Safeguarding People Who Are at Significant Risk of Self-harm and Suicide (Wales) Policy

Policy Statement

This policy outlines the service’s actions when assessing and responding to the needs of vulnerable people using the service who are at significant risk of harm because of their often complex needs that are related to their mental health difficulties and disorders. It includes people using the service who might place themselves in risky and dangerous situations, who are self-harming or at risk of self-harming in some way, including from self–neglect, or who are at risk of taking their own life.

The service considers that it has a duty to protect these vulnerable people using the service from the injurious effects of their actions and to promote their wellbeing to prevent them from coming to harm.

With the above issues in mind, {{org_field_name}} adopts the following approach and procedures, which it considers are in line with its duty of care and the regulatory framework in which it operates. This includes the following.

The Social Services and Wellbeing (Wales) Act 2014 requires local authorities in partnership with care providers to promote people’s wellbeing while at the same time keeping them safe from harm through the interventions of local safeguarding boards.
The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 require providers to deliver person-centred care within a care environment and ethos that also ensures people using services’ safety.
Guidance issued by the National Institute for Health and Care Excellence (NICE) with its quality standard QS34 Self-Harm (NICE 2013, updated 2022) and NG225 Self-harm: Assessment, Management and Preventing Recurrence (NICE 2022).
National guidance such as that contained in In Safe Hands and subsequent guidance issued by the Welsh Government.

The policy should be read and used in line with other safeguarding policies including the Safeguarding People Using the Service from Suicide by Hanging/Strangulation policy.

Defining and Recognising Self – Harm and Associated Risks

The situations and behaviours covered by this policy are very wide, but the more likely are as follows.

a) Exposure to Dangerous Situations

A person can deliberately expose him of herself to possible danger for different reasons, and not necessarily with a view to carrying out any expressed or implied threats, but all such actions must be taken seriously. The actions could include: threatening to jump off heights, walking or crossing busy roads or railway lines, cutting or holding electricity cables, running the risk of drowning, threatening to use sharp instruments, or guns etc.

b) Self-harming and self-neglect

Self–harming is associated more with young people, but can occur and start at any age. Examples include:

self–mutilation using knives razors and other sharp instruments (“cutting” behaviour)
punching or hitting oneself, pulling out hair, head banging and burning with cigarettes, lighters etc
repeated alcohol, toxic substance and drug abuse or overdose
eating disorders, through starvation or compulsory eating
severe neglect, which might result in increased vulnerability to illness and infection, failure or refusal to take prescribed medication that could be life – saving such as insulin injections, or without administration could seriously impair the person’s health and put him or her further at risk.

Self-harming behaviour can be triggered at any time, often when the person is feeling angry, frustrated or disgusted with themself. For anyone at risk of self–harming, care staff should be aware of the potential triggers and be prepared to act to prevent escalation. For example, they should:

look out for unexplained cuts, bruises or cigarette burns on e.g. wrists, arms, thighs and chest, or hair pulling
note any behaviour suggesting the person is concealing the signs e.g. keeping themselves fully covered inappropriately
be aware of changes of mood, signs of emotional distress, expressions of self-hate and self–punitive ideas
sudden expressions of low self-esteem and feelings of failure and worthlessness

c) Suicide Risks

The service recognises that people who self-harm do not necessarily do so with a view to committing suicide, though signs and symptoms might be similar, and people with suicidal thoughts might not express them at all. Care staff must still pay serious attention to people using the service with a history of suicidal behaviour and any who clearly express suicidal thoughts and intentions, eg anyone who:

seems to be in a state of considerable emotional pain and anguish, which seems to be overwhelming and making the person unable to cope
expresses complete feelings of hopelessness and despair that they will never get any better
seems totally powerless and unable to cope with daily life any longer
expresses feelings of worthlessness, shame, guilt, self-hatred, feels that no one cares or others would be better without them
expresses fear of losing control or harming self or others
becomes very sad, withdrawn, tired, apathetic, anxious, irritable or prone to angry outbursts
shows a declining interest in relationships, friends or activities previously enjoyed
neglects personal welfare and physical appearance deteriorates
drastically changes their sleeping or eating habits (particularly the elderly)
begins to starve themselves, mismanage their diet or disobey medical instructions
becomes depressed at difficult times such as holidays and anniversaries
reacts adversely to diagnosis of major or minor illnesses, prospects of going into hospital, of operations, etc.
fails to accept emotionally that they have recovered from illness or an operation
appear depressed after discharge from hospital.

Assessment of Care Needs in Relation to Suitability of Service

Before we agree to accept a person for the service, we will always ensure that a thorough assessment of the prospective person’s needs has been undertaken, either by the referring service, service commissioner or under our own procedures, as the basis for a plan of care and support.

The assessment will include the identification of people’s vulnerability to putting themselves into dangerous and risky situations or risk of self–harming. It will be regularly reviewed and reassessed in relation to any changes in the person’s wellbeing and behaviour.

Risk Assessment

The service will respond to any person who then presents or is subsequently found at risk of putting themself into dangerous situations, of self-harming or of attempting suicide by ensuring that they are formally assessed by appropriately trained and qualified mental health professionals to decide how the person can be best supported and to know how to act if they engage in any dangerous behaviour, self-harming or suicide threats or attempts.

The risk assessment will be recorded on the person’s care and plan, which will also outline and the responsibilities of care service staff in managing the risks or situations that might arise. Risk assessments will be reviewed regularly, if circumstances change significantly, or a new risk arises.

Depending on what has been agreed in the care and support plan, the service might need to intensify its monitoring and supervision of the person at risk, and negotiate the extra staffing and other resources that might be needed.

Sources of Danger for People Using the Service Who Are at Risk

The assessment will consider all sources of possible danger. These include the person’s own behaviour, their living environment and life-style, access to specifically dangerous items including medicines, the actions of other people regularly in contact with the person, and situations arising if the person goes out, where the service continues to have some responsibility for the person’s safety.

{{org_field_name}} will define its areas of responsibility in the person’s care and support plan, and it may, with the person using services’ permission, be prepared to alert other people or agencies who can provide advice or take appropriate action to minimise any danger in their involvement with the person using services.

Procedures in the Event of an Incident

The service recognises that it might have to deal with an event of a person who has exposed her or himself to danger, self–harmed or attempted suicide. This could be an unexpected event, which has occurred without there being any evidence of risk, or because the person has carried out their intentions despite preventive measures having been taken.

Where and when the incident takes place could vary, for example, it could be outside {{org_field_name}} setting. If it takes place within, say the person’s accommodation or in one of the service’s facilities, it is likely that care service staff will be the first responders, either because they have been alerted by someone or discovered it themselves. In this case the following procedures might apply, though because of the nature of the situation, it is difficult to be entirely prescriptive, and much will depend on the training, confidence and competence in emergency situation handling of the people involved.

Where there is a clear known risk, care staff should always have help available, and where possible there should be a co-worker. There should be the means to summon help immediately using a call system or mobile phone.
The service should also already have contingency plans for possible crisis situations, which staff can put into effect, including summoning para-medical service help e.g. in the case of someone who has taken a drugs overdose or from a crisis mental health teams for someone in acute emotional distress.
With a person having seriously hurt themself the care worker (or workers) will need to make a brief immediate assessment to decide the urgency of the situation before reporting the situation and summoning the appropriate help.
The care worker should reassure the person that help will be forthcoming and stay with the person (assuming it is safe to do so) until help arrives.
In all cases of visible self – harm the person will need first aid or medical attention, and in some cases further medical assessment to check any inadvertent adverse effects of the harmful act.

Changes to Agreed Actions Following a Risk Assessment and Incidents

The service will ensure that the incident is fully reported and all relevant organisations notified, including CIW and the local safeguarding authority so that a full investigation can take place to identify what lessons might be learned.

The service will enter into discussions with the person using the service, family members or other professionals with a view to a revision of the risk assessment and care plan. In some cases if the service cannot guarantee to keep the person safe or if its staff are put at significant risk it might proceed to terminate the service or recommend that the person is transferred to a more protective environment. All discussions and actions taken will be fully recorded.

The service will also ensure that staff who were directly involved and others affected by the event, including people using services, receive the appropriate support and counselling opportunities.

Involving Others in Decisions About Vulnerable People

People using the service whose lack of capacity to take responsible decisions about their own welfare will be treated under the current statutory provisions (Mental Health Act / Mental Capacity Act). Otherwise the people who use our services retain the right to take decisions about the risks they choose to take.

In decisions about care or risk-taking we will involve others — family members, friends, representatives or other professionals — with the specific permission of the person. People using services will always be fully involved in their care and support plans, including risk assessments and management measures.

All staff are expected to respect the right of the adult at risk to make their own decisions regarding their present and future circumstances wherever that adult can make informed choices. This must include decisions relating to situations perceived by professionals or others to be risky or dangerous. In such cases, the person will be given information about the options available to them that could protect them from coming to harm, including how to minimise any harm.

A person’s wishes must never be allowed to undermine the service’s responsibility to act in line with its duty of care, particularly, when working in partnership with the local authority exercising its duties under the Social Services and Wellbeing (Wales) Act 2014.

Inter-service Partnership Working

This service recognises the complexity often involved in working for the protection of adults at risk of harm and is aware of the benefits to be gained from good multi-disciplinary and inter-service working. All staff are required to work actively together with other services and local adult safeguarding teams on the prevention, identification, investigation, and treatment of alleged, suspected or confirmed self-abuse and management of risk. The local safeguarding authority will always be involved in line with its safeguarding policies and procedures.

Staff

We will ensure that all staff having contact with people using the service who are at risk of self-harm and self-neglect are adequately trained and appropriately experienced to provide the best possible service. Where a person using the service presents risks that are outside the experience of the staff allocated to their care, the staff will be given specific briefing or training. Qualified and experienced senior staff supervise care workers, who always have access to a responsible and competent person for advice and support.

Charging for Services

If the fact that a person using the service is especially vulnerable significantly effects the way in which our service needs to be provided or calls for special training or preparation of the responsible staff, this may be reflected in the agreed fees.

Training

All staff members receive training to make sure they understand the service’s policy regarding adults at risk who need specific measures to keep them fully safe.

Staff receive further and more specialised training in the care of adults at high risk of harm in line with their roles and responsibilities.

Training will include:

Understanding signs and symptoms of people at risk of harming or injuring themselves and of suicidal behaviour
Observing and reporting of concerning behaviour, and how to deal appropriately with it
Risk assessments and management planning
Emergency procedures
Availability of occupational health support to staff affected by having to deal with distressing situations and behaviour.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next review date: this policy is reviewed annually (every 12 months). When needed, this policy is also updated in response to changes in legislation, regulation, best practices, or organisational changes.

DW202. Safeguarding People Who Are at Significant Risk of Self-harm and Suicide