Freedom of Information Request – Ref: FOI 105-2026
Thank you for your recent Freedom of Information request. Please find our response below.
You asked:
1. A copy of your Policie(s)/ procedures, strategies and or any clinical guidance relevant to mental health care pertaining to clinical risk assessment and management and or suicide prevention.
Our response:
CLP249 Safety Assessment in Clinical Practice V15 issued 2.9.25
You asked:
2. Do you use any triage tools, rag rating or scales to stratify clinical risk?
Our response:
The Trust has largely moved away from the use of triage tools, RAG ratings, or numerical scales to stratify clinical risk within mental health and learning disability services (this does not include physical health services). Instead, Gloucestershire Health and Care NHS Foundation Trust uses a formulation-informed safety assessment and management approach across these services, focusing on an individualised, narrative-based understanding of a person’s needs, strengths, and circumstances, alongside collaborative safety planning (new policy formally implemented in January 2026).
As such, for the majority of Trust services:
- Stratified risk ratings do not inform care pathways or tiers of intervention. Clinical decision-making is based on individual formulation and clinical judgement rather than categorised risk levels.
- There are no standardised tools or scales in use that assign risk scores or ratings.
However, there is a specific exception within Young Minds Matter (YMM):
This service utilises a structured safety screening tool as part of their triage and initial assessment processes. This approach reflects the specific context of these services, including high referral volumes and a mixed workforce, and is designed to support consistent identification of potential safety concerns and prompt appropriate escalation where required.
The screening tool does not produce a numerical risk score or RAG rating, nor does it stratify patients into risk categories or tiers of care. It does not inform tiers of care; rather, it guides clinician decision-making, specifically supporting whether discussion with a senior clinician is required.
This approach is outlined within Section 13.4 of the Safety Assessment in Mental Health and Learning Disability Clinical Practice Policy (CLP249), alongside supporting Standard Operating Procedures for NHS Talking Therapies Safety Assessment and Planning, and aligns with the Trust’s broader safety-focused, formulation-informed model.
You asked:
a. If Yes, do they inform care in any way including different tiers.
Our response:
Not applicable.
You asked:
b. If Yes please provide a copy.
Our response:
Not applicable.
Next steps:
Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:
Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk
If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.