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{{org_field_name}}

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

Before agreeing to provide care and support to an individual, {{org_field_name}} will consider any risks to the individual’s well-being, together with the individual’s care and support plan, relevant health or other assessments, views, wishes and feelings and any risks to other individuals, as required when determining whether the service is suitable to meet the individual’s needs.

Where information available before admission identifies a current or previous risk of suicide, self-harm, hanging or strangulation, this must be considered when determining whether the service can safely meet the individual’s assessed needs and whether any reasonable adjustments or additional arrangements are required.

Within seven days of the commencement of the provision of care and support, the provider assessment required by Regulation 18 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, must assess relevant risks to the individual’s well-being and any risks to the well-being of other individuals.

Assessment of suicide and self-harm risk must be person-centred and must take account of information relevant to the individual. Depending upon the person’s circumstances, this may include:

• current or previous suicidal thoughts, intent, plans or behaviour;
• previous suicide attempts or self-harm;
• previous actual or attempted hanging or strangulation;
• recent changes in mental or physical health;
• significant loss, bereavement, trauma or other major changes in circumstances;
• expressions of hopelessness, distress or a wish to die;
• significant changes in behaviour, mood, sleep, social interaction or usual presentation;
• cognitive impairment or communication difficulties that may affect the person’s ability to express distress;
• relevant information provided by the individual, their representative where appropriately involved, health professionals or other agencies;
• access to potential means of self-harm, including individual-specific environmental risks; and
• protective factors, strengths, relationships and support available to the individual.

The presence of a mental health diagnosis or cognitive impairment must not, by itself, be treated as evidence that an individual is suicidal or lacks capacity.

Where a risk is identified, the assessment must inform the individual’s personal plan. The personal plan must clearly identify the steps that will be taken to mitigate the identified risk while supporting the individual’s rights, dignity, autonomy, personal outcomes and appropriate positive risk-taking.

The risk assessment and personal plan must be reviewed without delay when there is a material change in the individual’s presentation, needs, circumstances or level of risk; following a suicide attempt, self-harm incident or relevant near miss; following relevant advice from a health professional; or where existing risk-management measures are no longer effective.

The personal plan must in all cases be reviewed as and when required and at least every three months, in accordance with Regulation 16.

4.2 Ongoing Monitoring and Supervision

Where an individual is assessed as being at risk of suicide or serious self-harm, the level of monitoring, observation or supervision required must be determined by the individual’s current assessed risk, needs, circumstances and relevant professional advice and must be recorded clearly in the individual’s personal plan.

The service will not use a fixed observation interval as a substitute for individual assessment. The level of observation may include intermittent observations, increased staff presence or continuous direct observation where this is necessary and proportionate to the assessed risk.

The personal plan must state, where applicable:

• the type and frequency of observations required;
• whether observations must be undertaken at specified or varied intervals;
• the member or category of staff responsible for completing them;
• what staff are required to observe or establish during each contact;
• how observations must be recorded;
• what changes or warning signs require immediate escalation;
• circumstances requiring urgent professional assessment or emergency assistance; and
• when and by whom the observation arrangements will be reviewed.

Staff must remain alert to changes in behaviour, mood, communication, presentation or circumstances that may indicate increased distress or increased risk of self-harm or suicide.

Any significant concern or increase in risk must be reported immediately to the person in charge and appropriate action taken without waiting for the next scheduled review or observation.

Where an individual’s risk changes, the relevant risk assessment and personal plan must be reviewed and amended without delay and appropriate health or mental health advice obtained where required.

Monitoring and supervision must be undertaken in the least restrictive manner that is safe and proportionate to the identified risk and must respect the individual’s privacy, dignity, rights and autonomy. Any restriction of the individual’s liberty must comply with the Mental Capacity Act 2005 and must have lawful authority where it amounts to a deprivation of liberty.

4.3 Environmental Safety Measures

{{org_field_name}} will identify and reduce risks within the premises, facilities and equipment so far as is reasonably practicable, taking account of the needs and assessed risks of the individuals using the service.

A documented environmental safety assessment will include consideration of potential ligature, hanging, strangulation and entrapment hazards where these are relevant to the individuals accommodated at the service.

Formal environmental audits will be undertaken at least every six months. An additional assessment or review must also be undertaken where relevant:

• before or following the admission of an individual where a known risk of hanging or strangulation requires environmental controls;
• when an individual’s assessed risk materially increases;
• following an actual or attempted hanging or strangulation incident or relevant near miss;
• following identification of a new hazard;
• following significant alteration, refurbishment or change of use of an area;
• following installation, replacement or relocation of fixtures, fittings or equipment that could materially affect the risk;
• following relevant advice from a health professional, safety specialist, CIW or another competent authority; and
• where existing control measures are found to be ineffective or no longer appropriate.

Environmental assessment will include, where relevant:

• curtain, blind and other accessible cords;
• doors, door closers, handles, hinges and other projections;
• wardrobes, rails, hooks and other fixtures and fittings;
• bathroom and toilet fixtures and fittings;
• bedroom furniture and equipment;
• bedrails and other mobility or healthcare equipment;
• accessible cables, tubing and similar items; and
• other fixtures, fittings or items identified through individual or environmental risk assessment.

Where a hazard is identified, the service must determine and record appropriate control measures according to the level of risk. Action must be proportionate to the individual’s assessed needs and the nature of the hazard.

The use of anti-ligature or other specialist fittings must be based upon the assessed risk and, where necessary, competent professional advice. Such fittings must not be assumed to remove all risk and must be appropriately inspected and maintained.

Where an individual is identified as being at risk, personal belongings or necessary care equipment must not be removed automatically. Any proposed restriction or removal must be individually assessed, necessary and proportionate, recorded in the individual’s personal plan and reviewed. The individual’s rights, dignity, autonomy, care needs and the least restrictive available option must be considered.

Where the individual lacks capacity to consent to a proposed restriction, the Mental Capacity Act 2005 must be followed and lawful authority obtained where required.

4.4 Multi-Agency Collaboration

{{org_field_name}} will work collaboratively with relevant health, social care and safeguarding professionals where this is necessary to protect an individual from harm and to ensure that their assessed care and support needs are met. Depending on the circumstances, this may include:

• the individual’s GP;
• relevant mental health services;
• emergency and crisis mental health services;
• the relevant local health board;
• {{org_field_local_authority_authority_name}} adult safeguarding services;
• the ambulance service and police where an emergency response is required; and
• other health or social care professionals involved in the individual’s care and support.

Where a concern about suicide, self-harm, hanging or strangulation is identified, staff must take prompt and proportionate action according to the level and immediacy of risk. Relevant health or emergency services must be contacted without delay where urgent assessment or treatment is required.

The individual must be involved in decisions about their care, treatment and information sharing wherever they have capacity to make the relevant decision. Their views, wishes, feelings, preferences and personal outcomes must be taken into account.

An adult must be presumed to have capacity to make a particular decision unless it is established, in accordance with the Mental Capacity Act 2005, that they lack capacity to make that specific decision at the time it needs to be made. Where the individual lacks capacity to make the relevant decision, any decision made or action taken on their behalf must comply with the Mental Capacity Act 2005, including the statutory principles and best-interests requirements, and any lawful representative must be involved where applicable.

Information will be shared only where there is an appropriate lawful basis and to the extent necessary and proportionate for the purpose. Information may be shared without consent where this is lawful and necessary, including where required to protect the individual or another person from serious harm, to meet safeguarding duties, to provide emergency care or to comply with another legal obligation.

All information sharing must comply with the Data Protection Act 2018, the UK General Data Protection Regulation, applicable safeguarding requirements and the organisation’s Confidentiality and GDPR Policy (CHW34). Decisions about significant information sharing, including the reasons for sharing or not sharing information, must be recorded.

4.5 Personal Planning and Supportive Interventions

Where a risk of suicide, self-harm, hanging or strangulation is identified, the individual’s personal plan and relevant risk assessments must clearly describe how the identified risk will be managed on a day-to-day basis.

The personal plan must be person-centred and proportionate to the individual’s assessed needs and level of risk. It must include, where relevant:

• the identified risks, warning signs, triggers and changes in presentation that staff must be alert to;
• the individual’s views, wishes, feelings, preferences and personal outcomes;
• actions staff must take to reduce or manage identified risks;
• the level and frequency of observation or supervision required, where applicable;
• any environmental precautions required;
• arrangements for emotional support and regular contact with appropriate staff;
• how and when concerns must be escalated to the Registered Manager or person in charge;
• circumstances requiring contact with the GP, mental health services, NHS 111 Wales, emergency services or other relevant health professionals;
• any agreed safety planning or other interventions recommended by relevant health professionals;
• arrangements for access to appropriate therapeutic, social or meaningful activities;
• involvement of family members, representatives or significant others where this is agreed by the individual, where they have lawful authority to act, or where involvement is otherwise lawful and appropriate; and
• any safeguarding action required where there is reasonable cause to suspect that the individual is experiencing, or is at risk of, abuse, neglect or improper treatment.

The personal plan and associated risk assessments must be reviewed whenever there is a change in the individual’s presentation, behaviour, mental or physical health, expressed suicidal thoughts, self-harming behaviour, circumstances or level of risk; following any relevant incident or near miss; following relevant professional advice; and as part of the statutory review arrangements for the personal plan.

The personal plan must be reviewed as and when required and at least every three months in accordance with Regulation 16 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

An individual must not be treated as lacking capacity solely because they have a mental health condition, cognitive impairment, express suicidal thoughts, self-harm or make a decision that others consider unwise.

Where there is reason to doubt an individual’s capacity to make a particular decision, capacity must be assessed in relation to that specific decision and at the time the decision is required, in accordance with the Mental Capacity Act 2005. Where the individual lacks capacity for that decision, any act or decision made on their behalf must be in their best interests and otherwise comply with the Mental Capacity Act 2005.

Any restriction imposed to manage risk must be necessary and proportionate. Where an individual lacks capacity to consent to arrangements which amount to a deprivation of liberty, the service must ensure that appropriate lawful authority is obtained and maintained.

Staff will communicate about suicide and self-harm sensitively, respectfully and without judgement and will ensure that individuals are supported to express their concerns and participate as fully as possible in decisions about their care and support.

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, Incident Management and Notifications

Any actual or suspected hanging or strangulation, suicide attempt or other life-threatening act of self-harm must be treated as a medical emergency.

Staff responding to an emergency must:

• immediately summon appropriate emergency assistance, including calling 999 where there is an actual or suspected hanging or strangulation, suicide attempt, loss or alteration of consciousness, breathing difficulty, significant injury or other immediate threat to life;
• take immediate action, within the limits of their training and competence, to release the individual from any ongoing source of harm;
• provide first aid and cardiopulmonary resuscitation where required and in accordance with their training;
• follow instructions given by the ambulance service or other emergency healthcare professionals;
• ensure that the individual is not left alone where there is an immediate or continuing risk of further self-harm, unless emergency responders direct otherwise;
• obtain appropriate medical assessment following an actual or suspected hanging or strangulation or other serious suicide attempt;
• inform the Registered Manager or person in charge without delay;
• preserve relevant evidence and avoid unnecessary disturbance of the scene where a death, serious injury, safeguarding concern or police investigation may be involved, except where action is required to save life, prevent further harm or make the area safe; and
• make a contemporaneous record of the incident, actions taken, persons contacted and advice received.

Following the immediate emergency response, the Registered Manager or delegated competent person must ensure that:

• the individual’s risk assessments and personal plan are reviewed without delay;
• relevant health and mental health professionals are contacted and their advice is recorded and implemented;
• any new or increased risks within the environment are assessed and reduced so far as is reasonably practicable;
• appropriate support is provided to other individuals, staff and others affected by the incident;
• the individual’s representative or family is informed where the individual consents, where the representative has lawful authority, where this is required by law or where there is another lawful and appropriate basis for doing so;
• the organisation’s safeguarding procedure is followed where there is reasonable cause to suspect abuse, neglect or improper treatment;
• duty of candour requirements are followed where applicable; and
• the incident is reviewed to identify any necessary actions and learning, and completion of those actions is monitored.

Notification to Care Inspectorate Wales

A suicide attempt or incident of self-harm must not be treated as automatically notifiable to Care Inspectorate Wales solely because self-harm has occurred.

The service provider must notify Care Inspectorate Wales where the incident falls within a category specified in Regulation 60 and Schedule 3 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

This includes, where applicable:

• the death of an individual where accommodation is provided, together with the circumstances of the death;
• a serious accident or injury to an individual;
• abuse or an allegation of abuse involving the service provider, a member of staff or a volunteer;
• an incident which has been reported to the police; or
• an event which prevents, or could prevent, the provider from continuing to provide the service safely.

Where more than one notification category applies, the service must ensure that the information supplied to CIW accurately reflects the circumstances of the incident.

Notifications required under Regulation 60 must be submitted to CIW without delay through the applicable CIW notification process. The Registered Manager and Responsible Individual must ensure that responsibility for making the notification is clearly allocated and that evidence of submission is retained.

Where the incident involves a child accommodated by the service, the service provider must additionally comply with all notification requirements applicable to children’s care home services under the relevant parts of Schedule 3, including notifications to the placing authority and other prescribed bodies where required.

Safeguarding

A suicide attempt or act of self-harm does not, by itself, automatically constitute an adult safeguarding referral. However, where there is reasonable cause to suspect that the individual is experiencing or is at risk of abuse, neglect or improper treatment, immediate action must be taken to protect the individual and the service must make the appropriate safeguarding referral in accordance with Regulation 27, the Wales Safeguarding Procedures and the organisation’s safeguarding policy.

All safeguarding decisions, referrals, advice received and actions taken must be recorded.

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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