Good risk recording in a mental health care home describes what happens, when, and what helps, without turning the person into a diagnosis or a list of behaviours. The test of a risk record is whether the person could read it and recognise themselves, and whether a new worker could read it and know what to do tonight. Positive risk taking is the framework that makes both possible: the person's own view of the risk, an agreed plan, and a record that shows the decision was shared rather than imposed.
The short answer
Record risk in three parts. First, the facts: what the person has said or done, when, in their own words where possible, with the context around it. Second, what matters to the person and what helps: the things they want to keep doing, the early signs they and staff recognise, and the responses that have worked. Third, the agreed plan: what everyone has decided, including the person, what the risks of that plan are, why it is proportionate, who reviews it and when. That structure is positive risk taking in practice. It replaces 'high risk, non-compliant, manipulative' with something a night worker can act on and an inspector can see was made with the person. This article works through why labels creep in, how to write each part, how to handle incidents, restrictions and capacity, and how to audit what you already have.
What is positive risk taking?
Positive risk taking, sometimes called risk enablement, is the principle that people have the right to make choices that carry risk, and that the job of a service is to support those choices safely rather than remove them. It comes from the Department of Health's best practice guidance on managing risk in mental health services and from the Care Act's emphasis on wellbeing and control. It is not the absence of risk management. It is risk management that starts with what the person wants and asks how to make that possible, rather than starting with the risk and asking how to stop it.
In a care home it looks like this. A person wants to go to the shops alone, and has previously left without saying where they were going. Defensive practice records 'absconding risk, not to leave unaccompanied'. Positive risk taking records what the person wants, what happened last time and why, what would make it safer, what has been agreed, and when it will be reviewed. The second record allows the person a life. It also protects the home better, because it shows the decision was reasoned, shared and reviewed.
Why labels creep into risk records
Labels are quick. 'Aggressive', 'non-compliant', 'attention-seeking', 'manipulative', 'high risk'. They save the writer time and cost the person everything. Once a word like that is in a record it is read by every new worker, every agency nurse and every commissioner, and it shapes how they approach the person before they have met them. It also stops staff thinking. If someone is 'aggressive', nobody asks what happened before, what was going on for them, or what helped last time.
Labels creep in for understandable reasons. Templates ask for a risk level and nothing else. Staff are tired and write at the end of a long shift. Incident forms have a box for 'behaviour' and no box for 'what was happening'. Handovers pass on adjectives rather than events. And sometimes labels are fear made into words: a worker who was frightened writes 'violent' because that is how it felt. The fix is not to tell staff to be kinder. It is to change the templates, the prompts and the training so that describing is easier than labelling.
Describe, do not diagnose
The rule that fixes most records is simple: write what you saw and heard, not what you think it means. Compare the two records below.
Record one: 'Sam was aggressive and non-compliant this evening. High risk. Refused meds.'
Record two: 'At 6.15pm Sam came into the kitchen while staff were serving and asked for his medication early. When told it was due at 8pm he raised his voice, said staff never listen to him, and knocked a cup off the side. He went to his room. At 6.40pm he came back and apologised. At 8pm he took his medication as usual. He said later he was anxious because his sister had not rung.'
Record two is longer, and it is the one that helps. It tells the next shift what happened, what the trigger was, how it resolved and what to watch for. It gives the review something to work with. And Sam could read it and recognise the evening, which is the test. If a word in a record is a judgement rather than an observation, take it out and replace it with what happened.
At a glance: defensive recording versus positive risk taking
| Element | Defensive record | Positive risk taking record |
|---|---|---|
| The risk | 'High risk of self-harm' | What the person did or said, when, and the context |
| The person's view | Absent | In their own words, including where they disagree |
| What matters | Absent | What the person wants to keep doing and why |
| What helps | 'Monitor closely' | Early signs, responses that worked, who to call |
| The plan | A restriction | An agreed approach, its risks, why it is proportionate |
| Capacity | Assumed lacking | Assessed for this decision, recorded with reasons |
| Review | Monthly signature | A date, a trigger for earlier review, and what changed |
| Author | Staff only | Written with the person where possible |
Separate the risk from the person
A risk assessment should be about a specific risk in a specific context, not about the person as a whole. 'Risk of self-harm when alone late at night after contact with family' is a risk. 'Sam is high risk' is a label. Write each risk on its own, with its own triggers, signs, responses and plan. Most people in a mental health care home have two to four real risks, not one global level.
For each risk, record how it was identified. Was it something the person told you, something staff observed, something in the referral, or something a previous service recorded years ago? Old risks travel with people for decades. If the last incident was in 2019, say so, and say what has changed since. A risk assessment that carries a fifteen-year-old event forward at the same level is not an assessment; it is a rumour with a signature.
The person's own words
The single most useful thing in a mental health risk record is what the person themselves says about the risk. Ask them, and write it down as they said it. 'I cut when I feel nothing and I need to feel something. It is worse at night. It helps if someone sits with me and does not ask questions.' That sentence tells a night worker more than a page of professional assessment, and it belongs at the top of the record.
Include disagreement. If the person does not think there is a risk, or thinks staff overreact, record that in their words too. It does not weaken the record; it shows honesty and it gives the review something to discuss. Where the person cannot or will not contribute, record that you asked, when, and what you will try next. Where an advocate or family member contributed, record who and what they said, separately from the person's view.
Balance risk with what matters to the person
Every risk assessment should sit next to a statement of what the person wants from their life: the job, the relationship, the trip home, the drink on a Friday, the walk alone. Without it, the natural direction of a risk record is towards restriction, because every restriction looks safer on paper. With it, the question changes from 'how do we stop this?' to 'how do we make this possible?' and the plan changes with it.
A care plan for mental health that does this well reads like a plan for a life with risks managed inside it, not a plan for managing risks with a life squeezed around them. Inspectors read for this. Under the caring and responsive key questions they want to see that the person's goals drive the plan, and under safe they want to see that risks are managed proportionately. A record that shows both is strong on all three.
Writing the agreed plan
The plan is where positive risk taking either happens or does not. It should say what has been agreed, by whom, and why it is proportionate to the risk. Use this procedure.
- State the decision plainly: for example, Sam will go to the shops alone on weekday mornings, telling staff when he leaves and taking his phone.
- Record who was involved: the person, the keyworker, the manager, the care coordinator or community team, family or advocate where the person agreed.
- Record the risks of the plan honestly, and the risks of not doing it, including the effect on the person of a restriction.
- Record the safeguards: what makes the plan safer, such as a phone, a check-in time, a card with the home's number.
- Record the early signs that would mean the plan needs revisiting, and who decides.
- Record capacity for this decision if there is any reason to question it, and the outcome.
- Set a review date and a trigger for earlier review.
- Give the person a copy in a form they can use, and record that they have it.
A plan written this way is a positive risk taking decision that can be defended to a commissioner, a coroner or an inspector, because it shows the thinking. A plan that says 'not to leave unaccompanied' with no reasoning cannot be defended to anyone.
Recording incidents without the label
Incidents are where labels are born. A worker who has just been shouted at writes the form, and the form asks for 'type of behaviour'. Change the form. Ask for: what was happening before, what the person did and said, what staff did and said, how it ended, what the person said afterwards, and what the worker thinks might have helped. Ask for the person's own account, gathered when they are ready, and record it separately and in their words.
The manager's review then looks at the sequence, not the label. Was there a pattern with the time, the place, the people, the medication timing, the family contact? Does the risk assessment need updating with what happened and what helped? Does the plan change? Did the incident meet a threshold for safeguarding referral or CQC notification? Record each decision and the reason. Our guide to incident reporting in care homes covers the form, the review and the notification thresholds; the point here is that in a mental health home the form must be built to describe.
Restrictions, capacity and the least restrictive option
Any restriction in a mental health care home needs to be individual, recorded, justified and reviewed. That means: the specific risk it addresses, why less restrictive options were tried or ruled out, the person's view, a capacity assessment for that decision where relevant, a best interests decision or DoLS or LPS authorisation where required, a review date, and a record of what would end the restriction. Blanket rules that apply to everyone, such as a locked door, a fixed bedtime, no visitors after seven or no access to the kitchen, will be raised by inspectors unless each person's record shows why the rule applies to them.
The Mental Capacity Act is the framework. Assume capacity, assess for the specific decision when there is reason to doubt it, record the assessment with the reasons, and make any decision on the person's behalf in their best interests and in the least restrictive way. Our Mental Capacity Act and DoLS checklist sets out the paperwork. In the risk record, the capacity assessment and the restriction should sit next to each other so a reader can see that one led to the other.
Self-harm and suicidal thinking: recording what matters
Records about self-harm and suicidal thinking need particular care. Recording a level of risk on its own tells the next shift nothing about what to do. Record what the person has said, when, and in what context; what they say helps and what makes it worse; the early signs they and staff recognise; the agreed plan for nights, for after family contact, for the times they have identified as hard; means restriction that has been agreed with the person; who to contact and when, including the crisis team and out-of-hours; and what to do if the person asks for help at 3am.
NICE guidance on self-harm is clear that risk assessment tools and scales should not be used to predict future self-harm or to decide who gets care. The record is a shared understanding with the person, not a score. Review it after every episode with the person, and make sure the night team can find it in under a minute, because that is when it is needed.
Medication, PRN and the risk record
In mental health homes, medication is part of the risk picture and is often recorded as though it were separate. Refusals, PRN use and changes after review all belong in the same story as the risk assessment. A run of refused evening doses, three PRN doses in a week for agitation, or a dose change by the psychiatrist should each prompt a look at the plan. Record PRN with the reason in the person's terms, what else was tried first, and the effect, so the review can see whether medication is being used as the first response or the last. An eMAR that shows refusals and PRN patterns by time of day gives the review something to work with; on paper, someone has to count. Either way, when the community team reviews medication, the home should be able to hand over that pattern alongside the incidents and the person's own view of how the medication makes them feel.
Daily notes that support the risk record
The daily note is where the risk record lives or dies. A note that says 'settled, no concerns' for thirty days is no help when the review comes. A note that records mood in the person's words, what they did, contact with family, sleep, any early signs and what staff did about them is the evidence that the plan is being followed and the data the review needs.
Prompt for it. If the person's risk record says the early signs are withdrawing to their room and not eating, the daily log should ask about time in room and meals. If it says family contact is a trigger, the note should record contact. Structured daily logs tied to each person's plan make this happen without the worker having to remember; on paper it depends on the keyworker reading every note. Either way, audit the notes against the risk record monthly and ask whether the plan is visible in them.
Language to remove from your templates
Go through every template in the home and remove the words that label. The usual suspects:
- Aggressive, violent, challenging: replace with what the person did.
- Non-compliant, refused to engage: replace with what was offered and what the person said.
- Attention-seeking, manipulative, splitting: remove entirely and describe the event.
- Absconded: replace with left the building without telling staff, and where they went.
- Kicked off, went off on one: not clinical language and not acceptable in a record.
- High risk, low risk as a summary: replace with the specific risk and context.
- Inappropriate: say what happened.
- Allowed, permitted: ask whether the home is the right person to allow anything.
Then check the incident form, the risk assessment, the handover sheet and the daily note template for boxes that invite labels. A 'behaviour type' dropdown is a label machine. Replace it with a free text field that asks what happened.
Handover: passing on events, not adjectives
Handover is where labels are transmitted between shifts. 'Sam has been difficult today' becomes 'Sam is difficult' by the end of the week. Structure handover so that each person is discussed in terms of events and plan: what happened, what helped, what to watch for, anything changed in the plan. The record system should be open during handover so the incoming shift reads the note rather than hearing a summary of a summary. In mental health homes, a twenty-minute overlap where the outgoing worker introduces the incoming worker to the person, where the person wants that, does more for continuity than any written handover sheet.
Training staff to write this way
Staff write what they are trained and prompted to write. Three things change practice. First, a short session with real anonymised records from your own home: read two, identify the labels, rewrite them together. Second, feedback on real notes in supervision, specific and soon: 'this note said aggressive, what did you actually see?' Third, templates that make describing easier than labelling. Give it three months and audit again. Homes that do this find the records get longer, more useful and less frightening, and the incidents often go down, because staff who describe also start to notice what helps.
Include the person's own words in training. Invite someone who lives in the home, where they want to, to talk about how it feels to read their own record. It is the most effective training session most staff will ever have.
Working with community teams and commissioners
Risk in a mental health care home is shared with the community mental health team, the care coordinator, the GP and the commissioner. Your record should show that sharing: who was told what, when, and what they said. When the community team's risk assessment and yours differ, record both and record the conversation. When a commissioner asks for a risk summary, send the structured record, not a list of incidents, because the structured record shows the work. A care record that holds the risk assessment, the plan, the capacity decisions and the incidents against the person, with a professional contact log, means that summary takes minutes rather than an afternoon.
A quick audit of what you have now
Pick three people and read their risk records, incident forms and last month of notes. For each, answer:
- Could the person read this and recognise themselves?
- Could a new worker read it and know what to do tonight?
- Is the person's own view recorded, in their words?
- Is each risk specific to a context, with a date and a source?
- Does the plan say what has been agreed and why it is proportionate?
- Is any restriction individual, justified, capacity-assessed where relevant, and reviewed?
- Do the daily notes show the plan being followed?
- Has anything changed after the last incident?
Count the no answers. That is the size of the job, and the order above is the order to fix it in. Our risk assessment examples and template article gives a structure you can adapt.
Common mistakes
- One global risk level for the person instead of specific risks in specific contexts.
- Old incidents carried forward at the same level for years with no review of what has changed.
- No record of the person's own view, or of disagreement.
- Restrictions recorded without the less restrictive options considered or a capacity assessment.
- Incident forms with a behaviour type dropdown and no space for what was happening before.
- Daily notes that do not mention the early signs the risk record says to watch for.
- Monthly review by signature with nothing changed.
- Handover that passes on adjectives rather than events.
What good looks like on inspection day
The inspector picks the person with the most recent incident and reads the file. The risk assessment lists three specific risks, each with a date, a source, the person's own words at the top, what helps, and an agreed plan with reasons and a review date. One plan is a positive risk taking decision to go out alone, with the safeguards and the capacity assessment next to it and a note that the person has a copy. The last incident form describes what was happening before, what the person did and said, what staff did, how it ended, and the person's account the next morning; the manager's review changed the plan and the change is dated. The daily notes for the last month mention the early signs and family contact because the log prompts for them. The night worker on shift can say what she would do if the person asked for help at 3am. The person, asked by the inspector, says staff listen and that the plan was made with him. That is what a record system such as Kiwi, with risk, incidents, capacity decisions and daily logs in one place, is built to hold. If you would like to see how the templates avoid labels by design, book a demo.
Final conclusion
Positive risk taking is not a softer approach to risk; it is a more honest one. Record what happened, in the person's words wherever you can. Separate each risk from the person and give it a context, a source and a date. Put what matters to the person next to the risk, so the plan has somewhere to go other than restriction. Write the agreed plan with its reasons, its safeguards and its review. Build forms and notes that make describing easier than labelling, and train staff on their own records. Do that and the record becomes something the person can recognise, the night shift can use and the inspector can see was made with the person rather than about them.
Frequently asked
What is positive risk taking in mental health care?
Positive risk taking, also called risk enablement, means supporting people to make choices that carry risk rather than removing the choice. In practice it is a recorded, shared decision: what the person wants, the risks of doing it and of not doing it, the safeguards agreed, who was involved, and when it will be reviewed.
Is it wrong to record that someone is a suicide risk?
Not wrong, but not enough. Record what the person has said or done, when, in what context, what helps, what the agreed plan is including for nights, who to contact and when it will be reviewed. A level of risk on its own tells the next shift nothing about what to do.
How should restrictions be recorded in a mental health care home?
Individually, with the specific risk addressed, why less restrictive options were insufficient, the person’s view, a capacity assessment for that decision where relevant, any DoLS or LPS authorisation, a review date and what would end the restriction. Blanket rules that apply to everyone need a recorded reason for each person or they will be challenged.
How do I get staff to stop using labels in records?
Change the templates so describing is easier than labelling, train on real anonymised records from your own home, and give specific feedback on notes in supervision. Ask staff to write what they saw and heard, not what they think it means, and audit three files every month.
What should a care plan for mental health include?
What matters to the person and their goals, their history in their own words, specific risks with context and what helps, the agreed plan for each with reasons and safeguards, early signs and responses, medication and physical health, capacity decisions and any restrictions with reviews, contacts including the community team and crisis routes, and a review date.
Should the person see their own risk assessment?
Yes, wherever possible, and ideally they should help write it. Their own words should be in it, including where they disagree. Record that they have a copy in a form they can use. A risk record the person has never seen is a record about them, not with them.
How often should a mental health risk assessment be reviewed?
At a set date, usually monthly or quarterly depending on the level of change, and immediately after any incident, change in presentation, medication change or significant life event. Review means reading it with the person and changing what needs changing, not a signature in a box.
Sources
- Department of Health: Best practice in managing risk, principles and guidance for mental health services
- SCIE: Enabling risk, ensuring safety, self-directed support and personal budgets
- NICE: NG225 self-harm assessment, management and preventing recurrence
- CQC: Regulation 12 safe care and treatment guidance
- CQC: Regulation 13 safeguarding service users from abuse and improper treatment
- Mental Capacity Act 2005 Code of Practice
- CQC: Out of sight, who cares? review of restraint, seclusion and segregation
- Human Rights Act 1998
