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Registration Number: {{org_field_registration_no}}

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Preventing Suicide by Hanging and Strangulation Policy

1. Purpose

The purpose of this policy is to set out the procedures and preventative measures in place at {{org_field_name}} to identify, reduce, and manage the risks of suicide by hanging or strangulation within our care home. We recognise that residents who are vulnerable, experiencing mental health challenges, or living with cognitive impairment may be at increased risk of self-harm. Our policy is designed to ensure that all reasonable steps are taken to prevent such incidents and to safeguard the emotional and physical well-being of all individuals using our service.

This policy is grounded in the Regulation and Inspection of Social Care (Wales) Act 2016, the Social Services and Well-being (Wales) Act 2014, and is informed by best practice guidance from Care Inspectorate Wales (CIW), particularly in relation to safeguarding, risk management, and person-centred care. It reflects our legal and moral duty to promote safety, dignity, and respect while supporting autonomy wherever possible.

2. Scope

This policy applies to all staff employed at {{org_field_name}}, including care staff, domestic, maintenance, management, volunteers, agency workers, and contractors. It relates to all individuals receiving care and support in the home and covers preventive and responsive actions, environmental controls, assessments, care planning, and staff training.

3. Related Policies

This policy must be read alongside the following policies:

• CHW07 – Person-Centred Care Policy
• CHW11 – Safe Care and Treatment Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW17 – Infection Prevention and Control Policy
• CHW18 – Risk Management and Assessment Policy
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy
• CHW35 – Duty of Candour Policy

4. Policy Details

4.1 Risk Identification and Individual Assessment
All new residents undergo a comprehensive risk assessment prior to admission, which includes evaluating the risk of self-harm or suicide. This is part of our initial assessment process under CHW36 and is conducted in collaboration with the individual (where possible), their family, and relevant health professionals.

Factors considered include:

• History of mental health conditions or previous suicide attempts
• Recent bereavement or trauma
• Use of psychotropic medications
• Diagnosed cognitive impairment, such as dementia
• Behavioural indicators such as withdrawal, expressions of hopelessness, or agitation

If a risk is identified, it is documented in the personal plan, and appropriate measures are outlined and reviewed regularly.

4.2 Ongoing Monitoring and Supervision
Residents deemed at higher risk will have increased observation protocols, which may include:

• More frequent welfare checks (minimum hourly, adjusted according to need)
• Increased staff presence or supervision
• Location and activities monitored discreetly to respect dignity while ensuring safety

Staff are trained to notice and escalate signs of emotional distress, mood changes, or changes in behaviour that may suggest an increased risk of self-harm or suicidal ideation. These concerns are recorded and reported immediately to the Registered Manager, who will review the care plan and escalate to mental health services if needed.

4.3 Environmental Safety Measures
Environmental audits are undertaken every six months, and following the admission of any high-risk individual. These audits specifically assess the potential for ligature points or hazards associated with strangulation or hanging. This includes:

• Curtain and window blind cords – replaced or secured with breakaway or anti-ligature fittings
• Door closures and handles – inspected for risk and replaced with anti-ligature alternatives where required
• Wardrobes, rails, or hooks – assessed for strength and shape to reduce risk
• Bathrooms – fitted with anti-ligature fittings and support rails designed to prevent misuse
• Bed rails and mobility equipment – checked for entrapment risks

Bedrooms of individuals identified as high-risk are reviewed carefully, and items such as belts, cords, plastic bags, or medical tubing are risk assessed and removed or supervised when appropriate.

4.4 Multi-Agency Collaboration
{{org_field_name}} works closely with:

• GPs and mental health professionals to support residents identified as being at risk
• Local authority adult safeguarding teams: {{org_field_local_authority_authority_name}}
• The Crisis Resolution and Home Treatment Team, where relevant

In the event of a concern, immediate referral is made, with the resident’s best interest and safety as the priority. Information sharing is done in accordance with the Data Protection Act 2018 and our Confidentiality and GDPR Policy (CHW34).

4.5 Care Planning and Supportive Interventions
A person-centred care plan is developed in response to identified risks, which may include:

• Enhanced emotional support and regular keyworker contact
• Access to talking therapies or counselling
• Engagement in therapeutic or meaningful activity programmes to promote self-esteem and reduce isolation
• Close involvement of family or significant others where appropriate
• Mental capacity assessments and safeguarding reviews if mental illness or reduced capacity is suspected

We promote open conversations about mental health, ensuring that staff approach all concerns with empathy, non-judgement, and confidentiality.

4.6 Staff Training and Awareness
All staff receive annual training on suicide prevention, identifying warning signs, and responding to emergencies involving attempted self-harm or suicide. Training includes:

• Understanding ligature risks and environmental hazards
• How to speak to someone experiencing suicidal thoughts
• Mental Health First Aid
• Safeguarding procedures and emergency response (including first aid and emergency services protocol)

Staff are also trained in de-escalation and communication techniques to reduce distress and manage crisis behaviour.

4.7 Emergency Response Protocol
In the event of a suicide attempt or incident of self-harm:

• Emergency services will be called immediately
• First aid will be administered by a trained staff member
• The resident will be monitored continuously until help arrives
• The incident will be reported to the Registered Manager and safeguarding lead
• The resident’s family or representative will be informed appropriately
• A full internal review will take place, with learning actions identified and implemented

All such incidents will be reported to CIW, in line with Regulation 60 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, and any safeguarding concerns referred to {{org_field_local_authority_authority_name}}.

4.8 Promoting a Positive and Safe Culture
At {{org_field_name}}, we are committed to creating an environment where residents feel heard, respected, and safe. We promote a culture of openness, compassion, and early intervention in line with the CIW core values of caring, respect, and integrity.

Residents are encouraged to express their feelings, participate in wellbeing programmes, and develop trusting relationships with staff. We do not adopt a risk-averse model that limits autonomy but instead adopt a balanced, person-led approach to risk and safety.

5. Policy Review

This policy will be reviewed annually or sooner in response to:

• Any serious incident involving attempted or completed self-harm
• Updated national guidance or changes in legislation
• Recommendations from CIW, safeguarding boards, or partner agencies
• Internal audits or lessons learned

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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