Restrictive Physical Intervention

Restrictive Physical Intervention Policy

Version 3.2 February 2020

Restrictive Physical Intervention

Target Audience

Who Should Read This Policy

All Clinical Staff

MAPA® Trained Staff

Version 3.2 February 2020 2

Contents

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 5

4.0 Process 5

5.0 Procedures connected to this Policy 16

6.0 Links to Relevant Legislation 16

6.1 Links to Relevant National Standards 18

6.2 Links to other key policy/s 20

6.3 References 200

7.0 Roles and Responsibilities for this Policy 21

8.0 Training 24

9.0 Equality Impact Assessment 24

10.0 Data Protection and Freedom of Information 244

11.0 Monitoring this Policy is Working in Practice 25

Appendices

1.0 The Team Leader/ Controller Role 26

2.0 Person Centred Physical Intervention Protocol (PCPiP) 29

3.0 Clinical Holding MAPA Interventions 34


Explanation of terms used in this policy

Restraint - Use or threat of force to help do an act which the person resists, or the restriction of the

person’s liberty of movement, whether or not they resist (Mental Capacity Act 2005). In using this definition, restraint can be applied using chemical, environmental, physical and/or mechanical ways to

manage a prevailing or perceived risk however this policy only deals with physical restraint/

intervention

Physical Restraint/ Interventions - The use of physical contact which is intended to prevent, restrict or subdue movement of any part of the patient’s body (Mental Health Units (Use of Force) Act

2018).

Non-Physical Assault - Use of inappropriate words or behaviour causing distress and or constituting harassment

Physical Assault - Intentional application of force to the person or another, without lawful justification, resulting in physical or personal discomfort

Aggression - Non-physical assault (see definition above)

Violence - Physical Assault (see definition above)

PCPiP – Person Centred Physical Intervention Protocol


1.0 Introduction

Black Country Partnership NHS Foundation Trust (hereafter referred to as the Trust) in accordance with its statutory obligation under the Health and Safety at Work Act (1974) believes that the health and safety of its staff are of paramount importance to the Trust and to the patients they serve. The Trust will, as far as is reasonably practicable, ensure a safe and secure working environment, protecting staff from acts of aggression, both verbal and physical. The Trust views violence or aggression against their staff as being unacceptable, irrespective of who causes it. In addition, the Trust finds violence or aggression towards patients or visitors to its service equally unacceptable. The Trust provides training in the use of MAPA® (Management of Actual or Potential Aggression) techniques. The MAPA® model follows good practice guidelines in relation to managing violence, underpinning values and a holistic approach to person centred care. The physical techniques equip staff to safely manage aggressive situations, both in a ‘one to one’ situation and as part of a team approach. This policy promotes the use of a physical intervention in a way that respects dignity and protects individuals human rights and where possible respects the preferences of people who use services. It also requires that its use is always appropriate, reasonable, proportionate and justifiable to that individual. This policy must be read in conjunction with the Prevention and Management of Violence and Aggression including NHS sanctions policy.

2.0 Purpose

The purpose of this policy will be to detail the Trust’s strategy in managing physical and non-physical assaults against NHS staff and others by the use of restrictive physical interventions. The Trust recognises that person centred care is at the heart of all good practice and that all incidences of known or potential aggression must be dealt with on an individual basis in order to create a unique solution. The core aim is to promote a philosophy of proactive care and a reduction in the use of restrictive physical interventions. The policy has been developed following guidance from several influential publications on the prevention and management of violence/ physical interventions and includes: BILD guidance (2002 onwards); Care Quality Commission Essential Standards of Quality and Safety (2010); Deaths in Custody (2012/13); Positive and Proactive Care (2014); NICE guideline NG 10 (2015); Mental Health Act Code of Practice (2015); NICE NG10 Quality Standards QS154 (2017) and the Mental Health Units (use of force) Bill 2018. Managers and staff will use this document for reference and implementation across the Trust.


3.0 Objectives

The policy undertakes to provide support to staff on managing a violent and/ or aggressive incident with the use of a physical intervention. The overall objectives of this policy are to:

Identify organisational and individual responsibilities to the management of violence and aggression and the use of physical interventions

Identify good practice principles on how to assess and reduce physical intervention risks

Ensure patients/ employees are aware and provided with suitable support following a physical intervention

Recognise the importance of recording and monitoring physical interventions

Outline the standards/ key performance indicators associated with the policy

4.0 Process

4.1 MAPA® Model The trust has an Approved Training Centre (ATC) agreement through the Crisis Prevention Institute (CPI) for the delivery of the MAPA® model. The physical interventions skills within the MAPA® model have been independently risk assessed and are compliant with the UK National Physical Interventions Accreditation Scheme (PIAS). The MAPA® programme is a behaviour management system designed as a safe, non-harmful approach to assist staff in the management of a wide range of disruptive, challenging, aggressive, and violent behaviours, including the most acute behavioural disturbances and risk behaviour. The underpinning values and philosophy of this model are Care, Welfare, Safety and SecuritySM

Care - Demonstrating respect, dignity, and empathy; providing support in a non-judgemental and person-centred way

Welfare - Providing emotional and physical support; acting in the person’s best interests in order to promote independence, choice, and well-being

Safety - Protecting rights, safeguarding vulnerable people, reducing or managing risk to minimise injury or harm

Security - Maintaining safe, effective, harmonious, and therapeutic relationships which rely on collaboration

The MAPA® model consists of the following physical interventions ‘physical holding and disengagement/emergency responses’:

MAPA® Physical Holding skills form a hierarchy of restriction (low, medium and high). This hierarchy ranges from the least restrictive intervention that allows staff intervening to prompt and guide the patient; to an intermediate restriction that allows movement whilst being held; to the most restrictive intervention whereby all movements are limited

MAPA® Disengagements/ Emergency Responses: The use of a physical intervention to gain a release from any holding situation whilst minimising pain or


injury in situations in which the behaviour has been assessed as a low, medium, high or extreme risk to self and others

4.2 Best Practice in Reducing Restrictive Physical Interventions Early intervention can be extremely effective in reducing risks and the incident escalating into a crisis phase. De-escalation techniques should be used before any other interventions are considered (where possible). De-escalation strategies promote relaxation, e.g. through the use of verbal and physical expressions of empathy and alliance. They should be tailored to individual needs and should typically involve establishing rapport and the need for mutual co-operation, demonstrating compassion, negotiating realistic options, asking open questions, demonstrating concern and attentiveness, using empathic and non-judgemental listening, distracting, redirecting the individual into alternate pleasurable activities, removing sources of excessive environmental stimulation and being sensitive to non-verbal communication All staff must work in a person centred way that promotes the reduction and/or removal of restrictive practices. This will be achieved by all in-patient wards within the Trust working proactively to reduce the use of restrictive practices by adopting one or more of the following strategies ‘Safewards’, ‘Positive Behaviour Support’ and/or ‘See Think Act’. The implementation, application, monitoring and reporting of the reduction strategies will be managed by the Mental Health and Learning Disability groups. The Trusts Restrictive Intervention Reduction Plan will oversee and monitor all restrictive reduction strategies. 4.3 Best Practice when applying Restrictive Physical Interventions A physical intervention should always be used as a last resort in the management of violence and aggression where primary and secondary strategies have not had the required effect. If the situation continues to escalate and requires other interventions, then de-escalation must be used continuously throughout. Positive and Proactive Care (2014) promotes the following key points to improve care:

If a restrictive intervention is used it must not include the deliberate application of pain

If a restrictive intervention has to be used, it must always represent the least restrictive option to meet the immediate need

People who use services, families and carers must be involved in planning, reviewing and evaluating all aspects of care and support

Individualised support plans, incorporating behaviour support plans, must be implemented for all people who use services who are known to be at risk of being exposed to restrictive interventions

Staff should be aware that the use of force can only be justified if it is reasonable to use it to prevent injury or serious damage to property. In all contexts staff should use the minimum force necessary to prevent injury and maintain safety that is consistent with the training they have received. In such circumstances staff retain their duty of care to the patient and as such any response they make must be:


Proportionate to the circumstances

With any force used being "reasonable"

Commensurate with the achieving of appropriate outcomes (see section 6 for additional information)

Staff should be confident that the possible adverse outcomes associated with the intervention (for example, injury or distress) would be less severe than the adverse consequences, which might have occurred without the use of physical intervention. 4.3.1 Prone restraint The Department of Health (2014) defines prone restraint as: ‘the use of restraint in a face down or chest down position.’ Incidents of restraint that involve a service becoming face down or chest down for any period (even if briefly prior to being turned over), should be defined as prone restraint. Similarly if a service user falls or places themselves in a face down or chest down position during a restrictive intervention, this should be defined as prone restraint. The Mental Health Act Code of Practice (2015) Para 26.70 stipulates ‘unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface, not just the floor. A cogent reason for utilising a prone restraint may be for safety and security reasons such as the exiting of a seclusion room. 4.4 Managing a Physical Intervention 4.4.1 MAPA® Response Teams In order to facilitate a proactive response to MAPA® alerts each ward area is to designate MAPA® responders at the commencement of each shift. The percentage nominated will be based on existing staff team compliments. Responders for areas where more than one ward exists:

Macarthur will respond to the Gerry Simon Clinic

Gerry Simon Clinic will respond to Macarthur and Penrose House

Penrose House will respond to Macarthur and Gerry Simon Clinic (this response will be dependent upon staff levels)

Penn hospital ward staff will respond to each ward area as appropriate

Hallam Street Adult Mental Health ward staff will respond to each ward area as appropriate, to include the Larches.

The Larches will respond to Hallam Street Adult Mental Health wards MAPA® responders responding to alarms in another area should take their lead from the member of staff coordinating the incident unless clinical judgement or presenting risks to self or others otherwise dictate. The MAPA® responders in each area responding to the alarms must be available at all times to respond immediately. If they are unable to respond due to rest breaks, undertaking observations or vital clinical activity, the MAPA® responders must inform the nurse in charge who must then allocate another member of staff to be available to respond immediately.


If wards do not have sufficient staffing available to support other ward areas then this must be communicated to the specific wards at the commencement of each shift. MAPA® responders must physically attend to all alerts. Ward areas should not be phoned to ascertain whether they need the MAPA® responders. 4.4.2 MAPA Team Leader/ Controller The MAPA model and the Independent Advisory Panel on Deaths in Custody (2013) promote a Team Leader/ Controller to manage a physical intervention. This may be someone actively involved in the intervention or someone who is independent to the intervention. At the start of a physical intervention the staff member responsible for protecting the patient’s head, neck and breathing will assume the role of the Team Leader/ Controller. However if a MAPA trained member of staff, not involved in the actual intervention, is present then they should become the Team Leader/ Controller of the restraint as soon as is practical.

See Appendix 1 for a full description of the Team Leader/ Controllers role.

4.4.3 Emergency use of Physical Intervention Emergency use of physical interventions may be required when a patient acts unexpectedly and presents unforeseen risks for which there are no risk management measures planned. Once an incident is made safe a record should be made about the incident, the level of risk it presented and the interventions employed to make the situation safe. A PCPiP (section 4.4.4) should be created following an emergency physical intervention. 4.4.4 Planned Physical Interventions ‘Person Centred Physical Intervention Protocol (PCPiP)’ Any person who can reasonably be predicted to be at risk of being exposed to restrictive interventions based on their history of incidents and risk factors must have a PCPiP. PCPiPs follow the basic principles of identifying primary and secondary factors in an attempt to reduce risk. An individualised record of bespoke de-escalation strategies should be contained within the patients PCPiP ‘all about me’. This should be prepared with the patient and in consultation with families / carers (where agreed). This element of the PCPiP should be regularly reviewed and forms an essential component of the risk management plan. Where behaviour is predicted to continue to a point of crisis or an emergency intervention has occurred a PCPiP should be developed. This is to be undertaken by the Multidisciplinary Team in consultation with the patient and where appropriate family/ carers/ advocates, to ensure safe holds are deployed. Para 26.16 of the Mental Health Act Code of Practice (2015) states that patients and their families should be as fully involved as possible in developing and reviewing positive behaviour support plans.

The Mental Health Code of Practice (2015) Para 26.42 notes that the choice and nature of the restrictive intervention will depend on various factors, but should be guided by:

The patient’s wishes and feelings, if known


What is necessary to meet the needs of the individual based on a current assessment and their history

The patients age and ay individual physical or emotional vulnerabilities that increase the risk of trauma arising from specific forms of restrictive intervention

Whether a particular form of restrictive intervention would be likely to cause distress, humiliation or fear

Obligations to others affected by the behavioural disturbance

Responsibilities to protect other patients, visitors and staff, and

The availability of resources in the environment of care.

If the patient is unable or unwilling to participate, they must be offered the opportunity to review and revise the PCPiP as soon as they are able or willing.

A PCPiP template can be found in Appendix 2.

To support the development of PCPiPs staff are encouraged to contact MAPA® Certified Instructors for advice and support. 4.4.5 Risks presented by Physical Interventions Physical interventions pose a number of risks to the health, safety and well-being of people who implement them and those they are applied to because of the degree of force that is inherent in these techniques. Good practice requires services to assess and minimise the level of risk presented by the use and application of physical interventions to patients, staff and others. Patients should not be deliberately restrained in a way that impacts on airway, breathing or circulation. The mouth and/ or nose should never be covered and there should be no pressure to the neck region, rib cage and/ or abdomen. Unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface, not just the floor (para 26.70 of the Code). NICE NG10 (1.4.24) recommends that if this becomes necessary, use the supine position if possible or if the prone position is necessary, use it for as short a time as possible. Physical interventions should be avoided if at all possible, not used for prolonged periods and should be brought to an end at the earliest opportunity. NICE NG10 (1.4.29, 1.4.30) recommends that manual restraints (physical restraints) should not be routinely used for more than 10 minutes. If a manual restraint exceeds this then a consideration must be made to use rapid tranquillisation or seclusion as an alternative to a prolonged restraint. 4.4.6 Positional Asphyxia Positional asphyxia, also known as postural asphyxia, is a form of asphyxia which occurs when someone's position prevents them from breathing adequately. Any body position that obstructs the airway or that interferes with the muscular or mechanical components of respiration may result in positional asphyxia. For this reason MAPA®


does not endorse pressure to the neck region, restriction of the chest wall and impairments of the diaphragm. During physical interventions the patient must be observed and monitored to reduce the risks of positional asphyxia. If, at any time, concerns are raised regarding the patient’s physical health, physical holds should cease and the situation dealt with as a medical emergency. 4.4.7 Physical Care Monitoring On admission, or at least within 6 hours of admission, patients must have a basic physical examination and their physical condition assessed (see Physical Health Care policy). A baseline assessment is a useful comparator for episodes of restrictive intervention to determine the physiological impact of the intervention on the person. Any patient involved in a physical intervention should be physically/ psychologically monitored during a restrictive intervention, immediately following the intervention and hourly post intervention until there are no further concerns about their physical health status (adapted Para 1.4.45 NG10). If Rapid Tranquillisation has been administered and the BNF maximum dose has been exceeded or the service user: appears to be asleep or sedated; has taken illicit drugs or alcohol; has a pre-existing physical health problem or has experienced any harm as a result of the restrictive intervention, observations should be undertaken every 15 minutes (Para 1.4.45 NG10). During the intervention a nominated member of staff should monitor the individual’s airway and physical condition to minimise the potential of harm or injury. Observations, including vital clinical indicators such as pulse, respiration and complexion (with special attention for pallor/ discolouration), should be conducted and recorded (Para 26.71 Mental Health Act Code of Practice 2015). NICE NG10 Quality Standards QS154 (2017) further promotes the monitoring of consciousness levels during a physical intervention. Monitoring physiological parameters following a physical intervention as a minimum should be in line with the Royal College of Physicians (2017) National Early Warning Score (NEWS). All clinical observations undertaken during and following the restrictive intervention are to be reported on DATIX MAPA monitoring and a NEWS monitoring form. If consent and co-operation for these examinations and observations is withheld then this should be clearly documented and set out what alternative actions have been taken. If a deterioration in the patients physical presentation is observed, staff are to cease the intervention and clearly state “Medical Emergency”. If psychological distress is observed then this should be managed as indicated within the patients PCPiP. See section 4.5.3 for post incident support. 4.4.8 Physical Intervention and Administering Regular Intramuscular Medication

The Mental Health Act Code of Practice (2015) recommends that the use of restraint


to administer treatment in non-emergency circumstances should be avoided wherever possible, but may sometimes be necessary, especially if an emergency situation would be likely to occur if the treatment were not administered. The decision to use restraint should be discussed first with the clinical team and should be properly documented and justified in the patient’s notes and detailed in a PCPiP. 4.4.9 Physical Intervention and Rapid Tranquillisation In certain situations, the multidisciplinary team may agree the use of medication as the most appropriate method of managing extreme behaviour.

This practice is guided by the Mental Health Code of Practice (2015) Chapter 26 ‘Safe and Therapeutic responses to disturbed behaviour’ and in particular para 26.99 where it states::

Physical restraint may, on occasion, need to be used to administer rapid tranquillisation by intramuscular injection to an unwilling patient, where the patient may lawfully be treated without consent. It must not be used unless there is such legal authority, whether under the Act, the MCA or otherwise.

Rapid Tranquillisation procedures should be implemented in line with Trust policy. 4.4.10 Physical Intervention and Seclusion In some working areas staff may have to use physical interventions in order to transfer a patient to seclusion. Where seclusion is used the Trust policy on Seclusion should be implemented in full. 4.4.11 Removal of Clothing For the purpose of this policy, the removal of clothing would not be considered as appropriate, however, a patient may experience physiological signs of a possible physical collapse due to escalating temperature. This, and any other signs and symptoms of deterioration in physical health must be treated in a proportionate manner, i.e. adjusting patient’s position, reducing the level of restriction or even removing layers of clothing due to a physical emergency through the use of scissors. For continued issues regarding clothing advice should be sought from The Practice Development Team. 4.4.12 Interventions outside of Hospital sites When patients are transferred to receive care or services outside of the ward/ hospital then careful consideration needs to be afforded to the level of support provided. When it is considered staff may need to escort a patient due to anticipated aggressive behaviour this must be reflected in an up to date risk assessment and a Person Centred Physical Intervention Protocol. It is essential that escorting staff have sufficient knowledge of the patient and are MAPA® trained.


It is important to note however, that all staff activities in relation to MAPA® must follow the same ‘least restrictive’, proportionate and reasonable principles as within inpatient settings. 4.4.13 Physical Interventions and Pregnancy Special provision should be made for pregnant women in the event that a physical intervention has to be used. Physical Interventions should be adapted to avoid possible harm to the unborn child. Person Centred Physical Intervention Protocols must be completed for the planning of any potential use of restraint with pregnant women. This must be written with the Trusts MAPA® Certified Instructors, the patient (where possible) and the Multidisciplinary Team. Best practice procedures should include:

Proactive use of holding pregnant women in the seated position, semi recumbent

Staff letting go if the intervention moves to prone/supine

Pregnant women being medically assessed at the earliest opportunity after a physical intervention. The medical assessment should be recorded in the patient’s notes

Pregnant women should be monitored at least every 2 hours post-physical intervention for a period of 24 hours. Signs and symptoms to observe should be discussed with the Multidisciplinary team and where advised the local midwifery services

4.4.14 Physical Interventions and Children If a child is detained under the Mental Health Act 1983, the expectation is that the ‘staff intervene positively’ if that child attempts to leave without authority. In other circumstances, staff should only intervene where immediate action is necessary to prevent a child from significantly injuring themselves or others or causing significant serious damage to property. Injury in this context is taken to mean ‘’significant injury’’ and would include actual bodily harm or grievous bodily harm, physical abuse, risking the lives of, or injury of, or injury to self or to others by wilful or reckless behaviour. The law requires that force should only be used when every other approach has been tried and that all practical methods to de-escalate the situation have been employed. For further information please refer to para 26.52-26.61 of the Mental Health Act Code of Practice (2105). 4.4.15 Clinical Holding Interventions (Adult Services only) Clinical holding is concerned with the application of safe restrictive interventions in order to deliver essential care and treatment to patients who are unable or unwilling to comply due to a lack of mental capacity. Staff involved in the essential care and treatment must act in the best interests of the patient in order to maintain the patient’s health, safety and welfare. The use of clinical holding should be proportionate to the aims of the procedure to be carried out.


Clinical holding involves proactively holding a part of the body to which a procedure is carried out such as an arm from which blood is being taken to prevent reflexive withdrawal. On other occasions clinical holding may be necessary to restrict free movement which might otherwise interfere or prevent the safe and necessary implementation of care or treatment. Clinical holding should only be considered where a risk assessment accompanied by a Clinical Holding assessment (Appendix 3) determines that a patient’s care or treatment cannot be carried out effectively and/ or safely due to the behaviour likely to be presented by a patient. Clinical holding should be clearly recorded in a patient’s care notes. Where it is used as a one off in order to facilitate a medical procedure its use should be subsequently reviewed by the Consultant Psychiatrist. Where clinical holding is considered to be necessary as part of a routine care plan, its use should be expressly indicated along with the legal justification for its application. Such care plans should be subject to regular review by the multidisciplinary team. All clinical holding interventions must be recorded on DATIX. Clinical Holding techniques to aid this process will not be taught routinely during physical intervention training. The MAPA® Approved Training Centre (ATC) will provide specialised training/ advice to areas as appropriate. 4.5 Post Physical Intervention 4.5.1 Reporting It is important that all incidences of physical interventions are reported. Thorough record keeping not only ensures transparency of Trust activity but is also a key feature for planning service delivery to patients. The unit manager or designated other must ensure the team members complete the required documentation. Records will help to inform clinical audit and further development of practise. The documentation must include:

DATIX

Nursing notes / Medical notes

Statements (where necessary) All documentation must be completed as quickly as practicable after the physical intervention and no later than 24 hours after the incident. The records must be used for a number of different purposes including:

Reviewing of individual care, support and treatment

Monitoring of compliance with statutory requirements in relation to physical interventions

Auditing and evaluating service delivery


Monitoring of incidents of restrictive interventions will be by type. If the same type occurs multiple times within one incident/ episode, then this can be recorded as one incident of that type. For example, if an incident of restraint lasts an hour, and at four points during that hour the patient was restrained in a prone position, this should be recorded as one incident of prone restraint. However, if the patient calmed and was released and then a further episode occurred shortly afterwards in which prone restraint was used again, this must be recorded as a second incident of prone restraint (Health and Social Care Information Centre 2015). All records/ record keeping should comply with the Trust policies on Records and Record Keeping. 4.5.2 Post Incident Support for Patients Following a physical intervention it is important that the patient is monitored by the Multidisciplinary Team for assessment of any on-going physiological problems or psychological concerns as a result of a physical intervention. This may provide staff with an opportunity to positively engage with the patient regarding their care plan and any possible changes or considerations. This may also include contact with the family, as set out in para 26.68 of the Mental Health Code of Practice (2015). Post incident support may explore the following:

Circumstances that led to the physical intervention

How they felt in the lead up to the physical intervention

What they wanted to achieve and did it work?

What they did to try and manage their distress and did it work?

What support they need from others Post incident support should also be afforded to patients who witnessed the physical intervention. 4.5.3 Post Incident Support for Staff Post-incident support is seen as a matter of good management practice to limit, wherever possible, the effects of exposure to distressing workplace events. Responding quickly to the needs of a member of staff who has been through a distressing experience is important. The Trust will aim to make sure that everyone who has been involved in any sort of incident can feel supported and be given an opportunity to talk about and work through their experience. As a minimum all staff will be offered a meeting with their manager (for further information see Policy Supporting staff involved in an incident, complaint or claim). The manager should ensure that the:

Debrief is confidential and takes place in a suitable environment.

Member of staff is given time to talk and is listened to and feels supported

Arrangements are put in place for the staff member to receive any required medical assessment or treatment. For example, if they are in shock or suffer from a pre-existing medical condition that may have been exacerbated by the event.


24 - 48 hour debrief meeting is discussed and appropriate arrangements put in place.

Opportunity for referral to other sources of support is discussed and appropriate arrangements commenced, if required.

Advice is offered concerning any requirement to write a statement. This may be provided by: the manager; a member of the Legal Services or Risk Management Teams; or representatives of the professional body to whom the staff member belongs. Trade Union or staff side may also be able to provide assistance.

Other staff support: Ward based psychologists can be utilised to provide emotional support through individual or team reflective practice sessions. A confidential counselling service is available to all Trust staff through the Individual Staff Support Service. Further information can be found on the Trusts intranet - Staff Support. The Chaplaincy/ Spiritual Care Team offer an informal listening and support service to staff of all faiths and beliefs. Further information can be found on the Trusts intranet - Chaplaincy/ Spiritual Care. 4.5.4 Post Incident Analysis Post Incident Analysis is the reconstruction of an incident to assess the chain of events that took place, the methods used to control the incident and how the actions of staff contributed to the eventual outcome. The main purpose of a Post Incident Analysis is to:

Reinforce staff actions

Identify ward procedures that are effective/ineffective

Provide management with the insight into how effectiveness can be improved

Maintain therapeutic relationships between staff, patients and their carers Where the service decides a Post Incident analysis is required it should take place as soon as possible and at least within 72 hours of an incident ending. The 72-Hour report process is most commonly used for 'moderate to high' risk rated incidents (RED) but can also be used for any incidents, complaints, concerns, or near misses that require more details (for further information see Incident Reporting Policy). Appropriate help and support needs to be considered for all persons directly or indirectly involved, this should include the patient, staff members and significant others. 4.6 Staff Training All staff that are employed by the Trust and are identified as likely to use physical interventions require training in order to implement this policy safely and effectively. MAPA® training will equip staff with core knowledge, skills and values as required by the Trust when using physical interventions. To ensure continuing good practice staff are required to undertake yearly updates of physical intervention practices however in exceptional circumstances and with


agreement from the MAPA® Approved Training Centre this can be extended to 15 months. Failure to update within this timescale will result in staff repeating an Initial MAPA® course, therefore, staff, in conjunction with their line manager must ensure they book and attend training in a timely fashion. 4.7 Health Declaration MAPA® training does not rely upon physical strength but managing movement safely by maximising the use of body mechanics. Therefore the training is suitable for a wide range of staff in healthcare settings. Staff attending MAPA® training should expect that the fitness level and range of movement required is no more than required in a busy care environment. Prior to each training event staff are to:

Declare any injuries, medical or physical exclusions they may have to their line manager. This discussion should ascertain their appropriateness to attend a MAPA® training course. Individuals are to seek advice from their GP or Occupational Health Department if they have any concerns

On the day of MAPA® training participants must declare to the Certified MAPA® Instructors any injury, medical, physical or other condition, which may prevent them from fully taking part in training. These exclusions will be reported back to line managers

5.0 Procedures connected to this Policy

There are no procedures connected to this policy

6.0 Links to Relevant Legislation

Mental Health Act 1983: Code of Practice - 2015 Individuals in need of care and treatment for a mental disorder may, as a consequence of their disorder, present particular risks to themselves or others. Para 26.40 highlights the most common reasons for considering the use of a restrictive intervention:

Physical assault by the patient

Dangerous, threatening or destructive behaviour

Self harm or risk of physical injury by accident

Extreme and prolonged over-activity that is likely to lead to physical exhaustion, or

Attempts to escape or abscond (where the patient is detailed under the Act or deprived of their liberty under the Mental Capacity Act 2005)

The Mental Health Code of Practice (Para 26.36) is clear that the purposes of applying restrictive interventions are to:

Take immediate control of a dangerous situation where there is a real possibility of harm to the persons or others if no action is undertaken, and

End or reduce significantly the danger to the patient or others

Para 26.73 If an individual is not detained under the Act, but physical restraints of any form is necessary, consideration should be given to whether the criteria in sections 5


and 6 of the Mental Capacity Act (2005) apply (restraint to be used in respect of people aged 16 and over who lack capacity) and/or whether detention under the Act is appropriate (subject to the criteria being met).

Restrictive interventions should not be used to punish or for the sole intention of inflicting pain, suffering or humiliation.

The five guiding principles, as set out in Chapter 1 of the Code, should be considered when making all decisions in relation to care, support or treatment provided under the Act:

Least restrictive option and maximising independence

Empowerment and involvement

Respect and dignity

Purpose and effectiveness

Efficiency and equity Mental Capacity Act and Deprivation of Liberty Safeguards 2005 The Code of Practice states that anybody considering using restraint must have objective reasons to justify that restraint is necessary. They must be able to show that the person being cared for is likely to suffer harm unless proportionate restraint is used. A carer or professional must not use restraint just so that they can do something more easily. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest time possible. When someone lacks capacity to make decisions or take actions for themselves, others may have to make those decisions on their behalf. When they do this, they should not deprive the person of their liberty where they lack capacity, unless it is essential to do so in the person’s best interests and for their own safety. Duty of Care A Duty of Care exists when duties and responsibilities are imposed upon professionals or paid carers (Ashton and Ward 1992). In general terms, this means taking reasonable care to avoid acts or omissions which are likely to cause harm to another person. The guiding principle is to demonstrate clearly that staff have acted in the best interests of the patient and others. Human Rights Act 1998 The Human Rights Act 1998 sets out important principals regarding protection of individuals from abuse by public organisations or people working for those institutions. Implementation of this guidance, in particular Article 2 ‘the right to life’ and Article 3 ‘Freedom from torture and inhumane and degrading treatment or punishment’ will help to ensure that staffs practice in respect of supporting patients with violence and/ or aggression are consistent with this Act. Health and Safety at Work etc. Act 1974 Under health and safety legislation, employers are responsible for the health, safety and welfare of employees, patients and visitors. The Trust will, as far as is reasonably practicable, ensure a safe and secure working environment, protecting staff from acts of aggression, both verbal and physical.


Common Law and Criminal Law - The Use of Force The Trust recognises that the use of force may be necessary in the management of a violent or aggressive incident. Under Common Law a person may use reasonable force to defend themselves from an attack, prevent an attack on another person and defend property. The Criminal Law Act, Section 3 (1967) states that a person may use such force as is reasonable in the circumstances in the prevention of crime, or in effecting or assisting in the lawful arrest of offenders or suspected offenders or of persons unlawfully at large. However, the Human Rights Act (1998) states that the use of force must be proportionate and commensurate to the level of threat being faced. If the level or degree of force is legally challenged, the burden of proof that the force used was reasonable rests with the individual who applied the force. Mental Health Units (Use of Force) Bill (2018). The bill makes provisions about the oversight and management of the appropriate use of force in relation to people in mental health units.

6.1 Links to Relevant National Standards

Department of Health: Positive and Proactive Care: reducing the need for restrictive interventions (2014) This guidance provides advice to adult health and social care staff to develop a culture where restrictive interventions are only ever used as a last resort and for the shortest possible time (published April 2014). Department of Health: Mental Health Act 1983. Code of Practice (2015). The Code of Practice provides statutory guidance to registered medical practitioners, approved clinicians, managers and staff providers, and approved mental health professionals on how they should carry out functions under the Mental Health Act in practice (published April 2015). NICE Clinical Guideline NG10 - Violence and Aggression (2015) This guideline has been developed to advise on the short-term management of violence and aggression in mental health, health and community settings in adults, children (aged 12 years or under) and young people (aged 13 to 17 years). This guideline updates and replaces NICE guideline CG25 (published February 2005). CQC Regulation 9: Person-Centred Care The intention of this regulation is to make sure that people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves. Providers must make sure that they take into account people's capacity and ability to consent, and that either they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment.


Providers must make sure that decisions are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate. CQC Regulation 10: Respect and Dignity The intention of this regulation is to make sure that people using the service are treated with respect and dignity at all times while they are receiving care and treatment. To meet this regulation, providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times. This includes making sure that people have privacy when they need and want it, treating them as equals and providing any support they might need to be autonomous, independent and involved in their local community. Providers must have due regard to the protected characteristics as defined in the Equality Act 2010. CQC Regulation 11: Need for Consent The intention of this regulation is to make sure that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided. Providers must make sure that they obtain the consent lawfully and that the person who obtains the consent has the necessary knowledge and understanding of the care and/or treatment that they are asking consent for. Consent is an important aspect of providing care and treatment, but in some cases, acting strictly in accordance with consent will mean that some of the other regulations cannot be met. For example, this might apply with regard to nutrition and person-centred care. However, providers must not provide unsafe or inappropriate care just because someone has consented to care or treatment that would be unsafe. See the glossary for the definition of 'relevant person' in relation to Regulation 11. CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety and welfare. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment.


6.2 Links to other key policy/s

Guidelines on the Management of Self Harm within Mental Health Health Inpatient Settings These guidelines present clinical staff working with individuals who engage in self-harm behaviours, guidance on conducting risk assessments and the formulation of care plans that both promote recovery and maximise safety of the individual. Incident Reporting Policy The purpose of this policy is to make clear the system used for reporting incidents involving patients, staff and others undertaking activities on behalf of the Trust. Mental Capacity Act and Deprivation of Liberty Safeguards Policy The Act is supported by 2 Codes of Practice (one for the Act and one for the Deprivation of Liberty Safeguards). It is essential that all staff comply with the Law and its guidance. Physical Health Care Policy The purpose of this policy is to set out the arrangements for managing the risks associated with the physical health needs of patients/ service users and to make clear that duty of care extends to promoting overall, ongoing physical health and well-being and healthy lifestyles. Rapid Tranquilisation Policy The purpose of this policy is to provide staff with clear direction in regard to the use of rapid tranquillisation when faced with incidents of acutely disturbed behaviour and extreme aggression. Seclusion and Longer Term Segregation Policy The aim of this policy is to ensure that clinical staff working within all inpatient areas of the Trust have clear direction and guidance on the use of seclusion and longer term segregation and work within the Mental Health Act 1983 Code of Practice (2015).

6.3 References

Ashton G.R., & Ward A.D. Mental Handicap and the Law. Sweet and Maxwell. London (1992).

BILD Code of Practice for the use and reduction of restrictive interventions. A guide for trainers and commissioners of training. 3rd ed (2013).

CPI MAPA® Foundation workbook (2018).

Department of Health (2002) Mental Health Policy Implementation Guide: National Minimum Standards for PICU and Low Secure Environments

Mental Capacity Act 2005 Code of Practice (2007). Department for Constitutional Affairs. London: TSO.

Mental Health Act. Code of Practice (2015). Department of Health.

Mental Health Information update. Health and Social Care Information Centre (2015)

Mental Health Units (Use of Force) Bill (2018)

NHS Business Services Authority - Security Management Service Division (2004)

Positive and Proactive Care: reducing the need for restrictive interventions (2014)

RCN (2010) Restrictive Physical Intervention and Therapeutic Holding for Children and Young People. Guidance for Nursing staff


7.0 Roles and Responsibilities for this Policy

Title Role Responsibilities

Chief Executive Assurance - Ensure that statutory obligations are met and identified risks are adequately controlled in the reduction of incidents of

violence and aggression

- Ensure the provision of adequate resources to enable the effective implementation of this policy - Maintain effective reporting mechanisms into the Board in connection with this policy

Trust Board Strategic - Ensure the resources and support necessary to adequately implement and maintain the policy are made available - Accountable for the safe and effective care, support and treatment of patients and for promoting and improving their

quality of life outcomes

- Ensure the safety and safe practices of its staff through providing opportunities to access education and training programmes that are understood to be reasonable and necessary to fulfil their role and for the organisation to meet its

statutory and legal requirements - Accountable for maintaining an overarching restrictive intervention reduction programme

Executive Director of

Nursing, AHPs and Governance

Executive Lead - Continuous review of the appropriateness of MAPA® as the Trusts preferred model, based upon changing need and clinical

risks associated with the development of services provided by the Trust - Governance of the Approved Training Centre (ATC) License Agreement and the Trust’s continued licensing as a MAPA®

ATC for the provision of training to its staff

- Increase the use of recovery-based approaches and where appropriate, positive behavioural support planning and reducing restrictive interventions

- Receive reports in relation to the performance of the Trust against the licensing arrangement with Crisis Prevention Institute (CPI), as the Licensee of the MAPA® model

- Recommend and/ or agree to action as necessary to maintain the License Agreement

Health and Safety Committee

Monitoring - Monitor the effectiveness and overall compliance in meeting statutory obligations and practicalities of providing a safe environment for employees in areas of high risk and identified concern

Group Directors and General Managers

Monitoring - Ensure effective management and organisation of resources to enable effective implementation of this policy - Monitor and review departmental performance in connection with this policy

- Report mechanisms on departmental issues to and from the Chief Executive in connection with this policy

Care Governance Committees

Monitoring - Review MAPA® activity reports on a monthly basis, examining patterns and trends to the use of restrictive physical interventions

MAPA® Approved

Training Centre

Coordinator

Co-ordinator - Be the central contact between the Trust and the Crisis Prevention Institute (CPI)

- Liaise with CPI to organize the 3 yearly Centre Verification and Support site visits as part of the quality assurance structure

associated with the extension of the CPI British Institute of Learning Disabilities (BILD) accreditation - Report weekly MAPA® frequencies to the Mental Health and Learning Disabilities Risk and Governance coordinators: Risk

and Governance department - Provide a monthly report to the service groups detailing the percentage of physical interventions used

- Ensure sufficient availability, access to and provision of initial and update training in MAPA®, to the workforce



MAPA® Certified

Instructors

Training - Deliver MAPA® training according to the MAPA® curriculum and the British Institute of Learning Disabilities (BILD) Code of

Practice for minimising the use of restrictive physical interventions (2014)

- Encourage high-quality physical intervention practice within clinical areas by promoting, supporting and disseminating new physical intervention innovations and evidence based practice

- Assist clinical staff to develop, implement and evaluate Person Centred Physical Intervention Protocols - In collaboration with ward managers participate in the monitoring and reviewing of physical intervention incidents

- Lead on the delivery of the MAPA® programme

- Report concerns regarding the safe provision of training and also any professional concerns and issues that they become aware of with regards to unsafe or inappropriate physical intervention practices

- Adhere to CPI’s annual reassessments of physical intervention instructor competencies - Maintain a MAPA® portfolio of evidence to support continuous development and lifelong learning

- Access peer support in relation to physical intervention practice both locally and regionally - Hold and maintain a First Aid at Work certificate

- Support the ATC co-ordinator in the 3 yearly Centre Verification and Support site visits (when necessary)

MAPA® Trained Staff Accountable - Accountable for the safe and appropriate use of MAPA® physical interventions taught to them and for applying the physical skills in the context in which they are taught

Service Managers Implementation - Ensure that statutory Health and Safety requirements are complied with

- Monitor and review performance in connection with this policy

- Ensure that departmental issues are reported to and from the Group Managers - Ensure that risk assessments are undertaken and safe systems of work are adopted

- Ensure that unmanageable/ significant risks are escalated via the risk register process - Ensure that wards maintain a balanced skill mix and staffing levels through recruitment and retention

- Ensure that post incident action is initiated

- Ensure that appropriate systems for alerting staff and others following an incident of identified risk are in place - Ensure that incidents requiring physical intervention for patients are investigated (where appropriate)

Ward Managers Operational - Ensure systems in place to guarantee a safe service provision - Ensure assessment of environmental health and safety factors that can reduce the likelihood of violence/ aggression and

put plans in place to address them

- Review and Monitor cultures – staff attitudes, values and beliefs toward the service, patients and the use of physical interventions

- Ensure staff are aware of their role and responsibility as regards to the reduction of physical interventions, ensuring precautionary measures are put into action and carried out effectively, with the aim of reducing the risk of requiring a

physical intervention

- Minimise the number of occasions on which patients are exposed to unplanned physical interventions - Ensure all incidents of physical intervention are reported

- Ensure post incident care and support is afforded to those affected by a physical intervention - Ensure Staff Support and Occupational Health are contacted if staff are exposed to physical risks (where appropriate)

- Distribute resources to meet service provisions

- Take into account the likelihood of physical interventions when making a decision regarding staffing levels



- Ensure MAPA® responders are identified for each working shift and that this responsibility is distributed equally amongst

the staff team

- Identify appropriate staff to receive training and ensure their attendance at initial and subsequent update training annually - Ensure that where there are concerns about staff’s physical limitations that appropriate referrals are made to occupational

health or the staff members own G.P. Risks are to be made known to MAPA® Trainers before any training event - Ensure that where staff have received training but were assessed to be non-competent in applying the taught skills then

they, in conjunction with their manager, are responsible for ensuring that further support is accessed to enable their full

competence

Medical Staff Adherence - Participate in formal risk assessment with other key professionals involved in the patient care at appropriate intervals and

when significant changes to the patient’s situation occur and any subsequent plans - Take immediate action to address the concerns of staff regarding current or potential difficulties in caring for patients

- Take immediate action to address the concerns of staff where this may involve transferring the patient to an alternative/

suitable service provision - Ensure that patients are given accessible information to help them to adhere to standards of behaviour, including not

abusing others, verbally or physically - Identify issues which may trigger aggression

- Identify underlying problems and needs through an assessment resulting in a Person Centred Physical Intervention Protocol

- Help patients understand what may happen if they become violent and/ or aggressive - provide opportunities to enable carers to communicate any concerns to the Key worker/Care co-ordinator and/or Multi-

disciplinary Team; and contribute to a Person Centred Physical Intervention Protocol (where appropriate)

All Trust Staff Adherence - Familiarise themselves with this policy, including local processes and procedures and implement them in accordance to

their role and responsibilities

- Take reasonable care of their own and others safety and must follow procedures on risk reduction and reporting incidents of violence/ aggression

- Personally contribute to the assessment of situations where there is a risk of violent or aggressive behaviour - Identify environmental issues that may increase the risk of violence and aggression

- Contribute to a culture of respect, encouraging the expression of any concerns and feelings to an appropriate person

- Use equipment provided such as alarms/ warning systems that have been issued for their protection - Attend training applicable to their role

- Escalate any concerns that they have about the unsafe practices of other staff in the use of MAPA® physical interventions, to their line manager

User/ Advocacy Groups Adherence - Raise concerns if systems appear inadequate and support any complaints


8.0 Training

What aspect(s) of this policy will require staff

training?

Which staff groups require this training?

Is this training covered in the Trust’s Mandatory and Risk Management

Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require training

Who will ensure and monitor that staff have

this training?

MAPA (including Rapid

Tranquilisation)

All inpatient

qualified nurses and HCSWs in

MH & LD

Yes MAPA® Certified

Instructors

Annually Workforce

Development Group

9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected] 10.0 Data Protection and Freedom of Information Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right


11.0 Monitoring this Policy is Working in Practice

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this

monitoring?

How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

Completion of MAPA®

training by all inpatient

based staff within desired timeframes

8.0 Training Data collected into

training compliance

reports

Learning and

Development Team

Monthly Workforce

Development Group

Workforce

Development Group

Minutes of

meetings/

Action plans signed off

Examination of MAPA® incidences/ frequency

7.0 Roles and Responsibilities

Summary Reports - MAPA® frequencies

MAPA® Approved Training Centre

Coordinator

Weekly Mental Health and Learning Disabilities

Risk and Governance

coordinators

Governance Assurance Unit

Minutes of meetings/

Action plans

signed off

Summary Reports -

monitor and review local incidences and

consider, plan and

document possible actions to reduce

further incidences

MAPA® Approved

Training Centre Coordinator

Monthly Service Leads/

Managers

Service Leads/

Managers

Minutes of

meetings/ Action plans

signed off

MAPA® report MAPA® Approved Training Centre Coordinator

Annually Organisational Risk Committee and Care

Governance

Organisational Risk Committee and Care

Governance

Minutes of meetings/


Person Centred Physical

Intervention Protocols

4.0 Process Audit Modern Matrons Quarterly Reducing Restrictive

Intervention Group

Reducing Restrictive

Intervention Group

Minutes of

meetings/ Action plans

signed off

ATC License Agreement -

Quality assurance structure

associated with the extension of the CPI British

Institute of Learning Disabilities (BILD)

accreditation

7.0 Roles and

Responsibilities

Centre Verification and

Support site visit

Crisis Prevention

Institute (CPI)

3 yearly Reducing Restrictive

Intervention Group

Reducing Restrictive

Intervention Group

Minutes of

meetings/



Appendix 1

The Team Leader/ Controller Role

Every MAPA intervention needs a leader and organiser to help minimise confusion and

disorganisation. The team leaders/controllers role is to help staff focus on the

prevailing risk behaviour; focus people on the decisions that need to be made; act as

an overseer to ensure the intervention is professionally managed; and ensure that the

Care, Welfare, Safety, and SecuritySM of everyone involved is maintained. The choice

of Team Leader/Controller should not be determined by band or seniority, but should

be determined by the circumstances and the people involved.

In emergency interventions, a decision as to who will be the team leader/controller has

to occur quickly, but in situations where an intervention can be planned, the Team

Leader/Controller can be chosen on the basis of a collective decision by the staff

involved based on all the prevailing factors. In any situation, a calm, clear, and

confident member of staff who is able to provide verbal and non-verbal messages to

the individual which affirm that the situation is safe and under control is likely to enact

the team leader/controller role most effectively. It is important that the team remain

flexible and that the role of the Team Leader/Controller can be quickly changed

between team members as the individual being held may not respond in the manner

anticipated.

(a) Planning

If interventions are planned, it is the Team Leader’s/Controllers responsibility to ensure

that the intervention is carried out appropriately and safely. The Team

Leader/Controller should ensure that full consideration has been given to the individual

and known precipitating factors; the circumstances (including the individual’s risk

behaviour of concern and prevailing or perceived level of risk); an intended or desired

outcome; as well as the number of staff required and each staff member’s role.

It is also the Team Leader’s/Controllers responsibility to direct or cue staff during the

intervention and to ensure that there is a clear and simple communication route to the

individual being held. When planning an intervention, the Team Leader/Controller

should ensure observers or bystanders are guided from the area, and if possible,

identify and remove potential environmental hazards that could foreseeably

compromise people’s welfare and safety during the intervention.

At times, staff may have little or no opportunity to plan an intervention, as physical

interventions are often used as an emergency response to acute behavioural

disturbance. In such situations, it is still important that a Team Leader/Controller is

identified as soon as is reasonably practicable and that the Team Leader quickly

establishes his role and the role of other staff.


(b) Decision Making

It is the Team Leader’s/Controllers responsibility to ensure that effective decisions are

made in relation to the safe management of the incident. A Team Leader/Controller

does not have to make all the decisions, but will ensure that the right decision is

reached and acted upon by ensuring everyone involved in the intervention contributes

to the decision making process. Importantly, a good Team Leader/Controller focuses

attention on the needs of the individual being held, involves this person in any decisions

that need to be made, and looks for opportunities to de-escalate and enable the person

to regain self-control.

(c) Communication

It is important that the person being held remains the focus of everyone’s attention.

The Team Leader/Controller should ensure that there is clear and calm communication

between all staff, and that any requests or instructions given to the individual are

reasonable and achievable. All team members have a responsibility to ensure they do

not ‘talk over’ or ‘at’ the person, and regardless of the person’s behaviour, the Team

Leader/Controller must ensure other members of the team remain professional at all

times. In any crisis situation, there is often an anxiety amongst staff to reach and enact

decisions quickly. It is also the Team Leader’s/controllers responsibility to ensure

everyone involved takes their time and avoids hasty decisions, and to ensure that the

person being held is able to understand and follow instructions.

Although physical interventions should be applied for the least amount of time possible,

the Team Leader/Controller should ensure that the pace of communication and any

decisions and actions taken are commensurate with the prevailing risk as well as the

individual’s ability to understand and co-operate with such decisions. In some

situations, especially at the beginning of the intervention when events are more likely

to be chaotic, the Team Leader/Controller will want to encourage the individual and

team members to limit communication until the prevailing physical risk has been

managed. Whilst the Team Leader/Controller is often best placed to communicate with

the person, he may delegate this role to another team member who may have a better

rapport with, knowledge of, or relationship with the individual.

(d) Safety

All physical interventions carry risk, so all team members must be aware that at any

time a ‘restraint’ event can quickly become a medical emergency. Depending on how

many staff are available, the Team Leader/Controller may be actively involved in the

intervention or may be an observer. Whilst a responsibility for all staff, a primary role

of the Team Leader/Controller is to take an overview of the event to ensure at all times

that Care, Welfare, Safety, and SecuritySM of everyone involved is maintained by

continually assessing and monitoring the person with particular regard to any medical

emergency warning signs. The team leader/controller should observe for signs of

distress, injury, or medical emergency and be prepared to quickly act to address any

concerns including giving team members a clear instruction to release any physical

restrictions. The principles of Care, Welfare, Safety, and SecuritySM should be


maintained before, during, and after the incident as signs of distress, injury, or medical

compromise may not be immediately observed. In any situation where there is cause

for concern in relation to anyone’s welfare, the Team Leader/Controller must ensure

that immediate assistance is given, including emergency medical aid.

(e) Post-Crisis Approaches

It is important that the team leader delegates someone to manage the intervention

once the crisis is over. This is also a good time to continue observations and to check

for signs of injury or medical compromise.

CPI (2013)


Appendix 2

Person Centred Physical Intervention Protocol

(PCPiP)

Name Ward Hospital Identifier


All about Me

This is important to me.

This makes me frustrated/angry, frightened or upset. Triggers i,e noise, being prevented from doing something etc.

This is what I look like when I start to get frustrated/angry. Build up behaviours i.e pacing, going quiet etc.

This helps me calm to down/relax.


Emergency Holding using an Emergency Floor Procedure should only be used as a last resort to manage extreme risk behaviour where there is a clear and significant risk of harm. In circumstances where the individual has transitioned to the floor and the staff are unable to let go or assist the person to stand due to the level of risk then MAPA must be used for the minimum amount of time. Emergency holding interventions MUST always be supported by a minimum of 3 members of staff. The monitoring of vital signs is imperative – 1 member of staff MUST always be monitoring the head/airway.

RISK BEHAVIOUR POSITION OF HOLDING PATIENT PHYSICAL RISK FACTORS

Risk Factor

Please

Description of risk behaviour

Preferred position of the patient

Please

Description of patient physical risk factors

PHYSICAL ASSAULT SEATED

LOW

MED

IUM

HIG

H

SELF-HARM STANDING ‘STILL’

MED

IUM

HIG

H

DANGEROUS, THREATENING OR DESTRUCTIVE BEHAVIOUR

RESTRICTED ESCORT ‘WALKING’

MED

IUM

HIG

H

ATTEMPTS TO ABSCOND KNEELING

MED

IUM

HIG

H

ADMINISTRATION OF MEDICATION

SEMI-RECUMBENT

MED

IUM

CLINICAL HOLDING Personal care CH3

PRONE (FACE DOWN)

SUPINE (FACE UP)

ELECTROCARDIOGRAM

OTHER (Please describe)

SIDE ON Has an ECG been completed? YES NO

If No please state reason EMERGENCY INTERVENTIONS SHOULD NOT BE PLANNED FOR


RESTRAINT RELATED RISK, INJURY OR HARM ACTIONS TO REDUCE KNOWN RISKS Psychosocial Injury Including post-traumatic stress disorder and damage to therapeutic relationships.

Soft-Tissue Injury Including injury to skin, muscles, ligaments and tendons. Articular or Bony Injury Including injury to joints and bones. Respiratory Restriction Including compromise to airway, bellows mechanism and gaseous exchange which results in respiratory crisis or failure. Cardiovascular Compromise Including compromise to the heart and the peripheral vascular system.

Pre MAPA intervention

During MAPA intervention Post MAPA intervention

PCPiP has been developed with patient/ family/ carers/ advocates. Known soft tissue or articular/bony risk factors are identified and shared amongst the team. Known psychological factors are identified and shared amongst the team. Known Respiratory and/or Cardiovascular factors are identified and shared amongst the team.

MAPA controller to attempt to decelerate crisis behaviours. MAPA controller to monitor anxiety levels and provide verbal reassurance. MAPA controller to monitor physical observations (Level of consciousness; Pulse rate; Respiratory rate and Complexion). MAPA controller to ensure no pressure is applied to the torso. MAPA controller is to ensure the physical intervention is applied for the minimum duration of time. MAPA controller is to consider alternative MAPA positions to decelerate crisis behaviours. Medical Emergency – cease intervention. Staff are to contact emergency services.

To discuss the reasons as to why the physical intervention took place; to encourage the patient to discuss thoughts and feelings about the intervention. Monitor and record physical observations (Level of consciousness; Pulse rate; Respiratory rate, Temperature, Complexion, Systolic blood pressure, Oxygen saturations, Hydration). If Rapid Tranquillisation has been administered hydration levels are to be monitored and recorded. Examine for Soft Tissue or Articular/Bony injuries. Document post incident support. Document incident on DATIX. Review PCPiP.

Individuals with serious mental health illness, learning disabilities, from BME groups, high body mass index, or who are male between 30 -40 years of age, or anybody who is under 20 years are more vulnerable to restraint related collapse. Those patients who have underlying cardiac issues, stress related cardiomyopathy or who have received long term antipsychotics are of further risk. For further information regarding medication and side effects, please refer to the Rapid Tranquilisation Policy.

VIEWS OF THE PATIENT AND WHERE APPROPRIATE FAMILY/CARERS/ADVOCATES TO THE PERSON CENTRED PHYSICAL INTERVENTION PROTOCOL

THIS PERSON CENTRED PHYSICAL INTERVENTION PROTOCOL WAS DEVISED BY/DISCUSSIONS HELD WITH

NAME POSITION DATE

THIS PERSON CENTRED PHYSICAL INTERVENTION PROTOCOL WAS AGREED BY THE MDT ON:


DATE OF REVIEW REVIEW COMMENTS DATE

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:


Appendix 3

Clinical Holding MAPA Interventions

Pre assessment

Name of patient Date of Birth NHS Number

Does the patient have capacity to consent

to the proposed intervention?

YES/No

(please circle) If NO describe in detail the purpose and

rationale for treatment

Purpose & Rational for

Clinical Holding

Has a Best Interests meeting been held?

YES/No

(please circle) If YES please provide summary

If NO describe in detail the rationale and purpose for not holding a Best Interests

meeting

Summary of Best Interests

meeting (please also list staff/family/advocates

involved in meeting)

Name of Consultant Psychiatrist

Dated signature of Consultant Psychiatrist

Date:

Can known environmental triggers be removed prior to the delivery of care/treatment?

If YES – what triggers need to be removed before the

clinical holding procedure? Please describe:

If NO – what triggers do staff need to be aware of to

reduce anxiety and potential injury? Please describe:

Can therapeutic approaches be employed that promote relaxation?

If YES – what therapeutic activities are to be used

during the clinical holding procedure? Please describe:

If NO – what therapeutic activities have been tried?

Please describe:

Can desensitisation be used to reduce a patient’s anxious response to the care and treatment procedure?

If YES – what desensitisation practices are to be used

during the clinical holding procedure? Please describe:

If NO – what desensitisation practices have been

tried? Please describe:


Can supported communication approaches/health promotion strategies be employed to maximise opportunities for care?

If YES – what communication/ health strategies are to

be used during the clinical holding procedure? Please describe:

If NO – what communication/ health strategies have

been tried? Please describe:

Clinical holding should be clearly recorded in a patient’s care notes. Where it is used as a one off in order to facilitate a medical procedure its use should be subsequently reviewed by the Consultant Psychiatrist. Where clinical holding is considered to be necessary as part of a routine care plan, its use should be expressly indicated along with the legal justification for its application. Such care plans should be subject to regular review by the multidisciplinary team.

A Person Centred Physical Intervention Protocol (PCPiP) must be completed prior to a Clinical Holding intervention.


Policy Details

* For more information on the consultation process, implementation plan, equality impact

assessment, or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

3.2 Feb 2020 Appendix 2 reviewed and updated, no other changes to policy.

3.1 Jan 2019 Policy fully reviewed with minor amendments to definitions, legislation and section 4.2, 4.3, 4.4, 4.5, 4.6, and 6.0.

3.0 Jan 2016 Full policy review to reflect changes in legislation/ guidance and new policy format

2.1 Oct 2014 Minor amendments - Inclusion of ‘family/ carers/ advocates’ at page 14 and Appendices 2 & 3

2.0 June 2014 Revised policy – 2 year full review

Title of Policy Restrictive Physical Intervention Policy

Unique Identifier for this policy BCPFT-CB-POL-04

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Challenging Behaviour

Executive Director whose portfolio this policy comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Lead MAPA® Trainer

Committee/Group responsible for the approval of this policy

Reducing Restrictive Intervention Group

Month/year consultation process

completed * n/a

Month/year policy approved March 2019

Month/year policy ratified and issued April 2019

Next review date January 2022

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy

MAPA model, Managing a physical intervention, Post physical intervention, Health declaration, Person centred physical intervention protocol, Clinical holding MAPA techniques


1.0 Jan 2012 New aligned policy for BCPFT

Documents

Restrictive Physical Intervention