Recommendation
The trust should review its risk policy to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors.
Recommendation
When the trust has updated its risk policy, it should ensure that staff have a clear understanding of how to assess risk accurately.
Recommendation
The trust should ensure that a concise summary of the risks of each patient to themselves and others is prominently displayed on the patient record.
Recommendation
If there are not good examples of other trusts displaying concise summaries of risks prominently on patient records, NHS England should examine how it can support trusts to do this.
Recommendation
The trust should continue to review zoning and multi-disciplinary team meetings to ensure that they promote a positive discursive atmosphere where staff challenge and support each other.