Standard 16: Psychiatry and Mental Health (Version 11)

Why it matters. A person admitted to a psychiatric unit may be at risk of taking their own life. Screening every admission with a validated tool, and watching those at high risk, can prevent a death.

Sample. Review screening and observation records for every psychiatric admission in the last 6 months, and the observation logs for high-risk patients.

1. Every psychiatric admission is screened for suicide risk with a validated tool.

Method. Check each sampled admission record for the screening result and the tool name.

Evidence to show. Suicide risk screening record (PSY-FRM-001).

Pass when. Every sampled admission has a validated screen recorded on admission.

2. A high-risk patient is placed on continuous, documented observation.

Method. Check each sampled high-risk patient for continuous observation entries at the set interval.

Evidence to show. Continuous observation log (PSY-REG-001).

Pass when. Every sampled high-risk patient has continuous observation recorded for the whole high-risk period.

3. Observation is stepped down only with a documented psychiatric decision.

Method. Check each step-down for the psychiatrist decision and the reason.

Evidence to show. Continuous observation log (PSY-REG-001).

Pass when. Every step-down has a recorded psychiatrist decision and reason.

Immediate fail (any one means the criterion is not met). A patient who says they will end their life is screened low, and is found unobserved in the bathroom.

Good practice. Screening results and observation levels are reviewed together at each ward round, so a high-risk result changes the observation level the same day.

Partial because. screening is done with the tool, but the observation level is not changed when the score is high.

Why it matters. A person in crisis may hang themselves with a cord, a sheet or a fitting in the room. A systematic check of the environment, with hazards removed, prevents that.

Sample. Review the ligature survey and mitigation records for the psychiatric unit, and inspect a sample of rooms.

1. The unit is systematically surveyed for ligature and self-harm risk points.

Method. Check the survey schedule and the survey record for each room.

Evidence to show. Ligature risk survey record (PSY-FRM-002).

Pass when. Every room and area is surveyed on the set schedule.

2. Identified hazards are mitigated.

Method. Check each recorded hazard for its mitigation and the date.

Evidence to show. Ligature risk mitigation register (PSY-REG-002).

Pass when. Every identified hazard has a recorded mitigation.

3. Mitigations are re-checked.

Method. Inspect a sample of rooms and check the re-check dates in the register.

Evidence to show. Ligature risk mitigation register (PSY-REG-002).

Pass when. Every mitigation is re-checked on the set schedule, and the rooms match the register.

Immediate fail (any one means the criterion is not met). A ligature point in a bedroom is recorded and not mitigated, and a patient uses it.

Good practice. The ligature survey is repeated after any change to fixtures or furniture, and patients are asked to point out risks on the unit.

Partial because. the survey is done on admission, but the unit is not re-surveyed after changes to the rooms.

Why it matters. Restraint and seclusion can cause injury, distress and death. They must be the last resort, after real attempts to calm the person, and documented in full.

Sample. Review every restraint and seclusion episode on the unit in the last 12 months.

1. De-escalation is tried and recorded before restraint or seclusion.

Method. Check each episode record for the de-escalation steps and the time they were tried.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. Every episode has de-escalation recorded before it started.

2. Each episode is reviewed and time-limited.

Method. Check each episode for the review time and the end time.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. Every episode has a review and an end time within the set limit.

3. Each episode is justified by a clinician in the patient record.

Method. Check the clinician’s justification for each episode.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. Every episode has a justification signed by a clinician.

Immediate fail (any one means the criterion is not met). A patient is secluded for 14 hours with no documented review, and no de-escalation is recorded first.

Good practice. Each seclusion episode is reviewed by a senior clinician within the first hour, and the reason for each episode is reported to the unit team.

Partial because. episodes are recorded, but the de-escalation attempts before them are not written down.

Why it matters. Some psychiatric medicines interact with others or need careful monitoring, such as blood tests. A defined process for these keeps the treatment safe.

Sample. Review the medicine records of psychiatric patients on medicines with interaction risk or monitoring needs, for the last 6 months.

1. Psychiatric medicines are managed under a defined interaction and monitoring protocol.

Method. Compare the protocol with the medicines list for the unit.

Evidence to show. Psychiatric medicines: interaction and monitoring protocol (PSY-SOP-002).

Pass when. Every medicine on the list that needs monitoring is covered by the protocol.

2. Each prescription is checked for interactions before it starts.

Method. Check each sampled prescription for the interaction check.

Evidence to show. Psychiatric medicine monitoring record (PSY-FRM-003).

Pass when. Every sampled prescription has a recorded interaction check before it started.

3. Required monitoring tests are done on schedule.

Method. Compare the due and done dates in the monitoring record for each sampled patient.

Evidence to show. Psychiatric medicine monitoring record (PSY-FRM-003).

Pass when. Every required monitoring test was done on schedule.

Immediate fail (any one means the criterion is not met). A patient on a medicine needing blood monitoring has no test in a year, and toxicity is found late.

Good practice. A pharmacist checks the psychiatric medicines list each month and flags interactions to the prescriber before the next dose.

Partial because. the protocol exists, but the monitoring tests are not linked to the prescription record.

Why it matters. De-escalation is a skill that has to be practised, not only explained. Staff who have drilled it are more likely to calm a situation than to restrain.

Sample. Review drill and training records for all unit staff for the last 2 years.

1. Staff take part in practical drills, not only written policy review.

Method. Check the drill register for each staff member who was drilled.

Evidence to show. De-escalation drill register (PSY-REG-003).

Pass when. Every unit staff member has a recorded practical drill in the period.

2. Training is refreshed at the defined interval.

Method. Compare each staff member’s refresher due date with the date of the review.

Evidence to show. De-escalation drill register (PSY-REG-003).

Pass when. No staff member is past the refresher due date.

3. Each new staff member is drilled before working alone on the unit.

Method. Check the drill register for the drill date and the start date of each new staff member.

Evidence to show. De-escalation drill register (PSY-REG-003).

Pass when. No new staff member works alone before a recorded drill.

Immediate fail (any one means the criterion is not met). A staff member has read the de-escalation policy but never practised it, and a patient assault goes unmanaged.

Good practice. Drills include a real scenario on the unit, and the team debriefs each drill within a week.

Partial because. drills are done each year, but new staff are not drilled until their first refresher.

Why it matters. A person leaving psychiatric care is at a higher risk in the first days after discharge. A written safety plan and follow-up arranged before they leave reduce that risk.

Sample. Review discharge records of psychiatric patients in the last 6 months, for safety plans and follow-up appointments.

1. Every psychiatric patient has a documented safety plan before discharge.

Method. Check each sampled discharge record for the written safety plan.

Evidence to show. Discharge safety plan and follow-up confirmation (PSY-FRM-004).

Pass when. Every sampled discharge has a written safety plan.

2. A follow-up appointment is arranged and confirmed, not only recommended.

Method. Check each sampled discharge for the booked date and the confirmation with the patient.

Evidence to show. Discharge safety plan and follow-up confirmation (PSY-FRM-004).

Pass when. Every sampled discharge has a booked and confirmed follow-up appointment.

3. The patient receives a copy of the safety plan at discharge.

Method. Check the discharge record for the handover of the copy and the patient’s acknowledgement.

Evidence to show. Discharge safety plan and follow-up confirmation (PSY-FRM-004).

Pass when. Every sampled patient has a copy of the plan recorded as handed over.

Immediate fail (any one means the criterion is not met). A patient is discharged with a verbal suggestion to see a doctor, no appointment, and no safety plan, and returns in crisis the next day.

Good practice. The patient and a family member agree the safety plan together and receive a copy, and the follow-up is booked before the patient leaves the unit.

Partial because. the safety plan is written, but the follow-up date is not confirmed with the patient.