In–Patient Observation and Engagement Web viewWhere qualified healthcare professionals from a non-nursing background are ... as part of an integrated process of risk ... word is

Document name: In–Patient Observation and Engagement policy

Document type: Policy

Staff group to whom it applies: All staff within the Trust, but principally those working on in-patient areas

Distribution: The whole of the Trust

How to access: Intranet and internet / ward folder

Issue date: April 2004, reviewed January 2006, amended October 2006, appendix added March 07, further amendment added December 2007. Reviewed September 2008, reviewed March 2010, amendment added Aug 2010, Reviewed May 2012, Reviewed Jun 2014, reviewed July 2016

Next review: Jun 2017

Approved by: Executive Management Team

Name of responsible committee/individual:

Expert Reference Group

Director leads: Director of Nursing, Clinical Governance and Safety

Contact for advice: George Smith, Assistant Director of Nursing /Simon Robinson, Nurse Consultant, BBDU

Version:

Date approved:

Name of originator/author: Observation policy reference group

1

mailto:[email protected]

TABLE OF CONTENTS

Section Title Page

1 Introduction.......................................................................................................42 Purpose..............................................................................................................43 Duties.................................................................................................................44 Communication.................................................................................................55 Engagement.......................................................................................................66 Levels of Observation.......................................................................................6

6.1 Level 1 – Within Arm’s Length/Close Observation...............................6

6.2 Level 2 – Within Eyesight.....................................................................6

6.3 Level 3 – Intermittent............................................................................6

6.4 Level 4 – General.................................................................................7

7 Prescription of Observation.............................................................................78 Recording...........................................................................................................89 Risk Assessment...............................................................................................810 Care Planning....................................................................................................811 Skills and Training............................................................................................912 Reporting Incidents.........................................................................................1013 Consultation and Communication with Stakeholders.................................1014 Approval of this Document............................................................................1015 Equality Impact Assessment.........................................................................1016 Review and Revision Arrangements including Version Control................10

16.1 Process for Review of this Document................................................10

16.2 Version Control...................................................................................11

17 Dissemination and Implementation...............................................................1117.1 Dissemination.....................................................................................11

17.2 Implementation...................................................................................11

18 Document Control including Archiving Arrangements...............................1119 Monitoring Compliance With and the Effectiveness of this Policy............11

19.1 Compliance.........................................................................................11

19.2 Effectiveness......................................................................................12

20 Associated Documents..................................................................................1221 References.......................................................................................................12

2

APPENDICES

Section Title Page

Appendix 1 Application of this Policy within Residential and Recovery Services..........................................................16

Appendix 2 Observation Record – Level 1(Within Arm’s Length/Close Observation)................................................17

Appendix 3 Observation Record – Level 2 (Within Eyesight)......................................18

Appendix 4 Observation Record – Level 3 (Intermittent)............................................19

Appendix 5 Observation Record – Level 4 (General)..................................................23

Appendix A Checklist for the Review and Approval of Procedural Documents.........................................................................25

Appendix B Flowchart for the Creation and Implementation of Procedural Documents...............................................28

Appendix C Version Control Sheet..............................................................................30

Appendix D Plan for Dissemination of Procedural Documents....................................31

Appendix E Equality Impact Assessment Tool............................................................32

3

1 Introduction

Words and phrases within shaded boxes are explained fully in the glossary of terms.

This policy covers all sectors designated as in-patient areas for adult, forensic, older people and learning disability care groups. Specific guidance for its application in named Residential/Recovery settings ONLY is contained in the appendix. Additionally, professional staff may also wish to adopt this policy (or parts of it) for use in non-residential settings such as day hospitals and treatment centres. This policy acknowledges that the processes involved in managing risk posed by service users can at times be challenging. For this reason, an individual’s level of observation is determined and recorded utilising a formal recognised risk assessment tool (Sainsbury’s, HCR 20, etc.).

2 Purpose

The purpose of the Policy for the Observation of Service Users is to provide guidance for the planning and implementation of high quality and robust systems for observing service users, to identify and reduce the risks of potentially suicidal, violent or vulnerable service users from harming themselves or others. It is also relevant for service users who are at risk due to physical illness or incapacity.

This policy will also aim to encourage the development of therapeuticinteraction/engagement with service users that keeps a balance between intrusion and safety. To justify the level of observation for each service user as proportionate to the degree of risk they pose to either themselves or others.

3 Duties

Strategic Responsibility

The lead Director for this policy is the Director of Nursing, Compliance and Innovation, and the policy was initiated by the Practice Effectiveness Trust Action Group. The policy is developed and reviewed via the PETAG. It is communicated via Operational Leadership and Management framework. The Executive Management Team has responsibility for approval and ratification.

Determining Observation Levels

Determining observation levels for service users is principally a task which falls to nursing staff. However, good practice dictates that it should involve as many members of the MDT as practicable and in many instances joint nursing/medical assessments and decisions will be made. Where qualified healthcare professionals from a non-nursing background are acting in the key worker role, they assume the same responsibilities and follow the same procedures as described within this policy for nursing staff in that role.

4

Management of Observation

The nurse in charge of the ward establishes a rota of those workers who are required to carry out observation duties over the course of a span of duty, and this rota is communicated to all and understanding of responsibility clarified.

The person who takes on the delegated observation is responsible for carrying out the observation in accordance with this policy.

There is a clear exchange of information pertaining to the service user’s care when one worker is replaced by another and, where required, a written entry is made in the service user’s clinical notes. A worker does not engage in ‘within arm’s length/close observation’ observation duty for more than one hour at a time, unless there are compelling clinical or safety reasons why the worker should carry on for longer.

Where service users are transferred to the care of another provider (e.g. Acute Trust) the MDT need to consider how needs/risks in relation to observation can be met. If this involves deploying staff to undertake observations into another area, they must have the appropriate skills and experience to do so. This includes bank staff deployed to undertake observations.

4 Communication

It is essential that all members of the team caring for service users are aware of their levels of observation. All service users should be informed of the levels of observation that they are subject to, the reasons for this and any expectations of them.

It is acknowledged that shift handovers are a particularly vulnerable time in relation to observation as there is the potential for increased risk caused by misunderstanding or lack of communication. It is the responsibility of the oncoming nurse in charge to ensure that the handover procedure from the outgoing shift includes a review of the environment to establish that it is safe, that all service users being handed over are safe and accounted for, and that their levels of observation are clearly understood and documented. The responsibility for observations during the handover period remains with the outgoing shift and they are only released from that that duty when relieved by a colleague from the oncoming shift. (Any person joining a shift outside of handover times should report to the person in charge who must ensure that he or she is aware of and understands his or her responsibilities in relation to carrying out observations.)

5

5 EngagementEffective engagement with service users underpins effective observation.

The policy describes only what is required in terms of service user observation and is not prescriptive in relation to the development of therapeutic interventions and engagement. These should be determined and recorded in individual care plans and support effective risk assessment and management.

6 Levels of Observation

There are four levels of formal observation to which a service user might be subject. Assigning levels of observation is regarded as part of an integrated process of risk assessment and care planning. The level of assigned observation must be clearly and accurately recorded in the service user’s Observation and Engagement care plan.

It is important that practitioners read explanatory notes regarding these levels of observation which are contained in the glossary of terms.

6.1 Level 1 ‘Within Arm’s Length/Close Observation’

The service user is subject to close proximity observation by one or more health care staff. This level of observation is used where risk assessment indicates a high level of risk of self harm or harm to others without this level of intervention. The staff member will remain with the client when they are in the company of visitors and care must not be handed over to visitors at any time. The continuous observations are recorded at maximum intervals of one hour.

6.2 Level 2 ‘Within Eyesight’

The service user is subject to uninterrupted observation by healthcare staff . The care plan stipulates the maximum distance which is permissible between the supervising staff and service user, and whether the supervisor must remain in the same room as the service user. The staff member will remain with the client when they are in the company of visitors and care must not be handed over to visitors at any time. The continuous observations are recorded at maximum intervals of one hour.

6.3 Level 3 ‘Intermittent’

A visual check is made upon the service user at 15 minute intervals. Where risk assessment indicates upon step down from Level 2, observations may be care planned and recorded at more frequent intervals than every 15 minutes. However all service users on level 3 must be visually checked at least every 15 minutes. All checks are recorded on the observation documentation.

6

Any individual assessed as requiring a higher level than intermittent observation is made subject to ‘within eyesight’ or ‘within arm’s length’ observation. It is anticipated that level 3 will only be used in initial assessment or in step-down from level two or step–up from Level 4 (general observations).

A service user subject to intermittent observations must not leave the ward area unescorted.

6.4 Level 4 ‘General’ A visual check is made on the service user at least every hour and formally recorded. Clearly this can only be done when the service user is on the ward or its immediate environs. If the service user leaves the ward to the extent that his/her observation is not possible, this is recorded on the observation record in accordance with an agreed care plan. All service users must be subject to at least this level of observation.

7 Prescription of Observation

Determining Levels of Observation

The nurse in charge of the ward is ultimately responsible for ensuring that a service user is subject to observation. During the admission process a service user is jointly risk assessed by medical and nursing staff. This joint risk assessment is the basis on which the initial level of observation is determined. Subsequently the service user’s primary nurse and medical consultant/responsible clinician make significant contributions to decisions about levels of observation. Additionally, the service user, where possible, should be consulted and agreement sought about the level of observation and its associated care plan. The responsibility for changing the level of a service user’s observation at consequent reviews rests with the nurse in charge, who should consult with other members of the nursing or wider MDT.

If a disagreement arises between professionals that cannot be resolved about the appropriate level of observation required, the matter is brought to the attention of the service manager or on call manager. Until this is resolved, the higher level of observation is maintained.

The reason why a service user requires a particular level of observation and under what specific circumstances it can be decreased must be recorded in Observation and Engagement care plans. I.e. the service user must have met specific criteria which have been pre-determined and recorded in a care plan before the level of observation can be decreased.

7

8 Recording

An uninterrupted record of formal observation activity is maintained. If for any reason an observation is unable to be undertaken, the nurse in charge must be informed immediately and a risk assessment made. E.g. if the observing nurse has to attend to an emergency situation (this must always be reported using the Trust’s incident reporting procedures and an entry made in the service user’s notes). Observation is recorded using the documentation in appendices 2-5.

9 Risk Assessment

An individual’s level of observation is determined and recorded utilising a formal recognised risk assessment tool (Sainsbury’s, HCR 20, etc). The care plan/risk assessment should include consideration of environmental factors such as access to potential ligature points, ligatures or other potentially lethal means by which the service user may harm themselves. New equipment and change of use of environment should trigger consideration for further risk assessment.

10 Care Planning

A service user must have a specific care plan that details the observation requirements for that person. The care plan is the primary source where levels of observation are recorded and updated. In areas which do not have integrated clinical records, the nurse in charge ensures that the current level of observation in all records is the same as that recorded in the primary patient record. Care plans must include the following:

The reason why a service user requires a particular level of observation and under what specific circumstances it can be decreased. I.e. the service user must have met specific criteria which have been pre-determined and recorded in a care plan before the level of observation can be decreased.

Details of what is expected of staff providing ‘within arm’s length/close observation’ and ‘within eyesight’ observation:

The required proximity of the member/s of staff to the service user.

Whether the service user requires direct observation when engaging in personal/intimate activities, e.g. bathing.

The amount of privacy a service user may have in the confines of his/her bedroom.

Details of what is expected of staff providing other levels of observation:

The specific requirement of the supervising health care worker to note the activities in which the service user is engaged, whether a service user is simply present, or to determine the service user’s well being through observation of vital signs, or his/her engagement in purposeful activity.

8

Details of explicit therapeutic interventions and engagement the service user may require.

The need for care plan review (specific to observation) – see Review below.

Written information about observation is given to all service users and the Observation and Engagement care plan facilitates this.

11 Skills and Training

Each member of staff in areas that undertake observations receives instruction and guidance as part of their workplace induction, on the different levels of observation, appropriate documentation and how to use them. This will also include:

Observation levels – the types individuals may be subject to, what they mean and how they are carried out

Duty of care –in particular the responsibility to act to maintain safety

Assessment tools – and how they are used to support the practice of observation

MISPER – Missing Person – local procedures to be followed in the event of staff being unable to locate an individual

Record keeping – responsibilities and standards

Accident/Untoward occurrence reporting and procedures – when these should be completed

(Ref – SWYPFT Induction Policy)

Responsibility lies with delegating professional to ensure that the individual delegated has the appropriate skills and understanding to undertake observation (this includes any additional training). The patient’s gender, characteristics, circumstances, coercive intent and risks must be taken into account when allocating staff to undertake enhanced observations. Where the person undertaking observation is a student nurse, mentors must ensure the student can demonstrate the skills and understanding necessary to carry out the procedure competently and safely. Competence will vary from individual to individual, and in this instance relates to the ability to safely undertake duties in accordance with this policy.

9

Assurance of competence should be demonstrated by the student being able to reference the information in the section above, as well as repeatedly demonstrating practical skill and competence in undertaking the task whilst under the direct (observed) supervision of their mentor or co-mentor. Unless their mentor and person delegating is assured of their competence, and student is in agreement, student nurses must not undertake observation. This should be recorded in the practice documentation and signed by mentor and student. First year students in training must not undertake continuous supervision at Level 1 or Level 2.

Advice on application of the policy can be provided by Assistant Director of Nursing/Nurse Consultant, Acute, BBDU

12 Reporting Incidents

Staff would record incidents arising from observation in line with the Trust’s Incident Reporting System (Datix). Datix reports are routinely reviewed by Risk Sub Groups of Operational Leadership and Management framework.

13 Consultation and Communication with Stakeholders

This policy has been developed with support from an expert reference group, staff from different professional and care groups, specialist advisors, professional leads and service managers. This also included consultation with service user groups (the expert reference group reviewed in Apr 2014).

14 Approval of this Document

This policy is approved and ratified by Executive Management Team.

15 Equality Impact Assessment

Some individuals may find any observation practice intrusive.

Observation might impact upon an individual’s ability to fully practice all aspects of their religious practice, e.g. wearing certain items of clothing.

Individuals subject to detention under MHA may have higher observation levels imposed.

16 Review and Revision Arrangements including Version Control

16.1 Process for Review of this Document

This policy should be reviewed every 2 years by the Director of Nursing, Clinical Governance and Safety unless required earlier by legislative, clinical or procedural need. The review will consider equality impact assessment and will be in line with Trust policy for the development, approval and dissemination of policy and procedural documents.

10

16.2 Version Control

Will be in line with procedure set out in Trust policy for the development, approval and dissemination of policy and procedural documents.

17 Dissemination and Implementation

17.1 DisseminationPolicy is disseminated in line with Trust policy for the development, approval and dissemination of policy and procedural documents.

17.2 ImplementationThis policy is already implemented. New staff are inducted as described in section above, Skills and Training.

18 Document Control including Archiving Arrangements

In line with Trust policy for the development, approval and dissemination of policy and procedural documents.

19 Monitoring Compliance With and the Effectiveness of this Policy

The specific requirements to monitor compliance and effectiveness are set out below:

19.1 Compliance

A service user subject to ‘within arm’s length/close observation’ observation is reviewed at the end of each span of duty, and formally at least once every 24 hours. The formal review includes members of the multi disciplinary team, especially the primary/associate nurse and a doctor. The outcome of this review is recorded in the service user’s clinical nursing and medical notes.

Additionally, there must be a written statement in the notes for each span of duty which sets out the justification for the need of this level of observation.

Should the need for ‘within arm’s length’ observation exceed 72 hours, or have been used intermittently for 120 hours a review with the consultant/responsible medical officer or nominated deputy, the nursing team and other professionals takes place. The outcome of this review is recorded in the service user’s clinical nursing and medical notes.

Where a service user is subject to ‘within eyesight’, and ‘intermittent’ observation, a formal review is undertaken on every 48 hours, again involving other members of the multi disciplinary team. The outcome of this review is recorded in the service user’s clinical nursing and medical notes.

11

The reviews set out above are a minimum requirement and must be held more frequently if changes to the service user’s presentation or significant incidents occur.

Review is not limited to the formal measures above, but is a continuous process so that a formal review can be held as soon as practicable if this is considered necessary.

19.2 Effectiveness Monitoring of the effectiveness of this policy will take place via DATIX incident reporting system, Operational Leadership and Management framework, individual staff supervision and annual clinical audit.

20 Associated Documents

This document has been developed in line with guidance issued by the NHS Litigation Authority and with reference to model documents used in other trusts. It should be read in conjunction with:

Mission Vision Values and Goals, SWYPFT

Induction Policy, SWYPFT

MISPER procedures

Incident management and Patient safety policy and procedures

Induction policy

21 References

Mental Health Nursing: ‘Addressing Acute Concerns’ Report by the standing Nursing Committee, June 1999.

Violence, The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments, 2005.

Mental Health Act, Code of Practice, HMSO.

Bowers Len, City 128 study, www.citypsych.com.

Jones R. Mental Health Act Manual 14th Ed.

Sainsbury Centre for Mental Health (2006) The Search for Acute Solutions

Standing Nursing and Midwifery Advisory Committee Recommendations forObservation of Service Users within Mental Health Inpatient Areas(snmac:2000)

12

http://www.citypsych.com/

GLOSSARY OF TERMS

Determining levels of observation

This policy makes it clear that the initial responsibility for establishing a level of observation is a joint medical/nursing decision. It does not imply that others do not bear considerable obligations. In practice, the service user’s medical consultant/responsible medical officer and primary nurse have substantial influence in determining levels of observation. However, at any given time, there must be someone who holds responsibility for increasing or decreasing the level of observation in line with the service user’s risk assessed needs, and this is the nurse in charge, who will ideally take this decision in consultation with other members of the nursing team and MDT.

N.B. Section 7 (Determining Levels of Observation) indicates that the service user must have met specific criteria which have been pre-determined and recorded in a care plan before a decision to decrease the level of observation is made.

Formal/formally

Where this word is used in the text, it refers to an activity being made subject to record. E.g. ‘formally observe’ means the service user is seen and that this is recorded in writing or by initialling/signing a form.

Nurse in charge

This phrase refers to the nurse designated as ‘in charge’ of the ward over a span of duty. In some localities this person is called the shift leader. It should not be confused with the most senior nurse on the ward, e.g. a ward manager, or another ward nurse who at the time is the most senior present because the ‘nurse in charge’ is temporarily away from the ward.

Observation

Effective observation is facilitated by engagement. It is not sufficient when undertaking observations to merely record that an individual has been ‘seen’. The observer should satisfy themselves that the individual that they are observing is alive and appears free from harm.

Primary nurse

This is now a generally accepted term for the nurse who has on-going responsibility for the design, review, and development of the programme of nursing care for a service user. In some areas, this function falls to the ‘named nurse’. It must not be confused with the ‘allocated nurse’ etc who is the member of nursing staff who is designated to provide care to a specific service user or group of service users over a span of duty.

13

Professional health care worker

Any professional engaged in the provision of care or services to the service user in question.

Ward

This may appear self explanatory, but the word also applies to villa, unit, etc. where in-patient care is carried out.

Level 1 ‘Within arm’s length/close observation’

‘Arm’s length/close observation’ means that the member of staff supervising is positioned within touching distance of the service user or up to a maximum of 6 feet (1.82 metres) away. Actual distance of proximity must be determined by an assessment of risk, and must include consideration that the service user’s level of agitation might increase by as a result of proximity of staff and thus pose an increased risk of challenging behaviour. Following a risk assessment the service user may be allowed a degree of privacy when using the toilet. This must be detailed clearly in the care plan. This level of observation is indicated where there is significant risk of self harm and/or harm to others.

Level 2 ‘Within eyesight’

In the context of this policy, ‘within eyesight’ means that the service user should be visible (and under constant supervision of) staff observing. Within eyesight should place staff close enough to respond immediately should an incident be occur or be likely to. There may be times when the care plan allows for some degree of privacy, so that following a documented risk assessment, the observing staff member knows the exact whereabouts of the service user even though he/she might not be in direct line of sight. It is possible to supervise a person without actually having direct sight of him/her. An obvious example of this is when a person is allowed to have privacy for personal/intimate activities e.g. using bathroom. In these cases the extent and intensity of the observation is detailed in the care plan. In other words, previously agreed, planned and documented - it must never be a “spontaneous” decision.

Level 3 ‘Intermittent’

So indicated where the risk level is lower and there is not an acute or overt risk of self harm or harm to others. It is used where there is an assessed need to ensure the user’s safety via a clear understanding of their whereabouts at 15 minute intervals. Where risk assessment indicates upon step down from Level 2, observations may be care planned and recorded at more frequent intervals than every 15 minutes. However all service users on level 3 must be visually checked at least every 15 minutes.

14

Level 4 General Observations

All service users are subject to at least hourly observations and this is recorded. If the service user needs indicate a graduated increase in observation intervals from level 3, Level 4 observations may be recorded twice hourly – but will never be any less frequent than hourly for all service users.

Written information

This should ideally be included in copies of ‘Information to service users’ booklets rather than it being provided separately.

Responsible Clinician

A registered medical practitioner in charge of the treatment of a service user detained under a section of the Mental Health Act, 1983. This is normally the service user’s consultant but outside ‘office hours’ this responsibility falls to the on-call consultant. During periods of absence the consultant nominates another to act as Responsible Clinician.

15

Appendix 1

Application of this policy within residential and recovery service annexe buildings

This amendment ONLY applies to the annexe at Castle Lodge in Wakefield (Sandal House), and the unstaffed flats at Enfield Down in Kirklees.

The Trust has some residential based services that have unstaffed annexes where full application of the Trust Observation Policy is not reasonable or applicable. These buildings are used to support service users who are stable in terms of their mental health presentation and would be considered to present a very low risk to themselves or others. They may have undergone a significant period of rehabilitation and are being supported in unstaffed accommodation in preparation for a move towards independent or other supported living. With this in mind, the principle of caring for individuals in the least intrusive setting should be applied.

Where an individual’s mental health is deemed to be stable and is evidenced by risk assessment indicators that are very low, the multi-disciplinary team may decide that a service user is formally observed at intervals determined within their care plan which are less frequent than those outlined within this policy. This is supported by a contingency plan to be followed should the individual not be seen at the agreed interval. These arrangements must be reviewed should clinical presentation change.

16

Appendix 2Observation RecordLevel 1 (Within Arms length Close Observation)The service user is subject to close proximity observation by one or more health care staff. This level of observation is used where risk assessment indicates a high level of risk of self harm or harm to others without this level of intervention.

Is this referenced in Care plan? YES / NO (If no, please inform the nurse in chargeHave reviews taken place and been recorded in accordance with policy YES / NO

Name Date

Time Location Observedactivity/ behaviour

Intervention(related to care plan)

Staff signature,Print name and grade

01:0002:0003:0004:0005:0006:0007:0008:0009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:0024:00

Suggested InterventionsR = Reassurance Given C = Engaged in conversation RE = Relaxation, deep breathingA = Encouraged Activity L = offered time out of the wardM = Medication Given DE = de-escalation MVA = Restraint

This record of intervention does not replace the need for case note entries. This should be used as a guide when completing daily summaries on RIO. Individuals subject to Level 1 observations

should be reviewed daily with a member of the medical staff and every 72 hours by the MDT. The outcome is recorded in the clinical record.

17

Appendix 3

Observation RecordLevel 2 (Within Eyesight)

The service user is subject to uninterrupted observation by health care staff. The care plan stipulates the maximum distance which is permissible between the supervising staff and service user, and whether the supervisor must remain in the same room as the service user (see policy for guidance)

Is this referenced in Care plan? YES / NO (If no, please inform the nurse in charge)Have reviews taken place and been recorded in accordance with policy YES / NO

Name Date

Time Location Observedactivity/ behaviour



01:0002:0003:0004:0005:0006:0007:0008:0009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:0024:00

Suggested InterventionsR = Reassurance Given C = Engaged in conversation RE = Relaxation, deep breathingA = Encouraged Activity L = offered time out of the wardM = Medication Given DE = de-escalation MVA = Restraint

This record of intervention does not replace the need for case note entries. This should be used as a guide when completing daily summaries on RIO. Individuals subject to Level 2 should be

reviewed every 48 hours with a member of the medical team and the outcome recorded in the clinical record.

18

Appendix 4

Observation RecordLevel 3 (Intermittent)

A visual check is made upon the service user every 15 minutes or more frequently if risk assessed and care planned. Time intervals inserted as required.


Name Date

Time Location Observedactivity/ mental state



Suggested InterventionsR = Reassurance Given C = Engaged in conversation RE = Relaxation, deep breathingA = Encouraged Activity L = offered time out of the ward TA = Encouraged time aloneM = Medication Given DE = de-escalation MVA = Restraint

This record of intervention does not replace the need for case note entries. This should be used as a guide when completing daily summaries on RIO. Individuals subject to Level 3 should be

reviewed every 48 hours with a member of the medical team and the outcome recorded in the clinical record.

19

Appendix 4




Name Date




Time


This record of intervention does not replace the need for case note entries. This should be used as a guide when completing daily summaries on RIO.

20

Appendix 4



Is this referenced in Care plan? YES / NO (If no, please inform the nurse in charge)Have reviews taken place and been recorded in accordance with policy YES / NO

Name Date




Time



21

Appendix 4




Name Date






22

Appendix 5

Level 4 (General) All service users are subject to at least hourly observations. If the service user needs indicate a graduated increase in observation intervals from level 3, Level 4 observations may be recorded twice hourly – but will never be any less frequent than hourly for all service users.

Name 07.0

0

07.3

0

08.0

0

08.3

0

09.0

0

09.3

0

10.0

0

10.3

0

11.0

0

11.3

0

12.0

0

12.3

0

13.0

0

13.3

0

14.0

0

14.3

0

15.0

0

15.3

0

16.0

0

16.3

0

17.0

0

17.3

0

18.0

0

18.3

0

Signature

O = Out S = Sleeping SR= Smoke room AR = Activity room OL = On leaveB = Bedroom K = Kitchen DR = Dining room OT = at OT BR = BathroomL = Lounge C = Corridor ECT = at ECT SH = Shower G = GardenAWOL = Absent without leave VR = Visitors room WO = Ward office WC = Toilet

23

Date

Appendix 5

Level 4 (General)

Name 19.0

0

19.3

0

20.0

0

20.3

0

21.0

0

21.3

0

22.0

0

22.3

0

23.0

0

23.3

0

24.0

0

00.3

0

01.0

0

01.3

0

02.0

0

02.3

0

03.0

0

03.3

0

04.0

0

04.3

0

05.0

0

05.3

0

06.0

0

0630

Signature

O = Out S = Sleeping SR= Smoke room AR = Activity room OL = On leaveB = Bedroom K = Kitchen DR = Dining room OT = at OT BR = BathroomL = Lounge C = Corridor ECT = at ECT SH = Shower G = GardenAWOL = Absent without leave VR = Visitors room WO = Ward office WC = Toilet


24

Date (continued)

Appendix A – Checklist for the Review and Approval of Procedural Document

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed: Yes / No/ Unsure Comments

1. Title

Is the title clear and unambiguous? Y

Is it clear whether the document is a guideline, policy, protocol or standard? Y

2. Rationale

Are reasons for development of the document stated? Y

3. Development Process

Is the method described in brief? Y

Are people involved in the development identified? Y

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Y

Is there evidence of consultation with stakeholders and users? Y

4. Content

Is the objective of the document clear? Y

Is the target population clear and unambiguous? Y

Are the intended outcomes described? Y

Are the statements clear and unambiguous? Y

5. Evidence Base

Is the type of evidence to support the document identified explicitly? Y

Are key references cited? Y

Are the references cited in full? ?

Are supporting documents referenced? Y

25

Title of document being reviewed: Yes / No/ Unsure Comments

6. Approval

Does the document identify which committee/group will approve it? Y

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done? Y

Does the plan include the necessary training/support to ensure compliance? Y

8. Document Control

Does the document identify where it will be held? Y

Have archiving arrangements for superseded documents been addressed? Y

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Y

Is there a plan to review or audit compliance with the document? Y

10. Review Date

Is the review date identified? Y

Is the frequency of review identified? If so is it acceptable? Y

11. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation?

Y

26

Individual Approval

If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.

Name Date

Signature

Committee Approval

If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.

Name Date

Signature

Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust

27

Appendix B – Flowchart for the Creation and Implementation of Procedural Documents

Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust

Rationale and Priority Development Plan Content Evidence Base

Read the Organisation-wide Policy for the Development and

Management of Procedural Documents” before commencing

Identify: Who will do the work Who should be involved How will it be done

Identify clear, focused objectives

Identify what type and source e.g. research, expert opinion, clinical

consensus, patient views

Undertake prioritisation - is the document needed?

Identify all relevant stakeholders including service users

Target population e.g. service users, staff groups for whom the

document is intended

Is it based on a national document? If yes, is local

information needed?

Ensure proposed document does not duplicate national work

Ensure relevant expertise is used

Intended outcome - what you want it to achieve?

Include references cited in full in agreed organisational format

Ensure it does not duplicate work elsewhere in the organisation (see local register/library of procedural

documents)

Consult with service users and stakeholders

Keep statements simple and unambiguous

Agree the need for document with relevant committee if necessary

Identify who will be responsible for what e.g. dissemination, implementation, training and

review

Plan to develop any necessary support information, leaflets, etc.

Useorganisation’s

template

How will the organisation measure compliance? Set measurable

standards and design methods for monitoring compliance and

effectiveness

Continue to Consultation and Approval (next page)

28

Consultation and Approval Dissemination, Implementation and Access

Monitoring, Compliance and Review Responsibility

Consult with all relevant stakeholders including service

users

Identify: Who will do this How will it be done Period of implementation,

including start date

Implement the monitoring arrangements contained within the

procedural document

Who (clinical or service manager) will be responsible for co-ordinating

the ongoing development, implementation and review of the

document?

All procedural documents with HR implications must be taken to the

staff side/human resources committee (or equivalent)

Link with induction training, continuous professional

development, and clinical supervision as appropriate

Consider findings from monitoring arrangements at an appropriate

committee

Complete document review process, including Equality Impact Assessment Tool and Checklist for

the Review and Approval of Procedural Documents

How and where will staff access the document (at operational level)?

Implement changes to improve compliance of, and effectiveness with, the procedural document

Approve document as outlined in the Organisation-wide Policy for the Development and Management of Procedural Documents’ including completion of the Checklist for the

Review and Approval of Procedural Documents

Plan to remove old copies from circulation

Review document in accordance with planned review date

Log document on the organisation’s register/library of procedural

documents

Ensure staff are aware the document is logged on the

organisation’s register/library of procedural documents

Content - is there new evidence of best practice to be incorporated

into the document?

Re-approve procedural document at the appropriate committee/group

Archive old versions of the document according to organisation’s procedure

for archiving

29

Appendix C – Version Control Sheet

Version Date Author Status Comment

30

Appendix D – Plan for Dissemination of Procedural Documents

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document:

Date finalised: Dissemination lead:Print name and contact detailsPrevious document

already being used?Yes / No

(Please delete as appropriate)

If yes, in what format and where?

Proposed action to retrieve out-of-date copies of the document:

To be disseminated to:

How will it be disseminated, who will do it and when?

Paperor

Electronic

Comments

Dissemination Record - to be used once document is approved.

Date put on register / library of procedural documents

Date due to be reviewed

Disseminated to: (either directly or via

meetings, etc)

Format (i.e. paper or

electronic)

Date Disseminated

No. of Copies

Sent

Contact Details / Comments

Acknowledgement: University Hospitals of Leicester NHS Trust

31

Appendix E – Equality Impact Assessment ToolTo be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

No

Race no

Ethnic origins (including gypsies and travellers)

no

Nationality no

Gender No

Culture No

Religion or belief Observation may be regarded as an overly intrusive intervention which might impact upon an individual’s ability to fully practice all aspects of their religious practice.

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

Yes Individuals subject to detention in hospital may have more intrusive observation levels imposed.

3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

yes See 2 above

4. Is the impact of the policy/guidance likely to be negative?

yes Some individuals may find observation levels intrusive

5. If so can the impact be avoided? no

6. What alternative are there to achieving the policy/guidance without the impact?

none

7. Can we reduce the impact by taking different action?

yes Strict adherence to the policy, in particular those parts which address sensitivity issues.

If you have identified a potential discriminatory impact of this procedural document, please refer it to [insert name of appropriate person], together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact [insert name of appropriate person and contact details].

32