Adults of Working Age & Older Adults Version

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1 Revised November 2009 STAR Clinical Risk Assessment Tool DETAILS OF PERSON COMPLETING THE FORM: Adults of Working Age & Older Adults Version Surname: Forename: Team/Service: PATIENT DETAILS Unique ID: Date of Birth: Gender: Male/Female Forename: Surname: DETAILS OF ASSESSMENT Assessor: Assessor Team: Team Date of Assessment: Start Time of Assessment: Initial Assessment: Yes No Location of Assessment: Care Home - Other NHS Run Residential Care Home Local Authority Prison Consultant Clinic - NHS Off Site Residential Care Home non NHS/LA Public Place Consultant Clinic Resource Centre Local Authority Nursing Home NHS Day Centre Local Authority Resource Centre NHS off site Nursing Home non NHS Day Centre non NHS Resource Centre NHS on site LA Facility on site Group Home Local Authority Resource Centre non NHS/LA LA Site LA run Group Home - NHS NHS Day Care Centre (off site) LA Site NHS run Group Home non NHS NHS Day Care Centre (on site) LA Site Other run Health Centre Other GP Premises School (public/private) Health Clinic - NHS Other Location School (state) Health Clinic non NHS Patients home Telephone Health Organisation Patients Visiting Address Ward Hospice Work Note to Admin: Please set Status and Outcome to Complete. Page 1 of 13

2 Unique ID: NHS No: Date: CPA STAR RISK SCREEN Form 1 Is this an Initial Risk Screen Assessment? Is this a Subsequent Risk Screen Assessment? SELF-HARM/SUICIDE YES Current behaviour suggesting there is a risk of self harm/suicide Recent bereavement (or anniversary of) Past history of selfharm/attempted suicide Thoughts/plans indicating risk of self-harm / suicide Mental illness (eg depression, psychotic illness/personality disorder, etc) Current problems with alcohol or substance misuse (if yes complete Form2c substance misuse assessment) Any expression of concern (especially from a relative or carer) about the risk of selfharm/suicide Was serious intent expressed relating to any act of self harm/attempted suicide Any attempt to conceal an act of self harm Currently experiencing/responding to command hallucinations Other issue / concern re risk of suicide / self harm Is Full Risk Assessment of this domain indicated? SERIOUS SELF NEGLECT YES Fluid/dietary problems Personal Hygiene problems Risk of accidents (to self or others) Untreated physical illness Non-compliant with medication Relapse risk Non-compliance with treatment for physical illness Alcohol/Substance Misuse Homelessness Other concerns re self neglect Is Full Risk Assessment of this domain indicated? Yes/No Yes/No Does the Service User have the capacity to consent to Carer involvement in the process? Does the Service User consent to the Carer being involved in this process? HARM TO OTHERS YES Current thoughts/plans or symptoms indicating risk of violence/harm to others Current behaviour suggesting risk of violence/harm to others Current problems with alcohol or substance abuse Any expression of concern from others about the risk of violence History of sexually inappropriate conduct Physical factors (eg Acute confusional state, pain, etc) Evidence of disinhibited behaviour Any risk towards children (intentional or unintentional), or any concern about ability to care for dependant children Evidence of arson and fire setting Currently experiencing / responding to command hallucinations Current risk of violence from others Forensic History Index Offences Is Full Risk Assessment of this domain indicated? EXPLOITATION/ VULNERABILITY Exploitation Disinhibited behaviour Impulsive behaviour Grandiose ideas Confusion / disorientation forgetfulness / diagnosed dementia. Concerns regarding home conditions/ environment Physical health Risk of falls Wandering Night disturbance Is Full Risk Assessment of this domain indicated? YES Yes/No Yes/No Page 2 of 13

3 Has the Service User been involved in the risk assessment Does the Service User agree with the risk assessment Yes No Yes No Not Appropriate Not Appropriate SAFEGUARDING CHILDREN Is the Person likely to have or resume contact with their own children or other children ( please provide details ) YES Does the Person have delusional beliefs involving the children ( please provide details ) ( if Yes, refer to Consultant Psychiatrist for involvement in clinical decision making ) YES Is there concern that the Person might harm their child / unborn child as part of suicide plan please provide details ) ( If Yes, refer to social services immediately and refer to Consultant Psychiatrist for involvement in any clinical decision making ( refer to child protection policy for guidance) YES Mental Health Act Status: Detained / Section 117 / Guardianship / None / Other (please state) Date of Referral Referrer Address: Date Referral Received Name of Referrer Post Code: Telephone No: Reason for referral: Service User s understanding of the reason why referred: IS FULL RISK ASSESSMENT INDICATED IN ANY OF THE DOMAINS YES If : Complete Formulation of Risk and CPA Initial Assessment (Form 7) only, no further information is required. If YES: 1. Complete full risk assessment using CPA STAR Forms 2a, 2b, 2c as appropriate 2. Complete the CPA STAR Formulation of Risk Form 3 3. Complete the CPASTAR Risk Management Plan Form 4 4. Complete the CPA STAR Risk History (Record of Incidents) Form 5 5. Update the Service Users Care Plan Form 8 In the event of admission to an acute ward ensure a full Physical Health Check Form 9 is completed. Patients Signature: Page 3 of 13

4 Unique ID: NHS No: Date: CPA STAR CLINICAL RISK ASSESSMENT Form 2a SELF-HARM/SUICIDE YES HARM TO OTHERS YES Current Current Low in mood Hostile or threatening behaviour Current suicidal ideation Violent thoughts or fantasies Current misuse of drugs/alcohol Has problems controlling temper Impulsivity Possesses weapons with possible intent to use Hopelessness Has access to potential or threatened victim Recent disengagement or non compliance Is sexually disinhibited Recent adverse life events Has difficulty controlling sexual impulses High level of distress Drug or alcohol misuse Physical illness or disability Has symptoms which increases the risk of violence for this person Lives alone (or will do after discharge) Concern has been expressed by others about violence Social isolation Recent discharge from hospital. 1 st home leave after self harm attempt Concern expressed by significant others Specific factors which indicate level of intent (e.g. attempt to conceal): Other individual factors (e.g. stressors, particular symptoms): Other individual factors including risk to self and from others (e.g. stressors, delusions, coping methods, relationship problems, anniversary of significant events): Page 4 of 13

5 7PAST HISTORY (SELF HARM /SUICIDE) YES PAST HISTORY (HARM TO OTHERS) YES History of self-harm Has a previous history of violence Family history of suicide/self-harm Has a history of disengagement from services Witnessed or a victim of violence or emotional abuse in childhood History of Self-Harm/Suicide Attempt Has a history of deliberate or accidental fire setting Has a history of sexually inappropriate behaviour including sexual offences Any other risk to other people Consider risk to children intentional or unintentinal History of Harm to Others Forensic History (List Index Offences) Self Harm / Suicide - Users views Risk of Violence Users views. Patients Signature: Page 5 of 13

6 Unique ID: NHS No: Date: SERIOUS SELF NEGLECT YES Current Accommodation and homelessness Inability to complete own ADLs Unacceptable home conditions (e.g. hazards) Social isolation Dehydration Malnourishment Personal hygiene problems Risk of accidents to self/others Driving risk CPA STAR CLINICAL RISK ASSESSMENT Form 2b Is physical health affected by current mental state Persistent non-compliance with medication/errors of selfmedicating Alcohol/substance misuse/abuse of prescribed /non-prescribed medication Tissue viability/condition of skin Other individual factors (e.g. stressors, coping methods, relationships) EXPLOITATION/ VULNERABILITY Current Risk of physical abuse Risk of sexual abuse Risk of social abuse Risk of emotional abuse Risk of financial abuse Threats to privacy and dignity Disinhibited behaviour Impulsivity Confusion/disorientation/ Forgetfulness Grandiosity Consider risks to children intentional/unintentional Unacceptable home conditions (e.g. hazards) YES Recent falls. High risk of falls Wandering or night disturbance Other individual factors (e.g. stressors, particular symptoms) History of Serious self-neglect History of Exploitation/Vulnerability of Self and Others Self Neglect Users views Exploitation / vulnerability Users views This is not intended as a score sheet but to help prepare the Formulation of Risk Form 3. Other Information sources Patient s Carers/ Patient Agencies used: Records Friends (specify) Is further information needed? Yes No From what source? To be sought by: Is a further more detailed risk assessment needed? (Discuss with MDT) Yes No Patients Signature: Page 6 of 13

7 Unique ID: NHS No: Date: CPA STAR CLINICAL RISK ASSESSMENT Form 2c ADULTS OF WORKING AGE SUBSTANCE MISUSE SUBSTANCE MISUSE YES COMMENTS. Does misuse lead to deterioration in mental state? Does misuse lead to deterioration in physical health? Does misuse place person in high-risk situations? Does misuse lead to violence? Is there a pattern to their misuse? Are there identified triggers? Do they have insight into their misuse? Have they abstained for any period? What interventions have worked in the past? Dose person have coping strategies to manage misuse? Does misuse have a role? Does their injecting behaviour present a risk. Ie injecting alone, use of NEX and disposal of sharps. Risk of blood borne virus? Does misuse or risk taking behaviour present any risk to children? What substances do they misuse. Amount. Frequency. Duration. This is not intended as a score sheet but to help prepare the Formulation of Risk Form 3. Other Information sources Patient s Carers/ Patient Agencies used: Records Friends (specify) Is further information needed? Yes No From what source? To be sought by: Is a further more detailed risk assessment needed? (Discuss with MDT) Yes No Patients Signature: Page 7 of 13

8 Unique ID: NHS No: Date: CPA STAR FORMULATION OF RISK Form 3 Domain: Self Harm/Suicide Harm to Others Serious Self Neglect Exploitation/Vulnerability Current threat or likelihood Take into consideration: (1) Past history (2) Nature and Degree of Risk (who is at risk: when/why/how likely is it?); (3) Relationship between risk and mental disorder, current social circumstances or other contextual factors; (4) Service User, Carers & others views of risk: 1: 2: 3: 4: Indicators of increased risk Take into consideration: (A) Factors increasing the risk, and protection factors that reduce risk; (B) Previous helpful interventions; (C) Gaps in information (A) (B) (C) Please use the above formulation to inform care plans including crisis and contingency plans in CPA assessment and reviews. Each time full risk assessment is repeated a new formulation should be completed. Ensure relevant information is shared with all those who need to know. Note any constraints in passing this information on. Page 8 of 13

9 Patients Signature: Unique ID: NHS No: Date: CPA STAR FORMULATION OF RISK Form 3 Domain: Self Harm/Suicide Harm to Others Serious Self Neglect Exploitation/Vulnerability Current threat or likelihood Take into consideration: (1) Past history (2) Nature and Degree of Risk (who is at risk: when/why/how likely is it?); (3) Relationship between risk and mental disorder, current social circumstances or other contextual factors; (4) Service User, Carers & others views of risk: 1: 2: 3: 4: Indicators of increased risk Take into consideration: (A) Factors increasing the risk, and protection factors that reduce risk; (B) Previous helpful interventions; (C) Gaps in information (A) (B) (C) Please use the above formulation to inform care plans including crisis and contingency plans in CPA assessment and reviews. Each time full risk assessment is repeated a new formulation should be completed. Ensure relevant information is shared with all those who need to know. Note any constraints in passing this information on. Page 9 of 13

10 Patients Signature: Unique ID: NHS No: Date: CPA STAR FORMULATION OF RISK Form 3 Domain: Self Harm/Suicide Harm to Others Serious Self Neglect Exploitation/Vulnerability Current threat or likelihood Take into consideration: (1) Past history (2) Nature and Degree of Risk (who is at risk: when/why/how likely is it?); (3) Relationship between risk and mental disorder, current social circumstances or other contextual factors; (4) Service User, Carers & others views of risk: 1: 2: 3: 4: Indicators of increased risk Take into consideration: (A) Factors increasing the risk, and protection factors that reduce risk; (B) Previous helpful interventions; (C) Gaps in information (A) (B) (C) Please use the above formulation to inform care plans including crisis and contingency plans in CPA assessment and reviews. Each time full risk assessment is repeated a new formulation should be completed. Ensure relevant information is shared with all those who need to know. Note any constraints in passing this information on. Page 10 of 13

11 Patients Signature: Unique ID: NHS No: Date: CPA STAR FORMULATION OF RISK Form 3 Domain: Self Harm/Suicide Harm to Others Serious Self Neglect Exploitation/Vulnerability Current threat or likelihood Take into consideration: (1) Past history (2) Nature and Degree of Risk (who is at risk: when/why/how likely is it?); (3) Relationship between risk and mental disorder, current social circumstances or other contextual factors; (4) Service User, Carers & others views of risk: 1: 2: 3: 4: Indicators of increased risk Take into consideration: (A) Factors increasing the risk, and protection factors that reduce risk; (B) Previous helpful interventions; (C) Gaps in information (A) (B) (C) Please use the above formulation to inform care plans including crisis and contingency plans in CPA assessment and reviews. Each time full risk assessment is repeated a new formulation should be completed. Ensure relevant information is shared with all those who need to know. Note any constraints in passing this information on. Patients Signature: Page 11 of 13

12 Unique ID: NHS No: Date: Patients Name: CPA STAR RISK MANAGEMENT PLAN Form 4 PATIENT S NAME DATE & TIME PLAN FORMULATED SHEET PLANNED REVIEW DATE DOMAIN RISK FACTORS IDENTIFIED ACTIONS IDENTIFIED TO MINIMISE RISK DESIRED OUTCOMES RE-ASSESSMENT TECHNIQUES Patients Signature: Assessor Signature: Page 12 of 13

13 Unique ID: NHS No: Date: CPA STAR RISK HISTORY Form 5 Date of Incident/Event Describe risk event or incident. Where did it occur? Who suffered harm? Nature of injuries? Context of incident/event Any known precipitants (motivations, stressors). Include client and others views Patients view of Incident/Event. Are they aware of any triggers? Do they have any insight into their behaviour? Outcome of Incident/Event Any measures put in place to reduce risk & their effectiveness (from client & others view point). Legal Action Information Sources for Incident/Event Signed & Dated Date: Date: Date: Assessors Signature: Patients Signature: Sheet Number: Page 13 of 13

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