Prevention of Future Deaths reports · 2022

Samuel Gomm

Regulation 28 report to prevent future deaths, reference 2022-0163, written 1 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report1 Jun 2022
Reference2022-0163
DeceasedSamuel Gomm
CoronerGraeme Hughes
Coroner areaSouth Wales Central
CategoryMental Health related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Powys Teaching Health Board 

Powys County Council 

1 

CORONER 

I am Graeme Hughes, Senior Coroner, for the coroner area of South Wales Central. 

2 

CORONER'S LEGAL POWERS 

I make this report under paragraph 7,  Schedule 5,  of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On  10th  June  2019,  I  commenced  an  investigation  into  the death  of Samuel  Joseph 
GOMM.  The investigation concluded  at the end  of the inquest on 18th  May  2022.  The 
conclusion of the inquest was Suicide. 

The medical cause of death was: -

1a. Laceration to neck 

4 

CIRCUMSTANCES OF THE DEATH 

These were recorded as: -

Samuel Joseph Gomm suffered from chronic mental ill health exacerbated by periods of 
alcohol abuse.  On 3.6.19 whilst at home at
, 
he has deliberately self-inflicted a number of lacerations to his neck. These have led to 
acute blood loss and his death. It is more likely than not, that he intended the 
consequences of his actions to be his own death. 

The Inquest focused upon: -

a.  The direct circumstances leading to his death. 

b.  The role that Mental Health & Local Authority Services took in the management 

of his risk of self-harm in the months preceding his death & whether such 
management may have contributed to his death. 

I recorded no findings in relation to such management, which were directly causative of 
his death. 

 5 

CORONER'S CONCERNS 

At the conclusion of the Inquest,  I directed written submissions from the three Interested 
Person's as to whether my duty under Regulation 28 was engaged & if so, in respect of 
which matters. 

I have received & considered the same. 

During the course of the Inquest the evidence revealed  matters giving rise to concern. 

In  my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  -

(1)  The assessment of Sam's risk of self-harm was recorded by his care-co-

ordinator in a Wales Applied Risk Research Network (WARRN) assessment tool 
in March 2019. This form of assessment was adopted by the Integrated Mental 
Health Services (Powys County Council & Powys Teaching Health Board) in 
Powys. I also received evidence that it is used throughout Wales by similar 
services. 

(2)  The evidence I received indicated that the WARRN assessment 

documentation/tool could be routinely accessed, updated & revised by the 
Integrated Team. It was a fluid document for the purpose of recording 
information as to the current assessment of risk(s) of self-harm & how that 
risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk 
assessments were being undertaken with Sam, the WARRN documentation did 
not necessarily reflect that,  nor was it optimally viewable in terms of clearly 
recording fluctuating presentations & any accompanying re-assessment of risk. 

(3)  It appeared to me that the format/layout of the WARRN tool,  its accessibility, & 
in particular,  its ability to provide a user with clear & easily viewable information 
as to how Sam's risk of self-harm had fluctuated/altered/changed in the months 
preceding his death, could lead to important information/assessments being lost 
to a new/infrequent user. This, for example, might be a new care co-ordinator 
(as in Sam's case), Crisis Team/Community Nurse, or clinician not previously 
involved with Sam. 

(4)  Given the variety of services involved in Sam's care, this central document, 

addressing & recording fluctuating  risk appeared to me to be a crucial document 
in the recording of current risk (my emphasis). The ability of those charged with 
Sam's care to view those fluctuations might be hampered by the current 
presentation of/access to such information. That could  lead to an under-
estimation of the current risk & sub-optimal mitigating measures being put in 
place. 

(5)  The WARRN assessment tool might also benefit from a greater degree of 

interaction between it & the user. For example, it was clear, on the evidence that 
Social Worker's, Mental Health Nurses & Clinicians were all busy addressing the 
needs (&  assessing risk) of a wide number & variety of patients. Prompting (my 
emphasis) the user to consider & record referrals for,  for example, to advocacy 
services & for capacity assessments might optimise the benefits of the tool & 
reduce the risk of such opportunities being missed/un-recorded. Such then 
leading to the potential absence of key information for new/infrequent users 
when assessing risks of self-harm 

It may well be helpful (given the Integrated Services approach to Mental Health Services 
in  Powys) if I were to receive one jointly prepared response from both organisations to 
whom this Report has been sent. 

2 

 6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation  have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 26th  July 2022.  I,  the Coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to family who may find it useful or of interest. 

, Minister for Health & Social Services 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form.  He may send a copy of this report to any person who he believes may find it useful 
or of interest. You  may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

1st June 2022 

SIGNED: 

3

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Powys County Council and Powys Teaching Health Board (PDF)
IN THE WELSHPOOL CORONER’S COURT 

BEFORE SENIOR CORONER MR GRAEME HUGHES 

IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF: 

MR SAMUEL GOMM  

_____________________________________________________________ 

RESPONSE TO REGULATION 28  

PREVENTION OF FUTURE DEATHS REPORT 

_____________________________________________________________ 

This response is sent in accordance with the direction of HM  Senior Coroner Graeme 

Hughes  dated  1  June  2022  that  a  response  from  Powys  Teaching  Health  Board  and 

Powys County Council is provided to the Regulation 28 Prevention of Future Deaths 

Report in the inquest touching the death of Samuel Gomm.  This is a joint response on 

behalf of the local authority Powys County Council (PCC) and Powys Teaching Health 

Board  (PTHB).    This  response  seeks  to  explain  the  actions  to  be  taken  to  address  the 

matters of concern and recommendations as identified by the learned Coroner.  

Improvement  Risk  assessments  (self-Harming  patients)  record  keeping  systems 

throughout Powys County Council and Powys Teaching Health Board and Wales  

1. 

Powys  Teaching Health Board  and  Powys  County  Council  provide  co-located 

Mental  Health  Support  to  the  residents  of  Powys.    Both  organisations  have 

agreed  to  use  the  Welsh  Applied  Risk  Research  Network  technique  (Welsh 

Applied Risk Research Network) and the Welsh Community Care Information 

System  for  case  recordings  (WCCIS).    This  is  fully  implemented  in  all 

Community Mental Health Teams (CMHTs) with plans to expand to other parts 

of the service, e.g., inpatient, learning disability and primary care. This is being 

managed by the integrated organisational Gateway Group.   

 
 
 
 
 
 
 
 2. 

As Powys Teaching Health Board inpatient staff are currently only able to read 

information stored on the Welsh Community Care Information System for case 

recordings, they have relied on a Welsh Applied Risk Research Network Word 

Document.    This  is  then  uploaded  and  attached  to  Welsh  Community  Care 

Information  System  by  admin  staff.    It  is  accepted  that  this  has  led  to  a 

duplication of work and the risk of important information being lost.  Having 

identified this, Powys Teaching Health Board are updating training and access 

arrangements  for  inpatient  staff  required  to  complete  the  Welsh Applied  Risk 

Research  Network  document.    This  will  ensure  that  all  Welsh  Applied  Risk 

Research Network document will be recorded on the Welsh Community Care 

Information  System  and  there  will  no  longer  be  a  need  to  use  the  Word 

Document template.  It is anticipated that this will be achieved by the 2nd August 

2022.  

3. 

There  have  been  concerns  that  the  Welsh  Applied  Risk  Research  Network 

document  accessible  on  WCCIS  is  distorted  and  is  not  compliant  with  the 

copyright held by  Welsh Applied Risk Research Network authors. To address 

this,  both  organisations  have  worked  closely  together  to  change  the  current 

document and to ensure that the copyrighted form is used on the WCCIS system.   

This enables staff to use the research and formulation-based techniques for the 

assessment and management of serious risk. (Appendix 1) 

4. 

This work will be completed by the end of July 2022 when staff will be advised 

of  the  changes  and  any old  Welsh  Applied  Risk  Research  Network  document 

templates will be removed.     

5. 

Powys  Teaching  Health  Board  currently  commission  inpatient  services  from 

external  providers.    This  can  cause  difficulties  in  information sharing.    Powys 

Teaching Health Board will work collaboratively with commissioned services to 

ensure robust risk assessment utilising their formats with intensive handover of 

 
 
 
 
 service users on discharge to include risk information.  Their risk assessment will 

be used to populate Powys Welsh Applied Risk Research Network assessments 

following this handover.   

6. 

Powys County Council are in the process of updating WCCIS documentation to 

support  practitioners  in  identifying  a  list  of  services/people  who  should  have 

sight of the completed documentation.  This will include the cared for person, 

their  GP,  and  external  commissioned  services  (for  example,  Kaleidoscope  or 

Domiciliary  Care). 

  On  completion,  WCCIS/Practitioners  will  alert 

administration  staff  that  key  documents  are  ready  to  send  to  those  identified.  

These documents will include, the Welsh Applied Risk Research Network risk 

assessment, initial assessment and Care and Treatment Plan.  Practitioners will 

have  to  justify  on  clinical  grounds,  why  this  isn’t  appropriate  for  specific 

individuals. This will be re-enforced during Social Care Team Meetings.  Team 

administrators  will  take  responsibility  for  the  sending  of  documents  and  will 

keep a record of those sent.  Appendix 2, 3, 4 

7. 

“The Welsh Community Care Information System (WCCIS) is intended to enable 

health and social care staff to deliver more efficient and effective services using 

a  single  system  and  a  shared  electronic  record.”    (Welsh  Community  Care 

Information System, Report of the Auditor General for Wales, October 2020.)  It 

has been Welsh Governments intention to implement WCCIS in all Welsh Health 

Boards  and  Local  Authorities.    This  does  not  currently  include  external 

organisations  who  do  not  have  direct  access  to  records  held  by  statutory 

organisations due to IT limitations and Information Governance.   

8. 

The National roll out of WCCIS is taking much longer and proving more costly 

than  expected,  with  concerns  about  functionality  and  performance  being 

reported  in  the  media.   National  System  performance  issues  were  particularly 

difficult  during  Autumn  2021,  where  some  organisations  found  WCCIS 

 
 
 
 
 
 unavailable.    These  issues  were  resolved  following  a  Systems  upgrade  in 

February 2022 with the system performance now being reported  as good both 

nationally and locally.     

9. 

In  February  2022,  Welsh  Government  reported  its  findings  in  an  Independent 

Review  of  the  WCCIS  programme.    A  series  of actions  to  “reset”  and  “course 

correct”  were  identified.    This  included  an  increase  in  Welsh  Government 

funding  and  the  recommendation  for  a  new  WCCIS  business  case  to  support 

health  boards  and  local  authorities.      The  report  also  identified  the  need  to 

simplify processes and reduce its scope with regards to data collection and some 

of the programmes within Digital Health and Care Wales.  It is anticipated that 

this will allow for greater system stability and improvement of user experience.  

A further National review will take place in November 2022.    (Audit Wales, 1 

July 2022). 

10. 

Alongside  National  consideration,  WCCIS  remains  under  review  by  Powys 

Teaching  Health  Board  and  Powys  County  Council’s  internal  Change 

Management  groups  allowing  for  prompt  responses  to  local  challenges.    Joint 

initiatives are also improving access to WCCIS training by using a series of open 

access videos.  This is supporting user confidence for both new users and more 

experienced staffing groups.   

Welsh  Applied  Risk  Research  Network  assessments  (content  reviews/ 

integrating systems/ updating of current information) 

11. 

A  Risk  Assessment  is  an  essential  part  of  Mental  Health  Work  and  should  be 

evidence based and carried out in conjunction with cared for persons and their 

support networks.  

 
 
 
 
 
 
 
 12.  Welsh Applied Risk Research Network is the current risk assessment tool used 

by both organisations and is stored on the WCCIS system.  Whilst the document 

should be fluid and regularly updated it cannot remain as a live document on 

WCCIS.    Following  completion  on  WCCIS  the  form  should  be  closed  and  re-

opened at the point of review. WCCIS automatically copies the information from 

the previous form to aid completion.  This ensures that practitioners are able to 

clearly see how  often and when the  Welsh Applied Risk Research Network is 

updated.   

13. 

The  Welsh  Applied  Risk  Research  Network  document  should  be  considered 

alongside other Care and Treatment documentation which assists the writer in 

considering whether a formal Mental Capacity Assessment is required.   

14. 

Along  with  meeting  the  requirement  of  data  collection,  this  ensures  that  the 

fluidity  of  risk  is  reflected,  drawing  workers  attention  to  any  changes.  

Supporting staff to easily identify when a change of risk management is required.   

This  has  been  identified  as  the  preferred  method  by  Welsh  Applied  Risk 

Research Network authors.  To ensure that all risk activities are easily captured, 

WCCIS has introduced an embedded Chronology.  This allows for all events to 

be recorded, supporting practitioners to recognise when there is a change to risk 

behaviours.   Non-Welsh Applied Risk Research Network assessors can add to 

the  Chronology  and  events  reported  by  partner  agencies  can  be  included, 

supporting  the  sharing  of  information  and  highlighting  any  need  for  re- 

assessment of risk management.   

15.  Monitoring  and  reviewing  changes  are  an  essential  part  of  effective  care  and 

treatment  and  risk  management.    Completion  of  the  Welsh  Applied  Risk 

Research Network document should be part of the initial care planning process 

for everyone under Secondary Mental Health Services.  Along with the Care and 

Treatment Plan, the Welsh Applied Risk Research Network should be reviewed 

 
 
 
 
 
 
 a minimum of once in a 12-month period and at any change of circumstances that 

might impact on risk and wellbeing.  (Mental Health Measure Wales, 2010). 

16. 

This would include but is not limited to events such as, relationship breakdown, 

loss  of  carer,  increase  in  substance  use,  increase  in  contact  with  services, 

particularly out of hours.  All significant self-harming events should be recorded 

on the document, this includes disclosure of thoughts of self harm.  To support 

this WCCIS will be updated to include a Chronology of events to enable workers 

to  keep  a  succinct  and  easily  accessible  record.    This  will  allow  staff  to  easily 

identify  if  there  has  been  a  recordable  event,  creating  a  clear  timeline  of 

presenting  risks.    This  will  alert  practitioners  to  any  changes  or  patterns  of 

behaviour and enable better dynamic risk assessing.   

17.  Whilst  this  function  will  be  only  accessible  to  registered  WCCIS  users,  it  will 

enable  staff  to  update  incidences/concerns  easily,  without  necessarily  being 

involved  in  the  full  Welsh  Applied  Risk  Research  Network  assessment.    For 

example,  support  workers  recording  concerns  following  a  visit  in  addition  to 

reporting  this  to  Care  Coordinator/or  Senior  Member  of  staff.      This  will  be 

implemented by the end of July 2022. 

18. 

External agencies without access to WCCIS will be provided with an up to date 

Care Plan which will include the contact details for involved  Powys Teaching 

Health  Board  and  Powys  County  Council  staff.    They  will  be  advised  of  both 

organisations  Information  Sharing  Protocol  at  the  start  of  their  input  and  on 

regular  occasions  in  line  with  Care  and  Treatment  Reviews.    Whilst  external 

agencies are currently unable to use WCCIS, they will be supported to contribute 

to the development of Welsh Applied Risk Research Network by statutory staff 

who will then provide a copy of the updated assessment as detailed above.  

 
 
 
 
 
 
 19. 

Alongside  any  notable  changes  of  circumstances,  the  Welsh  Applied  Risk 

Research Network will be updated at the following points:   

(a)  Admission and discharge from Psychiatric Inpatient Care/CRHTT 

(b)  Referral to internal risk panels (REP, IRIS) 

(c)  Referral and review at MAPPA 

(d) Inclusion in Crisis Care Forum Multiagency discussion 

20. 

Any  concerns  noted  by  the  receiving  team  regarding  the  timeliness  of  Welsh 

Applied  Risk  Research  Network  assessment  update  or  divergent  staff  views 

should be reported via Powys Teaching Health Board Datix system and through 

Powys County Council line management structure.  This will ensure that both 

systemic and independent practitioner concerns are captured.   

21. 

Staff will be updated on the new  processes when complete by  Welsh Applied 

Risk Research Network Lead and Quality and Safety Team for each organisation. 

22. 

In  October  2021  and  April  2022  Powys  Teaching  Health  Board  undertook  an 

internal  audit  of  Welsh  Applied  Risk  Research  Network  documentation.  

Compliance with reviews and the quality of content was rated as good.  Powys 

Teaching Health Board will continue to audit Service User records on a 6 monthly 

basis.  

23. 

Prior  to  entering  business  continuity  through  Covid,  Powys  County  Council 

undertook regular monthly in-depth random audits, which included feedback 

from service users and carers as appropriate.   

 
 
 
 
 
 
 
 
 24. 

Part  of  this  process  included  analysis  of  the  Welsh  Applied  Risk  Research 

Network  and  CTP  (care  and  Treatment  Plan)  documentation,  alongside  case 

recordings.    Audit  feedback  was  provided  to  Powys  County  Council  Senior 

Managers and staff both at supervision and in team meetings.  Powys County 

Council  Team  meetings  are  used  to  support  staff  in  understanding  when 

improvements need to be made but also to celebrate good practice.   

25. 

Unfortunately,  Audits  were  stopped  due  to  Covid  Business  Continuity  and 

increased pressures on the local authority.  A small number of audits have taken 

place during this time but there will be a full rollout of mental health audits by 

the end of August 2023.   

26. 

Recommendations by  the  Welsh Applied  Risk  Research  Network  author  from 

this case will be used to inform training for both Powys Teaching Health Board 

and Powys County Council staff. 

Welsh  Applied  Risk  Research  Network  assessments  (format/  ease  of 

accessibility / infrequent users/ new users) 

27.  Work  is  currently  in  progress  to  ensure  that  the  correct  Welsh  Applied  Risk 

Research  Network  is  available  on  the  WCCIS  system  by  the  end  of  July  2022.    

This will enable all Community Staff to have access to the copyrighted version, 

stored in an easily accessible part of the database.  This can be accessed by both 

Powys Teaching Health Board and Powys County Council.  To enable the Welsh 

Applied Risk Research Network to maintain its evidence base it needs to remain 

in its original state and cannot be altered to provide additional prompts or data 

collection.  The accompanying CTP documentation focuses on areas not directly 

included  in  Welsh  Applied  Risk  Research  Network.    For  example,  capacity  is 

 
 
 
 
 
 
 considered  within  the  CTP  assessments,  asking  the  practitioner  to  consider 

whether an additional WCCIS embedded Capacity Assessment also needs to be 

completed.    The  practitioner  is  directed  to  offer  the  support  of  an  advocate 

through this non-Welsh Applied Risk Research Network document.  

28. 

As the lead agency for Welsh Applied Risk Research Network, Powys Teaching 

Health  Board  facilitate  initial  and  refresher  training.    ESR  (Powys  Teaching 

Health Board Electronic Staff Record) system will provide information on Powys 

Teaching Health Board staff requiring updates to ensure appropriate targeting.   

29. 

Powys County Council will use their Business Insight process to identify workers 

requiring Welsh Applied Risk Research Network updates and infrequent users.   

This  will  ensure  that  refresher  training  is  undertaken  within  the  specified 

guidance  of  3  years.    Both  organisations  will  use  their  Welsh  Applied  Risk 

Research Network trainers as “Champions” who can act as a point of contact for 

infrequent users supporting them to develop skills and confidence and ensuring 

that  completed  Welsh  Applied  Risk  Research  Networks  are  of  an  acceptable 

standard.    

30. 

Powys  County  Council  induction  policy  will  be  extended  to  include  Welsh 

Applied Risk Research Network training as mandatory as is the case in Powys 

Teaching Health Board.  This will be overseen by Powys County Council Service 

Improvement Manager and  Powys  Teaching Health  Board  Quality  and Safety 

Team. 

31. 

Staff  changes,  particularly  agency  staffing,  will  create  extra  pressures  for 

training.    Whilst  Welsh  Applied  Risk  Research  Network  training  is  currently 

provided by Powys Teaching Health Board, the local authority Powys County 

Council will nominate 2 workers to train as trainers, to support this programme.  

 
 
 
 
 
 
 We  anticipate  an  integrated  approach  to  WCCIS  training  across  both 

organisations, with Powys Teaching Health Board and Powys County Council 

staff delivering joint Welsh Applied Risk Research Network training.     

Welsh  Applied  Risk  Research  Network  and  associated  assessments  – 

reviews/  quality  assurance  monitoring/updating  of  current  needs/ 

access by relevant bodies) 

32. 

The Welsh Applied Risk Research Network document sits alongside additional 

Care and Treatment paperwork (Assessment, Care and Treatment Plan).  It is an 

integral part of the assessment and treatment process.  Powys Teaching Health 

Board  and  Powys  County  Council  will  continue  to  follow  their  own  internal 

audit as detailed above.   

33. 

Along with considering the Welsh Applied Risk Research Network document, 

Powys County Council’s audit process extends to include additional electronic 

records  and  feedback  from  service  users/carers.    This  process  is  overseen  by 

Powys  County  Council  Service  Improvement  Manager  and  outcomes  are  fed 

back to Senior Management and to individual workers through supervision and 

during team meetings if appropriate. 

34. 

Outcomes of these audits are embedded in Service User records and available to 

Powys Teaching Health Board.  Powys Teaching Health Board have identified 

greater service user/carer involvement as a piece of work following their most 

recent audit in June 2022. 

35. 

Powys  Teaching  Health  Board  audit  outcomes  are  discussed  in  monthly 

Learning  and  Development  Group  and  disseminated  to  front  line  staff,  with 

 
 
 
 
 
 
 
 service improvements and action plans delivered directly by Service Managers 

and overseen by Operational Leads. 

36. 

The offer of advocacy is a legal requirement of both the Mental Health Measure 

(2010) and the Social Services Well Being Act, 2014.   This is reflected in Care and 

Treatment Programme documentation, where staff are directed to offer advocacy 

and to confirm whether it is required.  This is reported on through Powys County 

Council  Business  Insight  programme  and  in  Powys  County  Council  audits.  

Advocacy clinics have been reinstated in CMHT’s and inpatient units following 

Covid19.  These are advertised in patient access areas and can be booked directly 

with the advocate if preferred.  

37. 

The Information Sharing protocol is explained to a cared for person during any 

initial assessment, where the person is advised that any information provided 

may be shared with supporting agencies.  The need to break confidentiality in 

relation to concerns about risk is included within this explanation.  Workers shall 

remind cared for persons of this duty at all reviews and further will do so should 

a requirement to inform partner agency arise.  (Appendix 6). 

38. 

To  support  understanding  of  this  protocol,  Powys  County  Council  are  in  the 

process  of  updating  their  “privacy  notice”  which  includes  a  guide  written  for 

those using services.  This is currently in the process of being ratified, with no 

changes expected.  This is attached as Appendix 7. 

 
 
 
 
 
 
 
 
 
 
 Welsh  Applied  Risk  Research  Network  assessment  tools  –  accessibility  to 

Patient / integration referral process to secondary services, working together 

optimisation approaches 

39. 

The Welsh Applied Risk Research Network as per all other CTP documentation 

should be written in conjunction with the cared for person where possible and 

unless  this  leads  to  increased  risk  to  self  or  others.    The  Welsh  Applied  Risk 

Research Network is one part of an assessment process and should be considered 

alongside the Initial Assessment which provides an overall view  of a person’s 

life  and  helps  develop  an  understanding  of  the  impact  of  any  mental  health 

problem and what matters to them as individuals.  Both documents should sit 

together  to  form  a  Care  and  Treatment  and  Risk  Management  Plan.    Powys 

Teaching Health Board currently use the All Wales Assessment Document held 

on the Welsh Applied Risk Research Network.  Powys County Council have not 

implemented this document as they felt it did not align with the Social Services 

Wellbeing  Act.    This  view  was  shared  by  a  visiting  Inspector  from  the  Care 

Inspectorate  Wales  at  the  time  the  decision  was  made.    Regardless  of  which 

documentation is used the plans should be done in partnership with identified 

individuals and organisations.  

40. 

To  improve  communication,  staff  will  be  directed  to  identify  those  that  are 

involved in the person’s care.  Administration officers will be notified by WCCIS 

and will ensure that the correct documentation is sent directly to them.  This will 

include, the cared for person, the GP and any other organisation providing care 

and support.  

41. 

On completion the document should be shared with the cared for person’s GP 

and other appropriate agencies as documented in the care plan.  Any changes 

that  affect  risk  are  to  be  communicated  with  appropriate  partner  agencies.  

External  agencies  who  do  not  have  direct  access  to  the  Welsh  Applied  Risk 

Research Network document should ensure that their information is passed to 

 
 
 
 
 the Care Coordinator or representative.  This can then allow for review of the 

Welsh Applied Risk Research Network documentation held on WCCIS system.  

It is not possible for external agencies to have access to the WCCIS system due to 

the level of information governance compliance required.  

42. 

Identification  and  management  of  risk  is  a  shared  responsibility  and  partner 

agencies should work closely together to protect the safety of service user, staff 

and members of the public.  External agencies without access to WCCIS will be 

provided with an up-to-date Care Plan covering both a relapse plan and 24-hour 

contact  details  for  statutory  services.    Whilst  this  is  routinely  available  on  the 

WCCIS system, staff will be advised of the need to share risk information with 

involved agencies under the appropriate framework.   

43. 

External  agencies  who  are  not  included  in  the  WCCIS  programme  will  be 

encouraged to report any changes in risk to statutory staff, normally the Care Co-

ordinator or their deputy.  The details will be added to the chronology and used 

to inform robust risk assessment.  This will be communicated to involved partner 

agencies.  

44.  Whilst staff may have concerns about the sharing of relevant information, they 

should  be  supported  to  understand  the  legal  framework  that  facilitates 

partnership  working.    Once  approved  a  copy  of  the  Powys  County  Council’s 

Privacy Notice will be forwarded to staff to ensure that staff are comfortable in 

this process.    

45. 

Any referral to external agencies should be accompanied by an up to date Welsh 

Applied  Risk  Research  Network  and  Care  and  Treatment  Plan,  which  will 

include relevant contact details and a relapse plan.   These documents will be 

 
 
 
 
 
 
 embedded in WCCIS and forwarded to agencies in their preferred means, digital 

or paper.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 

1   The new Welsh Applied Risk Research Network now available on WCCIS 

system 

2 Assessment – All Wales (used by Powys Teaching Health Board) 

3 Assessment – used by Powys County Council 

4 Care Plan - All Wales (used by Powys Teaching Health Board) 

5 Care Plan – Powys (used by Powys County Council 

6 Powys County Council Privacy Notice 

7 Joint Action Plan 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 APPENDIX 1 

 
 
 
 
 
 
 
 
 Powys - MHM – Welsh Applied Risk Research Network Risk Formulation 
(CTP4) 

Service User Details 

CCIS ID 

First Name 

Date of 
Birth: 
Gender 

Religion 

Primary 
Address 

Post Code 

Home 
Phone 
Preferred 
Language 

NHS No 

Middle 
Name 
Age 

Email 
Address 
Mobile 
Phone 
Preferred 
Contact 
Method 

Last Name 

Age if 
Estimated 

Nationality 

Ethnicity 

Work Phone 

Interpreter 
Required 

Risk Formulation and Management Plan 

This document provides a template to allow the accurate recording of your 
risk assessment.  

Please give as much detail as possible 

Assessment Start Date 

Assessor Details 

Name of Assessor 

Team 

Designation 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 RISK FORMULATION 5Ws 

What 

What is the nature of the risk (describe) remember there can be more than 
one risk area, remember children/vulnerable adults.  Please put as many 
details as possible 

Who 

Who are the likely victims, either specifically or the type or nature of the likely 
victims if this can be specified. Remember risks to other children/ vulnerable 
adults. Do not forget risk to self. 

Why 

What are the likely trigger situations for risk related behaviour: e.g., response 
to feeling threatened, arguments with others, command hallucinations etc. 

Where 

Where is the risk posed (in the context it is most likely to occur - e.g., home, 
hospital, community setting etc.) Are there any protective environments (e.g., 
a grandparent's house, school/college, foster care, etc)? 

When 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 How imminent is the risk likely to be? When is the risk most likely to occur? 
Are there any dates that indicate a particular vulnerability (e.g., Christmas, 
anniversary of a death or of trauma, etc)? Is there any time of day when risk is 
increased (e.g., night-time)? 

Key Risk Indicators 

Those factors most associated with the risk increasing e.g., drug/alcohol use, 
being in confined space (ward), command hallucinations, lack of insight into 
illness. 

Risk Reducing Factors 

Those factors that can decrease the risk (e.g., being at home/in school, being 
with a family member, good relationship with a teacher, involvement of Social 
Services, compliance with medication). 

Please give as much detail as possible.  Select the appropriate category. 

Probability: What is the likelihood that the risk behaviour will 
occur 

Risk Category 

Severity: Describe the impact of the risk behaviour on self or 
others 

Risk Category 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Imminence: When do you consider the risk behaviour is likely 
to occur? 

Consider presence of active risk indicators 

Risk Category 

Summary of Risk Formulation: 

- Include RISK REDUCING FACTORS: those factors that can decrease the risk 
e.g., being at home/in hospital, being with a family member/compliance with 
medication. 

CLINICAL FORMULATION - 4 Ps 

Predisposing Factors 

Things that make a person vulnerable to developing psychological problems 
(e.g., childhood trauma, physical health problems, or family history of mental 
illness). 

Precipitating Factors 

Things that happened in a person's life that seems to trigger an episode of 
illness/change in functioning (e.g., significant life changes, bereavement or loss 
of job). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Perpetuating Factors 

Things that seem to keep a person in their current state of distress (e.g., 
pervasive negative thinking, lack of close relationships, or lack of adherence to 
medication). 

Protective Factors 

Things which seem to keep a person well and if maintained or strengthened 
decreases the likelihood of the problem reoccurring e.g., strong relationships, a 
skill/strength in a specific area, or good sense of humour (personality traits). 

Risk Management Plan: 

Clearly highlight the measures that you feel are necessary to manage 

Consider what you need to do now, as well as longer term options. 
Include contingencies (e.g., what if mental state changes?) 
Who do you need to inform of your formulation/plan? Consider your 

• 
the identified risks.  
• 
• 
• 
responsibilities to inform external agencies (e.g., If children have been 
identified as at risk inform Child and Family Social Services and/or the police).  
• 

Remember "What I Can Do (WICD)" 

REVIEW 

What signs/symptoms/circumstances/events would prompt an urgent review 
before the planned review date? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Future Reviews Due? 

Yes 

     No 

Date of Next Planned Review 

DD 

  MM 

  YYYY 

Comments/Action 

Form Data Entry 

Owne
r 

Actua
l Start 
Date 

Statu
s 

Modifie
d On 

Modifie
d By 

Completio
n Date 

Complete
d By User 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 2 

 
 
 
 
 
 
 
 Person Information 

Is the person information in the banner up to date? 

Yes 

     No 

Is the person a veteran 

Yes 

     No 

Consent to Share Information 

Consent to share information within health /social care professionals is covered by GDPR. 
Record consent or refusal to share information with individuals ( rather than care 
professionals). 

Consent
ed To 

Mod
e 

Wh
o 

Free 
Text 
Nam
e 

Conse
nt 
Given 
to 
Perso
n 

Conse
nt 
Given 
to 
Provid
er 

Refus
al 
Reas
on 

Remov
al 
Reaso
n 

Consents 

Conse
nt 
Given 

Sta
rt 
Dat
e 

En
d 
Dat
e 

Social Context 

Emergency Contact 

 
 
      
   
   
        
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Last 
Name 

First 
Name 

Property 
No 

Property 
Name 

Postcode 

Phone 

Address 
Phone 1 

Carer 

Is the person a carer? 

Does this person have a carer? 

Yes 

     No 

Language 

Languages 

Language 

Fluency 

Preference 

Are there any language accessibility needs 

Yes 

     No 

Interpreter Required 

Yes 

     No 

If yes please specify: 

About this Assessment 

Please be aware of any ceiling of care documents or agreements. These may include but not 
limited to: Do Not Attempt Resuscitation (DNAR)/Do Not Attempt CPR (DNACPR); Advance 
directives/ decisions/ refusal of treatment; Living will; Lasting power of Attorney. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Confirmation that an Active Offer to have this Assessment undertaken in the Welsh Language 
has been made 

Yes 

     No 

Assessment Start Date 

Location of Assessment 

Assessing Service 

Type of Assessment 

MHM Care Coordinator 

Professional (User) 

Start Date 

End Date 

Who Has Been Involved/Contributed to this Assessment 

Date 

Name 

Designation 

Location 

Involvement/C
ontribution 

First/Follow/Reassess/Repeat 

Name of Assessor 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Designation 

Person Engagement 

Do you have any concerns about the person's capacity to engage in this assessment 

Yes 

     No 

Is there a record/concerns of Deprivation of Liberty Safeguards (DoLS) 

Please specify any restrictions and expiry date (maximum 12 Months) 

What other agencies, care & support that have been / are involved? 

Detail any Services/Agencies that have supported you in the past, and what care & support 
you are currently receiving. 

Person Perspective and 'What Matters' 

Include the individuals own words. If the person isn't able to communicate this, an advocate 
can provide the answers. 

Person's Current Circumstances 

Tell me a bit about what's happening/ What concerns you most? / Presenting Needs 

Presenting need 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Background/Personal History 

MHA Section 117 Applicable 

Accommodation need 

Accommodation Status 

Property Access Arrangements 

Children the person has contact with 

Name 

DOB 

Person's Education 

Relationship to 
child 

if known 

In household 

Yes 

     No 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Establishme
nt Type 

Statu
s 

Person 
Educatio
n Year 

Year 
Grou
p 

Education 
Establishme
nt 

For
m / 
Clas
s 

Year 
Grou
p 

Curre
nt 
Year 

Yea
r 
End 
Dat
e 

Person's Employments 

Employment Status 

Employment Type 

Start Date 

What Matters 

Supporting person's perspective 

Supporting persons’ view 

Physical Health 

Is the person currently pregnant 

Physical Health 

Has the person received information / had a conversation about how to manage their lifestyle 
choices? 

Yes 

     No 

Height and Weight 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Weight 
Kilograms 

Height Metres  Date/Time 

Taken 

Date/Time of 
Next Screening 

BMI Score 

Waist Circumference 

Measured in centimetres 

Client Disability/Impairment 

Diagnose
d Date 

Disability 
or 
Impairmen
t 

Disabilit
y 

Impairmen
t 

Severit
y 

Registere
d 
Disability 
No 

End 
Dat
e 

Star
t 
Dat
e 

Allergies 

Allergy Type 

Allergen - 
What 
Substance 
Caused the 
Reaction 

Reaction 

Start Date and 
Time 

Level 

Surgery/Practice 

GP Name 

Surgery/Practice Address 

Surgery/Practice Phone Number 

Is the person in regular contact with their GP 

Does the person smoke or use a vape 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Current Alcohol Intake – weekly 

Other substances misused including prescribed and over the counter 

Current Medication/Treatments at The Time of This Assessment 

Is the person currently taking any medication 

Yes 

     No 

The Person's Experiences of Treatment & Responses To Medication 

Mental State Examination 

Person's view of their current mental health conditions 

Objective Mental State Examination 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Safety and risk screening 

Past Risk History 

Forensic History 

What 

What is the nature of the risk (describe) remember there can be more than one risk area, 
remember children/vulnerable adults.  Please put as many details as possible 

Have risks that require management been identified? 

Yes 

     No 

Person risks 

Role 

Type 

Details 

Created 
On 

Review 
Date 

End Date 

End 
Reason 

Clinical Measures Undertaken and Scores 

What, if any, other assessment tool(s)/ outcome measure(s) have been completed 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Assessment 

Date of 
previous 
Assessment 

Previous score  Date of 

Assessment 

Score 
following 
current 
assessment 

Other tool/s completed 

Measure 

Date of 
previous 
Assessment 

Previous score  Date of 

Assessment 

Score 
following 
current 
assessment 

Outcome of Assessment 

Agreed Needs 

Agreed Need 

Eligibility 

Personal Outcomes 

Personal 
Outcome 

National 
well-
being 
outcome 

Care and 
Treatment 
Plan 
Outcomes 

Baseline 
self-
assessment 
measure 
(1-10) 

What 
does this 
look 
like? 

Baseline 
self-
assessment 
goal 

What 
does this 
look 
like? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Recommended next actions 

Recommended actions and immediate 
next steps and by who 

Target Date 

Formulation 

This is a summary of how the person's life events, and circumstances have led to the current 
difficulties, and the impact and meaning this has had. This should be shared and agreed with 
the person if appropriate 

Is a safeguarding referral required? 

Yes 

     No 

Outcome of Assessment 

If Signposted Enter Name of Service(s) 

Eligibility decision 

Assessment Information 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Confirm the current assessment is complete 

Has the individual been offered a copy of the assessment 

Date Offered 

DD 

  MM 

  YYYY 

Name of Assessor 

Designation 

Assessment last Modified On 

Assessment last Modified by Whom 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 3 

 
 
 
 
 
 
 
 
 Service User Details 

CTP Assessment 

CCIS ID 
First Name 

Date of 
Birth: 
Gender 
Religion 
Primary 
Address 

Post Code 

Home 
Phone 
Preferred 
Language 

NHS No 
Middle 
Name 
Age 

Email 
Address 
Mobile 
Phone 
Preferred 
Contact 
Method 

Last Name 

Age if 
Estimated 

Nationality 
Ethnicity 

Work Phone 

Interpreter 
Required 

No 

CTP Assessment 

Assessment Date 

DD 

  MM 

  YYYY 

Location of Assessment 

Assessor 

Designation 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Referrer 

Name 

Address 

Telephone 

Initial/Full/Re-assessment 

Source Of Information/Contributors 

Service User 

Referrer 

Past Notes 

Family/Carer 

Other 

Carer 

Name 

Address 

Telephone 

Carer's Assessment Offered? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Carer's Assessment Accepted / Declined? 

Is this person a young carer 

Issues of confidentiality & consent have been explained 

Consent to approach your Carer / Next of Kin / Advocate 

Details of advocacy requirements 

Service user and Carer Perspective 

Service users expectations/outcomes 

Carer's Perspective 

Presenting Problem 

History of presenting problem, previous contact with mental health services 
and interventions. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mental Health 

Speech, presentation, mood, symptoms, insight, cognitive ability.  

Medical history, family history of mental illness, childhood, and schooling 

Are there any particular risks to children due to the service 
user's mental illness? 

i.e. delusional beliefs / suicide plans involving children. If yes, a referral to 
Children's Social Services should be made. 

Does the service user care for children? 

How many children, of what ages? 

Does the service user's mental health affect their role as a parent? 

Are there any other significant carers? 

Does the service user need support in their role as a parent? 

Is the child on the Child Protection Register? 

Yes 

     No 

Is a referral to Children's Social Services required? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Date of Referral 

DD 

  MM 

  YYYY 

Substance Misuse 

Alcohol use - If use is problematic, should assessment of this be made? 

Tobacco and caffeine use  

Use of other substances 

Day To Day Living & Environmental Resources 

Personal care, sleeping pattern, mobility/falls. 

Budgeting, financial circumstances, benefits, keeping warm, transport, exercise 
and leisure, shopping, cooking, eating and drinking, household tasks, work or 
education. 

What are the factors supporting the service user? What are their personal 
strengths? 

Social Circumstances 

Current social circumstances, housing needs, family circumstances, cultural 
needs, spirituality, needs for support. What support is available from others? 

Are there any immediate issues / decisions requiring an assessment of mental 
capacity? 

 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Does a Mental Capacity Assessment and Best Interest Decision Form need 
completing? 

Is there a need to consider whether a Deprivation of Liberty Assessment 
should be made? 

Physical Health 

Physical illnesses, chronic pain, mobility/falls, sensory deprivation 

Medication At Time of Assessment 

N.B. Medication changes frequently. This information should not be relied 
upon as an accurate reflection of current prescribed medication 

This page to be sent to GP following completion of initial assessment 

Current 
Medication 

Frequency 

Dose 

Date 
Commenced 

Does a review of medication need to be made? 

Assessment Date 

DD 

  MM 

  YYYY 

RISK ASSESSMENT 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ensure all appropriate risk assessment tools are completed, in addition to this 
assessment form. 

Evaluation of Risks (including Forensic History) 

Date of Welsh Applied Risk Research Network Risk Assessment 

DD 

  MM 

  YYYY 

Is a referral to POVA required? 

Date of Referral 

DD 

  MM 

  YYYY 

Formulation / Summary of Needs 

Fair Access to Care (FaC) Eligibility 

Health & Safety 

Autonomy 

Managing Daily Routines 

Involvement 

Plan 

Does the individual have complex health needs that require further 
assessment? 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Does the individual have needs that could trigger eligibility for Continuing NHS 
Health Care? 

Concerns 

Consider: concerns / issues re: discharge, home circumstances, 
accommodation, ability to manage, carer issues, large packages of care, the 
need for specialist equipment, the nature, intensity, complexity and 
unpredictability of the individual's needs. 

Are any Specialist Assessments Required? 

Specialist Assessments required 

Referral 
Passed 
To 

Role 

Organisation  Date 

Referred 

Date 
Returned 

Reason 
If Outcome 
is 
Assessment 
Completed 
for S4 
please state 
reason 

Data Protection Act 1998 

All 'data subjects' can apply for access to records held about them, this could 
include this assessment document. Please indicate whether or not access 
should be given, in the event of an application, in your opinion: 

Reasons for access not being given 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 If the Service User is unable to sign, please state the reason below 

Assessed Person 

Name 

Initial Assessor 

Name 

Joint Assessor 

Name 

Manager 

Name 

Date 

Date 

Date 

Date 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 4 

 
 
 
 
 
 
 
 
 CARE AND TREATMENT PLAN 

Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn 
rhannol yn Saesneg 

This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in 
English 

Mental Health (Wales) Measure 2010 Section 18 – Care and Treatment Plan 

This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure 
2010, and in accordance with the requirements of the Mental Health (Care Coordination and Care and 
Treatment Planning) (Wales) Regulations 2011. 

This is the care and treatment plan of  

Name of 
relevant patient 

Full usual 
address of 
relevant patient 

who lives at  

The care coordinator who has prepared this care and treatment plan is 

who can be contacted at  

The care coordinator has been appointed by, and is acting on behalf of,  

Name of care 
coordinator 

Telephone 
number, postal 
address, and 
where 
appropriate, 
email address  
of care 
coordinator 

Name of Local 
Health Board or 
Local Authority 
that appointed the 
care coordinator 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
   
 
 
 
 
 
 
 
 
 
 This plan was made on                                                           

and is to be reviewed no later than 

Date plan was made and 
date by which the plan 
must be reviewed 

However,  

Name of relevant patient  

his or her carer(s), or adult placement carer(s), may request a review of 
this care plan at any time.

 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to 
achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those 
outcomes. 

Area of life 

Outcome to be 
achieved 

What services are to 
be provided, or 
actions taken 

When 

Who by 

The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help 
from the care team (these are sometimes called relapse signatures): 

If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the 
following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be 
contacted): 

49 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh 
Language) ought to be recorded here: 

The views of the person on this care and treatment plan, the Mental Health services that are to be provided, and any future 
arrangements that ought to be considered, are: 

This care and treatment plan has: 

Date Care and Treatment Plan Agreed/Not Agreed with Person 

50 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 DD 

  MM 

  YYYY 

So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health 
services set out in this care and treatment plan are provided: 

Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health 
services to the relevant patient 

Has the individual been offered a copy of the Care and Treatment Plan 

Date copy of Care and Treatment Plan was offered 

DD 

  MM 

  YYYY 

The relevant patient may sign the care and treatment plan, if they wish- Did they? 

Yes 

     No 

51 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Individuals Electronic Signature 

Date Care and Treatment Plan Made 

Date Care and Treatment Plan last Modified 

52 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 53 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 5 

54 

 
 
 
 
 
 
 
 Care and Treatment Plan 

Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn 
rhannol yn Saesneg 

This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in English 

Mental Health (Wales) Measure 2010 Section 18 – Care and Treatment Plan 

This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure 

CCIS ID 
First Name 

Date of 
Birth: 
Gender 
Religion 
Primary 
Address 

NHS No 
Middle 
Name 
Age 

Last Name 

Age if 
Estimated 

Nationality 
Ethnicity 

55 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This is 
and 

Post Code 

Home 
Phone 
Preferred 
Language 

Treatment Plan of: 

Care Coordinators 

the Care 

Email 
Address 
Mobile 
Phone 
Preferred 
Contact 
Method 

Work Phone 

Interpreter 
Required 

No 

The care coordinator who has prepared this care and treatment plan is 

Who can be contacted at 

The care coordinator has been appointed by, and is acting on behalf of 

Date of Care & Treatment Plan 

DD 

  MM 

  YYYY 

56 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 And is to be reviewed no later than 

However, the patient, his or her carer(s) or adult placement carer(s) may request a review of this care plan at any time 

DD 

  MM 

  YYYY 

Care Plan 

This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to 
achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those 
outcomes. 

The planned outcome(s) included in the following part of the plan must relate to one or more of the areas listed, and include an 
explanation of how each outcome relates to each area. 

Outcomes also may be achieved in other areas, and are to take into account any risks identified in relation to the relevant patient.  
This part of the plan should also set out details of the services that are to be provided, or actions taken, to achieve the planned 
outcomes, including when, and by whom those services are to be provided or actions taken.  Outcomes to be achieved must be 
agreed in relation to at one of the following areas: 

Accommodation 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

Completed 

57 

 
 
 
 
 
 
 
 
 
 What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Education and training 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

What services are to be provided, or actions taken 

58 

Yes 

     No 

Completed 

Yes 

     No 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Finance and money 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

Completed 

Yes 

     No 

What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

59 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Medical and other forms of treatment, including psychological interventions 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

What services are to be provided, or actions taken 

Yes 

     No 

Completed 

Yes 

     No 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Parenting or caring responsibilities 

60 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Personal care and physical well-being 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

61 

Completed 

Yes 

     No 

Completed 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Social, cultural and spiritual 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

What services are to be provided, or actions taken 

62 

Yes 

     No 

Completed 

Yes 

     No 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

Work and occupation 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

Completed 

Yes 

     No 

What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

63 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Outcomes to be achieved may also be agreed in relation to other areas 

Outcomes to be achieved may also be agreed in relation to other areas 

Outcomes to be achieved 

Outcome 
Number 

Outcome to be achieved 

Yes 

     No 

Completed 

Yes 

     No 

What services are to be provided, or actions taken 

Intervention 

When 

Who by 

Completed 

Related 
Outcome 
Number 

Yes 

     No 

64 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Relapse signatures 

The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help 
from the care team (these are sometimes called relapse signatures): 

Crisis plan 

If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the 
following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be 
contacted): 

Language or communication requirements 

Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh 
Language) ought to be recorded here: 

65 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Person views 

Record any views that the relevant patient wishes to be included (including past and present wishes and feelings about the matters 
covered by the plan) and include any statements about any future arrangements which may apply. 

If the patient does not have any views or statements on these matters, or the patient's views cannot be ascertained, this ought to be 
recorded also.  The views of the person on this care and treatment plan, the mental health services that are to be provided, and any 
future arrangement that ought to be considered, are: 

This care and treatment plan has: 

Date Care and Treatment Plan Agreed/Not Agreed with Person 

DD 

  MM 

  YYYY 

Provider and sharing of information 

So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health 
services set out in this care and treatment plan are provided 

Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health 
services to the relevant patient 

66 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Has the individual been offered a copy of the Care and Treatment Plan 

Date copy of Care and Treatment Plan was offered 

DD 

  MM 

  YYYY 

The relevant patient may sign the care and treatment plan, if they wish- Did they? 

Yes 

     No 

Actual Start Date 

67 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 6 

68 

 
 
 
 
 
 
 Privacy Notice 

Purpose 

Powys County Council Adult Social Care 

This privacy notice has been developed by Powys County Council’s (the Council) Adult Social Care (ASC) service, to ensure its 
transparency with collecting and processing personal information. 

Anyone receiving a service from ASC will have a record kept about them. We collect personal information to enable us to provide 
you with social care services, in partnership with other agencies and voluntary organisations. This privacy notice also includes the 
processing of personal information that takes place by the Social Services Customer Feedback Team in order to improve our 
services.  

This notice explains what information we collect, why we collect it and how we keep it secure. It also explains your rights and our 
legal obligations. 

The Legal Basis 

ASC have considered appropriate lawful grounds for collecting and processing your data. Your personal information is needed so 
that we are able to carry out our legal responsibilities. 

In some cases, this may result in a legal requirement for information to be provided and collected. If you refuse to provide the data 
we require, this could result in us not being able to provide you with services. Some of the key pieces of legislation that ASC work 
under includes: 

•  Social Services and Wellbeing (Wales) Act 2014 
•  Wales Safeguarding Procedures 2019 
•  Mental Health Act 1983 

-  Mental Health Act Code of Practice for Wales 
-  Mental Health (Wales) Measure 2010 

69 

 
 
 
 •  Mental Capacity Act 2005 

-  Deprivation of Liberty Safeguards (soon to be replaced by the Liberty Protection Safeguards) 

•  Regulation and Inspection of Social Care (Wales) Act 2016 

The Data Protection Act 2018 

The Council is a Data Controller under the Data Protection Act 2018 which is the UK’s implementation of the General Data 
Protection Regulation.  

The Council’s Data Protection Officer (DPO) can be contacted at the Information Compliance Team at 
information.compliance@powys.gov.uk or at 01597 826 400.  

What information we hold about you 

ASC will store any details relating to your situation in a way that will assist us in supporting you to meet your, and / or your family’s, 
care and support needs as well as our responsibilities regarding the protection of adults at risk from abuse and neglect. 

Categories of personal data obtained 

ASC may obtain the following categories of your personal data: 

•  Name 
•  Address 
•  Date of Birth 
•  Gender 
•  Contact Details 
•  National Insurance Number 

We may also obtain and hold more specific information, including: 

•  Details about your care and support needs 
• 
•  Details of family relationships in and outside of your household 

Information about other members of your household 

70 

 
 
 •  The names and contact details of your close relatives and/or carers 
• 
•  Things that other organisations (such as health, schools, or care homes) tell us to help us understand your situation and 

Information used to assess your situation, such as assessments and reports 

needs and co-ordinate your care services more effectively 

•  Recordings of any visits or contact you have made, or we have made with you 
•  Any additional needs or disability 
•  Financial information 
•  Details of your mental health and capacity 
•  Details of your physical health 
•  Details of your wellbeing 
•  Details of your personal outcomes 
•  Details about your lifestyle 
•  Details about your engagement with ASC 
•  Culture, religion/ belief 
•  Criminal record 
•  Restorative justice 
•  Allegations of abuse or neglect towards you 
•  Allegations or concerns raised regarding your conduct or safeguarding concerns from you about others. 

Source of the personal data 

•  You 
•  Your representative/ advocate/ legal representative 
•  Your family 
•  Police 
•  Health authorities 
•  Education authorities 
•  Other local authorities 
•  Housing associations/ registered social landlords 

71 

 
 
 •  Regulatory bodies, such as Care Inspectorate Wales/ Health Inspectorate Wales 
•  Partner Agencies 
•  Medical professionals/ General practitioners 
•  Disclosure and Barring Service 
•  Members of the public 
•  Domiciliary Care Agencies 
•  Residential and Nursing Care Homes 
•  National Prosecution Service 
•  Secure Estates (prisons) 
•  Others (including professionals/ volunteers/ carers) who may be involved in your care 
•  Your employer 

Is Personal Information shared with anyone else? 

The sharing of your information will be undertaken in line with our tasks and the applicable legislation.  

We will only share information with an organisation if they need it to do their job, or where the law requires or allows us to do so, for 
example:  

If a Court orders that we provide the information 

•  Partner organisations that provide care and support services 
• 
•  Regulatory bodies (such as CIW) that inspect and monitor our work 
•  Organisations such as the police, health, education services and third sector partners who work jointly with us to provide 

services and protect individuals. 

Retention of Personal Information 

ASC will retain your information for some time after we have stopped delivering services to you. The Retention Periods are 
specified within the Council’s Corporate Retention Schedule. After this time records are safely destroyed. 

Further information 

72 

 
 
 For more information as to how the Council uses personal data, and on your data protection rights, please visit the Council’s 
privacy notice here: Data Protection and Privacy - Powys County Council  

73 

 
 
 
 
 
 
 
 
 Appendix 7 

74 

 
 
 
 
 
 POWYS TEACHING HEALTH BOARD and POWYS COUNTY COUNCIL 

PATIENT SAFETY INCIDENT  

ACTION PLAN from Regulation 28. 

FOR WEB39318. 

June 2022. 

REF 

ISSUE 

ACTION 

MHLD LEAD 

OUTCOME 

1.  Welsh Applied Risk 
Research Network 
assessments content 
reviews/ integrating 
systems/ updating of 
current information. 

a) Copyrighted Welsh 
Applied Risk Research 
Network to be added to 
WCCIS database. 

a) Service 
Improvement 
Manager/Powys 
County Council 
Powys Teaching 
Health Board IT 
Service Manager  

a) Correct 
evidenced 
based Welsh 
Applied Risk 
Research 
Network 
available on 

75 

COMPLETION DATE AND 
ACTIONS TAKEN 

a)  Early August 

2022 

PROGRESS 
AND/OR 
ACTION AT 
REVIEW DATE 
a) July 2022- 
correct form 
has been built 
and currently 
in testing 
stage.   

  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 shared IT 
system 

b) Inpatient 
staff able to 
use WCCIS 
Welsh Applied 
Risk Research 
Network, 
avoiding 
duplication and 
possibility of 
lost 
information. 

b)  Acute General 
adults to be in 
place by 
September 
2022, Older 
adults to follow.   

b) July 2022 
Increased 
authorisations 
in progress. 
Digital 
training 
available to 
support 
increased 
permissions.  

d) WCCIS 
stability has 
improved – 
July 2022 

d) Further National 
monitoring November 
2022, monthly 
monitoring via internal 
Gateway Group 

b) Powys Teaching 
Health Board Inpatient 
Staff to be given 
improved WCCIS access 
to enable them to 
complete documentation.   

b) Powys 
Teaching Health 
Board Clinical 
Lead Quality & 
Safety. 
Consultant 
Nurse Welsh 
Applied Risk 
Research 
Network Lead.  

c) Powys Teaching 
Health Board to work 
with external partner 
agencies to improve risk 
sharing information with 
commissioned inpatient 
care.    

d) National and Local 
Review of WCCIS 

c)Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead 

76 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Welsh Applied Risk 
Research Network 
assessments format/ ease 
of accessibility / 
infrequent users/ new 
users. 

A) Approved Welsh 
Applied Risk Research 
Network form will be 
placed on the person 
level in WCCIS so this is 
accessible to both 
services in Powys County 
Council and PtHB.   

d) Welsh 
Government/ 
Powys Teaching 
Health 
Board/Powys 
County Council 
gateway group 

a) Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 
Head of MH 
services Powys 
County Council. 

b) Chronology form 
added to WCCIS, 
replicating that 
recommended by Welsh 
Applied Risk Research 
Network.  

b) Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 

77 

d) Ongoing 
monitoring of 
WCCIS system 
performance 

a) Updates to 
include new 
format and 
form will 
enable a 
consistent 
approach to 
risk 
assessments 
and evaluation 
for Powys 
County Council 
and PtHB staff. 

b) This will 
allow for all 
risk activities 
to be added in 
an easily 
accessible way 
by internal 
practitioners.  

a) This will be 
completed by 01 August 
2022 

a) July 31st 
2022. 

The approved 
form is going 
live and has 
been agreed/ 
approved by 
the author. 

b) July 2022 
Developed 
and in testing 
stage.   

b) To be completed by 
01 August 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 c)Identification of staff 
ongoing. 

c)Powys 
County 
Council staff 
records 
updated to 
reflect Welsh 
Applied Risk 
Research 
Network 
training as 
mandatory 

c)Organisational Staff 
record to be used to 
identify staff requiring 
Welsh Applied Risk 
Research Network 
training.   

Head of MH 
services Powys 
County Council. 

c)Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 
Quality 
Improvement 
Manager, and 
CMHT Team 
Manager for 
Powys County 
Council. 

c)Staff 
requiring initial 
and refresher 
training will be 
identified and 
monitored.  

Names of 
Powys County 
Council staff 
requiring 
training will be 
given to Powys 
Teaching 
Health Board 
who lead on 
training, 
enabling them 
to target 
staffing 
groups.  This 
will be 
reviewed on a 
3 monthly 
basis.   

78 

d)Training is dependent 
on courses being run by 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Welsh Applied Risk 
Research Network 
authors.  No dates have 
been set but it is hoped 
that they will occur in 
Spring 2023.   

e) August 2022 

d)Identification of Powys 
County Council 
practitioners to train as 
trainers.  

e) Business Insight 
programmes used to 
identify infrequent Welsh 
Applied Risk Research 
Network users.  This will 
allow targeted support 
for those less confident 
via contact with 
Champions.     

Powys County 
Council CMHT 
Team Manager 

d)Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 
Quality 
Improvement 
Manager, and 
CMHT Team 
Manager for 
Powys County 
Council 

79 

d)2 Powys 
County Council 
Welsh Applied 
Risk Research 
Network 
Practitioners 
will be trained 
as trainers to 
support 
ongoing 
programme. 

d)Powys 
County 
Council Staff 
have been 
identified and 
their names 
will be 
submitted to 
Welsh Applied 
Risk Research 
Network 
authors by 01 
August 2022. 

e) Practitioners 
will feel more 
confident in 
undertaking 
Welsh Applied 
Risk Research 
Network 
assessments.   

e) The need 
to link in with 
Champions to 
be reiterated 
through 
Powys 
Teaching 
Health Board 
Learning and 
Development 
Group and 
through 
Powys County 
Council Team 
Meetings.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Alongside 
supervision.  

a)Audit processes to 
continue through Powys 
Teaching Health Board. 

3.  Welsh Applied Risk 

Research Network and 
associated assessments – 
reviews/ quality 
assurance 
monitoring/updating of 
current needs/ access by 
relevant bodies. 

a)Clinical Lead 
Quality & Safety. 
Consultant Nurse 
. Welsh Applied 
Risk Research 
Network Lead. 
Head of MH 
services in Powys 
County Council. 
Head of MH 
services in Powys 
County Council. 

a)6 monthly 
audits to target 
learning and to 
identify any 
development 
to be 
completed 
jointly by 
Powys County 
Council and 
PtHB. 

a)next audit scheduled 
for October 2022.   

b)Powys County Council 
to restart Quality 
Assurance Audit 

b)Clinical Lead 
Quality & Safety. 
80 

b)Powys 
County Council 
to reinstate 

b)Service 
Improvement 
Manager is 
currently 
restarting 

b)To be restarted in 
September 2022, with 
results fed back via 
Senior Management, 
supervision and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Learning and 
Development Group on 
completion. 

random 
audits, with 
each 
identified 
auditor 
allocated 2 
per month. 

Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 
Quality 
Improvement 
Manager, and 
CMHT Team 
Manager for 
Powys County 
Council 

randomised 
monthly audits 
focussing on all 
electronically 
held 
documentation.  
This process 
requires the 
auditor to 
speak directly 
with the person 
cared for and if 
appropriate, 
their Carers. 
Audit findings 
to be shared 
with Senior 
Managers and 
at Team 
Meetings. Also 
discussed with 
involved 
practitioners 
during their 
monthly 
supervision. 

4.   Welsh Applied Risk 
Research Network 
assessment tools – 
accessibility to Patient / 
integration referral 
process to secondary 

a)Greater users/carer 
involvement in the 
assessment process and 
the sharing of that 
information as identified 
as a piece of work 

a)Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 

a)Feedback 
provided by 
the author of 
Welsh Applied 
Risk Research 
Network Dr 

a)October 
2022. 

81 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 services, working 
together optimisation 
approaches 

following the last audits 
completed by PtHB. 
Confirmed this will be 
part of the training 
moving forward with the 
Welsh Applied Risk 
Research Network 
trainers to be delivered 
to Welsh Applied Risk 
Research Network 
assessors in both PtHB 
and Powys County 
Council. 

b) Powys Teaching 
Health Board and Powys 
County Council to 
support practitioners in 
understanding how and 
when to share 
information.  

Head of MH 
services in Powys 
County Council. 

b) Clinical Lead 
Quality & Safety. 
Consultant Nurse 
Welsh Applied 
Risk Research 
Network Lead. 
Quality 
Improvement 
Manager, and 
CMHT Team 
Manager for 
Powys County 
Council 
supported by 
Head of Data 
Protection.   

82 

Gray has 
provided good 
learning and 
development 
to take forward 
to improve and 
imbed future 
collaborative 
working, audit 
and review of 
the Welsh 
Applied Risk 
Research 
Network. 

b) Powys 
Teaching 
Health Board 
to share 
information 
sharing 
processes via 
Learning and 
Development 
Group. 

Powys County 
Council are in 
the process of 
updating its 
Privacy 
Statement, 

b) Ongoing 
and on a 
monthly 
basis. 

This was sent 
for ratification 
at the end of 
June 2022 
and is 
expected to 
be approved. 
This will then 
be shared 
with 
practitioners. 

August 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 which can 
support 
Practitioners 
and those we 
care for to 
understand the 
need to share 
information.  
(Attached as 
Appendix 6) 

c)The People we Care for 
should remain integral in 
assessment process.  
Assessments should be 
shared routinely with 
them unless there is a 
risk to self or others.   

c)Practitioners 
to be reminded 
of the need to 
coproduce 
documents 
with those we 
care for.   
Practitioners to 
update admin 

83 

October 2022 

Completed and ongoing 

Powys County 
Council 
Professional 
Lead for Data 
Protection 
invited to 
Teams 
Meeting, to 
support 
practitioners 
understanding 
of information 
sharing 
process. 

c)Practitioners 
reminded of 
need during 
Team 
Meetings and 
throughout 
supervision.  
To be 
considered 
through audit 
process. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 staff when 
documents are 
completed and 
ready to share 
with those 
identified in 
care plan, 
including 
external 
agencies, 
subject to 
appropriate 
authorisation.   

84 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 85

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