118. The environment in which care is delivered in mental health services can have a direct impact on the risk that both those using the service and those providing it experience. Whether in a community facility, a crisis house, a drop-in centre, or an in-patient ward, there are design features which make a building welcoming, easy to use, and safer.24 To ignore these is courting trouble, does not comply with health and safety at work regulations and puts unneeded additional pressure on those within. When new facilities are being designed, the architects have to be briefed in a clear and consistent way. However, many services are delivered from older buildings, perhaps designed for other purposes, or erected at a time when operational practice in the service was very different to the philosophy and style described in this report.
119. No building is entirely risk free, and excessive attempts to minimise risk are likely to lead to a sterile, "clinical" atmosphere, which does not bring out the best in human behaviour. There are clashes too between the need for privacy, and some personal space, and clear sight lines. A facility which is designed obviously to deal with crises risks causing an atmosphere of tension and alarm. To have to run a gauntlet of security measures to gain access to a facility will tend to make an individual wonder whether getting in will lead to satisfactory care. Some points must be attended to - shower or bed curtain rails must not be able to bear an individual's weight. This simple measure can be life-saving. Facilities generally should be on the ground floor whatever the precautions. Upstairs windows are fail-danger.
120. There are gender issues too. While people generally belong to social networks which contain both genders, single sex existence in the community is a matter of choice. The wish to normalise in-patient or residential care suggested that mixed sex accommodation was to be preferred, to lessen the jump from the outside world to the care situation. Now it is clear that in ward mixed sex accommodation many women feel intimidated and at risk of constant harassment, particularly in acute in-patient care. It may not be only the ward environment - corridors, entrances and lifts may all be risky places. For that reason, all Trusts in Scotland have been asked to implement changes in accommodation which will meet guidelines by 2001.30
121. Individuals, unless liable to detention on an order under the Mental Health legislation should be free to come and go. Because of the high prevalence of substance misuse described in Chapter 10 and the related problems for mental health care delivery, that freedom to come and go should not be used as an opportunity to replenish supplies of an illicit drug, or to distribute those supplies to fellow service users or to consume disproportionate amounts of alcohol. For that reason a multiplicity of entrances and exists from a facility makes the management of this area of risk more difficult.
122. Another risk associated with substance misuse is the increased likelihood of assaultative and violent behaviour by an individual affected by both the substance and a mental health problem. The impact of assaults on staff and fellow residents has been documented well.25 The more private and secluded individual sleeping accommodation becomes in line with good practice to promote personal dignity, the more vulnerable individuals are, out of sight and out of hearing. For that reason, many mental health services have found it necessary to install some system involving personal alarms for the protection of staff. Unobtrusive systems exist which involve individual clip-on boxes, the size of a personal pager, and detectors in every room used for clinical purposes. These are linked to a warning light external to each room which shows those coming to an individual's assistance from where the alarm call has come. A master panel near to the duty room gives those coming into the unit to give assistance from outside a clear indication of where to go. Such systems in themselves do not reduce risk. As has been said repeatedly in this report in other contexts, the alarms and indicators are viable only if they are incorporated into a system which is robust, supported, reviewed and maintained.
123. Reference has already been in a vignette (page 19) to the problems associated with assessing an individual who has been brought to an Accident & Emergency Department by the police. All too often, interview rooms have not been designed with any recognition of risk reduction.
A mental health facility is on the edge of a District General Hospital site. The psychiatric and clinical psychology out-patient department is situated in a former nurses' home at the very edge of site, 300 yards from the DGH. The width of the corridors and layout of the rooms is unchanged from the original design. Apart from clinical staff there is just the one receptionist. There is an answerphone system but individuals frequently have difficulty operating it and the receptionist has to walk to the front door to let them in. She has an office, but there is no microphone to allow her to hear through the glass panel, so she has to go to the door and open it to speak to the individual. Some staff have alarms, but there is no pinpointing system and the alarms would only be heard if there were individuals in other offices. Each office has only one door, with a handle on the inside. The width of the corridor means that it could be easily barricaded. Calling for outside assistance would require people to be available in the DGH building and to be fit enough to run 300 yards uphill to give assistance. There is no rehearsed or reviewed security policy.
124. Rooms in which people whose behaviour is not predictable are to be interviewed and who therefore pose a potential risk should be modified to meet the following requirements:
125. The Estates Department of a Trust or service needs to be closely involved in the reduction of risk. Any facility which is used by individuals for whom the service has responsibility should be the subject of a regular audit of its fitness for purpose, paying attention to the points above, and those mentioned in any guidance material.26 The results of these regular audits should feed in to the organisation's risk management committee and a senior member of the Estates Department should be a member of that committee. The organisation should be in a position to fund any modification to buildings or rooms which the audit, or the results of critical incident reviews, have indicated constitute a risk to both staff and the individuals receiving a service from there. There are wider issues concerned with the state of fabric, decoration and comfort of facilities which also contribute to risk.