk/wp-content/uploads/2019/12/Mental-Health-CORP-Report-2019-FINAL.pdf
xlv HBN 03-02 - Facilities for child and adolescent mental health services (CAMHS) (2017) - https://www.gov.uk/government/publications/facilities-for-child-and-adolescent-mental-health-services-hbn-03-02
xlvi CQC - Brief guide: the use of ‘blanket restrictions’ in mental health wards (2017) - https://www.cqc.org.uk/sites/default/files/20170109_briefguide-blanket-restrictions.pdf
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xlvii Design Quality Indicator (DQI) http://www.dqi.org.uk/
xlviii Center for Health Design, SRA tool https://www.healthdesign.org/sra/about
xlix The Royal College of Psychiatrists, CPD on-line module Patient Safety in Mental Health http://www.psychiatrycpd.co.uk/default.aspx
l NHS England: Serious incident framework (March 2015) https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf
li National Confidential Inquiry into Suicide and Safety in Mental Health - The assessment of clinical risk in mental health services – October 2018 http://documents.manchester.ac.uk/display.aspx?DocID=38466
lii Safer Services: A toolkit for specialist mental health and primary care http://documents.manchester.ac.uk/display.aspx?DocID=40697
liii Ward Leaders Handbook
https://improvement.nhs.uk/documents/3359/Ward_leaders_handbook.pdf
liv Patient Safety Programes NHSi - https://improvement.nhs.uk/resources/patient-safety-improvement-programmes/#h2-national-patient-safety-improvement-programme
lv HUSH Programme - https://improvement.nhs.uk/resources/safety-huddles/
lvi Huddle up for Safer Healthcare - Basic Information Leaflet 2019 https://www.improvementacademy.org/documents/Projects/hush/HUSH%20Basic%20Information%20Leaflet_Aug2019.pdf
lvii CQC – Section 12 – Safe Care and Treatment guidance https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-12-safe-care-treatment#guidance-links
lviii HNB 00-10 part E– Tracking [add URL when available]
