Domain 4: risk and safety

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Standard 4.1: The service has risk management procedures.


Evidence Requirements

  • Risk management policy outlining responsibilities of individuals and reporting process.
  • Training for staff awareness.
  • Evidence of communication to staff about findings from risk management activities, including risk mitigation plans, risk reduction activities and the results of risk assessments and associated metrics (team meeting minutes/staff bulletins).

Standard 4.2: The service records risks in a risk register.


Evidence Requirements

  • A risk register to include named risk owners, risk mitigation, timescales for implementing changes and evidence of escalation, where appropriate.

Guidance

  • The risk register will cover as a minimum:
    • infection control
    • medicine management
    • oxygen management
    • adequacy of clinical space
    • workforce planning
    • slips, trips and falls.

Standard 4.3: The service has a procedure for how incidents, adverse events and near misses are reported, investigated and used to inform changes to service delivery.


Evidence Requirements

  • Examples of communication to staff to encourage reporting.
  • Meeting agendas and minutes demonstrating discussions of incidents and outcomes.
  • Examples of how learning is communicated to all staff.

Standard 4.4: The service undertakes and records a clinical risk assessment of individual patients.


Evidence Requirements

  • SOP for completing clinical risk assessments with individual patients
  • Evidence of individual risk assessments where clinical risk has been identified.
  • Evidence of staff training/competence in clinical risk assessment.

Guidance

  • The clinical risk assessment must include:
    • the risk of harm to the servicer user and others
    • the patient’s changing risks
    • deteriorating health and wellbeing
    • challenging behaviour
    • medical emergencies
    • medication management.
  • The results of the risk assessment must be recorded in the patient record.

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