MANAGING VIOLENT & ABUSIVE BEHAVIOUR (Including Lone Working)

Transcription

1 Wirral University Teaching Hospital NHS Foundation Trust Policy Reference: 068 MANAGING VIOLENT & ABUSIVE BEHAVIOUR (Including Lone Working) Version: 10.1 Name and Designation of Policy Author(s) Ratified By (Committee / Group) Joe McLaughlin, Lead Facilitator for Conflict Resolution & PI Training Andre Haynes Health & Safety Advisor Workforce & Communication Group Date Ratified 5 th December 2014 Date Published 9 th February 2015 Review Date 5 th December 2017 Target Audience Other Associated Strategies, Policies, Procedures, etc All staff employed by Wirral University Teaching Hospital NHS Foundation Trust. Trust Policy Risk Management Strategy Trust Policy Health & Safety Policy Trust Policy 041a - Incident Reporting Policy Trust Policy Management of Inoculations and Exposure to Bodily Fluids (Including Sharps & Needlestick) Trust Policy Safe Management of Healthcare Waste Trust Policy Infection Prevention & Control Trust Policy 180 Learning and Development Policy Trust Policy 119 Stress Management Policy Trust Policy 124 Mandatory Training Policy Trust Policy Behaviour Management and the use of Restraint Relevant to Healthcare for Adults who Lack Capacity Trust Policy 197 Positive Handling/Physical Intervention of Children Young Persons #PROUD TO CARE FOR YOU #proud

2 Content CONTENTS Page 1 Introduction Purpose Scope NHS Protect - National Guidance The Legal and Trust Position Preventative Measures Lone Workers Risk Assessments Ad-Hoc Risk Assessments Development of Action plans Monitoring and Follow up Actions Keeping Patients, Relatives, Visitors and Members of the Public Informed Keeping Staff Informed Electronic Alert System Considerations Specific to Individuals Below 16 Years of Age Managing Aggressive Behaviour Informal Stage Non Physical Informal Stage Physical Formal Stage Trust Sanctions for Patients Under the Care of the Trust Instigation of Yellow Card Patients Instigation of Red Card Patients Formal Sanctions Relatives or Visitors (Anyone who is not a Patient) Reporting Violent and Abusive Behaviour and Lone Working Incidents Support for Staff Training Identification of Staff requiring Aggression Management Training Identification of Lone Workers requiring training Lone Worker Training Requirements Management of Training Records Compliance Reporting and Recording Evaluation of Training Definitions Physical Assault Non-Physical Assault Lone Worker Static Lone Worker A Community Lone Worker Alert Code... 18

3 12.7 Lawful Visitors Yellow Card Red Card Duties / Responsibilities Directors Senior Managers Security Manager The Local Security Management Specialists (LSMS s) Health and Safety Adviser Security Steering Team Line Managers and Supervisors Occupational Health Training Aggression Management & Lone Worker All Employees References Appendices Appendix 1 Violence or Abuse from Patients, Relatives or Visitors Appendix 2 - Flowchart to Show the Management of Security, Violence and Aggression... 24

4 1 Introduction This policy covers the prevention and management of violent and aggressive behaviour, both physical and verbal, towards employees of the Wirral University Teaching Hospital NHS Foundation Trust (WUTH) from patients, relatives, visitors or other members of the public. The policy also covers staff who work alone in fixed bases for example, in hospitals, clinics, schools, health centres, canteens etc. and staff who work away from their fixed bases, for example, in doctors surgeries, patients homes, day centres, etc. It also covers staff who work outside normal working hours including security and portering staff, maintenance and repair staff and a range of clinical staff. The Trust is committed to tackling the issues of violence and aggression to staff and recognises its duty of care under the Health and Safety at Work Act (HASAWA) 1974 and the Management of Health and Safety Regulations. The Trust has adopted a Zero Tolerance and pro security culture to violence and aggression towards its staff and patients. This is publicised in public notices displayed throughout Trust premises. Violent and abusive behaviour will not be tolerated and decisive action will be taken to protect staff. This policy and procedure supports the Trust to comply with NHS Protect the Counter Fraud and Security Management Service National Strategy, A Professional Approach to Managing Security in the NHS and the Secretary of State Directions on Work to Tackle Violence Against Staff and Professionals who Work In or Provide Services To the NHS. 2 Purpose This policy aims to give guidance to Trust employees in the management of violence and aggression within the organisation including activities which require staff to work alone. It also sets out measures for protecting staff from individuals who are persistently abusive or violent either whilst under the care of the hospital or present on Trust premises for any other reason. Although the policy describes the process for managing this type of behaviour against staff, the same approach will be taken if the aggression is focussed towards patients, relatives, visitors or other members of the public present on Trust premises for legitimate purposes. 3 Scope This policy gives direction to all direct employees of the Trust and those who are acting on behalf of the Trust. It applies to violent and abusive behaviour which occurs on any part of Trust premises or towards Trust staff working off site on behalf of the Trust. It applies to violent and abusive behaviour independent of the origin including all children and young people under the age of 16 years. 4 NHS Protect - National Guidance NHS Protect is part of the Counter Fraud and Security Management Service (CFSMS) and has overall responsibility for all policy and operational matters related to the Wirral University Teaching Hospital NHS Foundation Trust Page 1 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

5 management of security within the delivery of NHS services. The aim of NHS Protect is a simple one - to protect the NHS so that it can better protect the public s health. NHS Protect is developing both proactive and reactive initiatives in relation to NHS security management which include: Creating a pro-security culture amongst staff, professionals and the public. Deterring those who may be minded to breach security. Preventing security incidents or breaches from occurring. Detecting security incidents or breaches and ensuring these are reported in a simple, consistent manner across the NHS. Investigating security incidents or breaches in a fair, objective and professional manner. Applying a wide range of sanctions against those responsible for security incidents and breaches. Seeking redress through the criminal and civil justice systems against those whose actions lead to loss of NHS resources. NHS Protect is committed to the delivery of an environment for those who use or work in the NHS that is properly secure so that the highest possible standard of clinical care can be made available to patients. This guidance is designed to reflect good practice which is used throughout the NHS. 5 The Legal and Trust Position The Trust is committed to tackling the issues of violence and aggression to staff and recognises it has a duty of care under the Health and Safety at Work Act (1974) and the Management of Health and Safety Regulations. In determining what action can be taken against abusive patients, relatives or visitors, the first point to consider is who is allowed on Trust premises. Patients under the care of the hospital or other clinical service have a right to be on the premises. The Trust has a duty of care to those receiving treatment and the formal elements of this procedure must be applied before a patient can be excluded from the Trust. Lawful visitors also have the right to be on Trust premises; however a Matron, Lead Nurse, Assistant Divisional General Manager, a Clinical Director or Senior Manager on call can request that a lawful visitor leaves Trust premises until they can commit to adopting appropriate behaviour towards staff. If the visitor then refuses to leave as requested, they become a trespasser. A trespasser can then be removed by Trust staff provided that no more force is used than the situation requires. Any resistance by trespasser to a person lawfully removing them constitutes an assault, i.e. is a criminal offence. If a lawful visitor returns to the Trust following their temporary exclusion and further behaviour is appropriate, then no further action will be taken, but if the violent or aggressive behaviour continues, the formal elements of this procedure must be applied before a lawful visitor can be excluded. The Criminal Justice and Immigration Act (CJIA) 2008 makes it a criminal offence for a visitor to cause a nuisance or disturbance on NHS premises. This may apply to a person who has received medical advice and/or treatment is causing a nuisance or disturbance and is refusing to leave hospital premises. Wirral University Teaching Hospital NHS Foundation Trust Page 2 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

6 Nuisance or disturbance behaviour is defined as any form of low-level antisocial behaviour on NHS premises that breaches the peace. This can include: using foul language and verbally abusing NHS staff using intimidating gestures towards NHS staff, patients or visitors creating excessive noise in waiting areas or wards obstructing thoroughfares. 6 Preventative Measures 6.1 Lone Workers The safety of staff who are working alone, either on Trust premises or off site, is critical and an assessment of an individual or staff groups circumstances must be undertaken formally using the Trust risk assessment process described in Section 8.2. All actions highlighted from lone worker risk assessments must be actioned or escalated if local resolution is not possible as it is the responsibility of the Trust to ensure that its lone workers are safe. The following is a non exhaustive list of activities that may involve working alone: Occupational Therapists, Physiotherapists Midwifes Receptionist, Medical Secretary, Clerks Community Mental health Workers, Assertive Outreach workers, Community Psychiatric Nurses, Social Workers Carers in the Community and in Community Homes Those that provide Out of Hours Services, dispense controlled drugs or make domiciliary visits Security, Portering and other ancillary staff Those who travel between NHS sites and premises On-call staff required to respond to clinical or non-clinical emergencies, for examples to include clinical staff, estates staff and those on the on-call rota Those who open (or reopen) and close NHS buildings either early in the morning or late at night Health Promotion Co-ordinators or counselling staff Employees who attend public events to present on WUTH issues Volunteers, contractors and employees of other organisations working on behalf of the Trust Staff working from home Cleaners Maintenance Staff The above list is not exhaustive, but identifies a number of activities that are, or potentially may be carried out alone. 6.2 Risk Assessments All Department Managers must ensure that a Violence and Aggression and Lone Worker Risk Assessments have been completed or updated for their area at least once a year. Wirral University Teaching Hospital NHS Foundation Trust Page 3 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

7 This should be completed by the person in charge of the area e.g. ward or department manager or delegated to the local Health & Safety Representative. The risk assessments will identify potential risks from violence and aggression and to lone workers, and include control measures to ensure that they are managed safely. The Annual Violence and Aggression and Lone Worker Risk Assessments must be scored in line with Trust risk scoring methodology which is available on the Trust intranet and should be reviewed whenever there are changes and as a minimum at least annually. High risk areas will be identified using trends analysis, the findings of local risk assessments and the frequency of use of physical restraint. These arrangements will be monitored though the Security Steering Group and reported to the Health & Safety Partnership Team and Mandatory Essential Leader Trainers (MELT) meetings. The Health & Safety Partnership Team will recommend whether additional areas have been identified as high risk and inform the MELT accordingly. Please refer to the Conflict Resolution / Aggression Management Training page on the Intranet for further guidance. See link below: There are many activities that may potentially involve lone working of our employees. Please see below guidance on how to carry out lone worker risk assessment. Lone Worker Risk Assessments can be accessed via the links below Generic risk assessment for Home visits: Lone Worker (Home Visits) Generic risk assessment for premises: Lone Worker (Generic-Trust Premises) The manager is to identify whether the department they are responsible for has lone workers, and whether the lone worker activity is premises based (internal or external to the trust) or whether it involves carrying out home visits Complete the relevant lone worker generic risk assessment contained with the policy and modify the risk assessment so that it is specific to the ward or department and the type of lone working activity. Score the Lone Worker risk assessments using the Trusts scoring matrix. Keep the completed lone worker risk assessment within the local Health & Safety File Develop local standard operating procedures based on the guidance included within the policy and ensure any other control measures that are identified to reduce the risk to lone workers are implemented Communicate the findings of the risk assessments to all relevant staff and ensure they are fully aware of the local lone working arrangements and what they are required to do to comply with these arrangements. Ensure all Lone workers identified receive appropriate training in accordance with the Trust Policy Review the risk assessments at least annually, or where there is significant change (following an accident, following a request by the H&S Advisor or Staff Side Union Representative) Wirral University Teaching Hospital NHS Foundation Trust Page 4 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

8 The Local Security Management Specialist (LSMS) and Security Manager will review these risk assessments and provide support to issue resolution and escalation as appropriate. At the end of each financial year the LSMS and Security Manager will collate an overarching risk assessment for each division comprised of the detail within the risk assessments for each individual department. The manager of the individual area is responsible for ensuring that any actions required from the risk assessments are managed or escalated if they cannot be managed locally but the division wide risk assessment will support each division to monitor its status on departmental risk assessments. Once finalised these division wide risk assessments and action plans will be placed on the risk register and actions will be managed via the Trust risk management process. If all actions are complete and only a residual risk remains then this will be escalated to the Hospital Management Board for a decision to be made regarding the acceptability of the residual risk. 6.3 Ad-Hoc Risk Assessments In the event that a risk from violence and aggression or to lone workers is identified then the manager or PIC must ensure they complete the relevant Health & Safety generic risk assessment form. Low risk issues would not be included within an action plan unless the department is unable to resolve these issues. A generic risk assessment form would then be completed and the issues would be escalated in accordance with the Risk Scoring and Escalation Policy and Trusts governance structure. 6.4 Development of Action plans Low risk issues would not be included within an action plan unless the department is unable to resolve these issues. A generic risk assessment form would then be completed and the issues would be escalated in accordance with the Risk Scoring and Escalation Policy and Trusts governance structure. Action plans must also be developed for root cause analyses undertaken in response to orange or red coded incidents. All actions in a plan must have a due date and the overall lead for an action plan must make sure that anyone who is assigned a task is aware of the action, has agreed to undertake it and agreed the date by which it must be delivered. When a Trust-wide risk has been identified, the assessor must develop an organisation-wide action plan to ensure that the risk and subsequent remedial actions are addressed in all Divisions and Corporate Departments. It is essential that the assessor engages relevant stakeholders to ensure that the action plan is practical and capable of implementation. For assistance in undertaking risk assessments and action plans for local areas, please contact the LSMS, Security Manager or the Trusts Health & Safety Advisor. 6.5 Monitoring and Follow up Actions Action plans for violence and aggression or to lone workers that are being addressed locally will be monitored by the relevant Divisional/Department Managers. Wirral University Teaching Hospital NHS Foundation Trust Page 5 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

9 Risks that are orange or red associated with Lone workers or Violence and Aggression will be placed on the Trust Risk Register and monitored in line with the Trust risk management process. All actions will have due dates and the Risk Register/ Risk Management process will prompt follow up when the due date occurs. The minimum review date will be intervals of 6 months in line with the Trust risk management process. The Security Steering Group will discuss violence and aggression and lone worker risks and incidents as they arise. Those identified as part the annual audit process will be reported as part of the Annual Security Report each year and then will be followed up via the Risk Register. Action plans for risks that have been scored 10 or above or incidents colour coded orange or red will be escalated to the Trust Wide Clinical Governance Team. This committee has representation from across the Trust and has responsibility for monitoring and further escalation of risks if mitigation does not occur. 6.6 Keeping Patients, Relatives, Visitors and Members of the Public Informed The provision of information to patients, relatives, visitors and members of the public is extremely important in preventing violence from occurring. This applies at all times but particularly in situations of acute distress and/or long waiting periods such as in Accident and Emergency, Outpatients, Care of the Elderly Departments or any area where patients have cognitive impairment. Many individuals will be anxious and apprehensive on Trust premises because of unfamiliar surroundings, a fear of the unknown or a fear of known procedures or tests. In these circumstances they must be provided with sufficient information to reduce any uncertainty, anxiety and any misunderstandings. It is important that the individual areas of the Trust and its surroundings are subject to risk assessments to identify and manage risks involving of violence. Effective management of potential security risks may include: Keeping patients fully informed of what is happening and why Giving each patient defined personal space Providing diversionary activities where appropriate Encouraging energetic activities for younger patients with disturbed behaviour Monitoring the mix of patients in a given area The effective utilisation of staff at ward level Ensuring that patient concerns or complaints are dealt with objectively and quickly Removing aggressive patients to a single room or cubicle to protect other patients and staff Removing from the aggressor access all items such as vases etc which could be used as missiles or instruments to cause damage Using only disposable catering items Checking personal belongings for offensive weapons and potential incendiary devices (matches, cigarette lighters) Maintaining regular checks on the patient s behaviour and condition 6.7 Keeping Staff Informed Information about the behaviour of patients who are being cared for in different departments must be communicated to other healthcare professionals in both written Wirral University Teaching Hospital NHS Foundation Trust Page 6 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

10 and verbal form. This is essential for the protection of Trust staff but will also support them to proactively identify and manage potentially or actually difficult situations. If it is a relative or visitor who has been violent or abusive then this should also be communicated. Written information should be documented in the medical notes and is particularly important when: New members of staff may be involved in the care of a patient There has been a change in a patient s medical / physical state involving e.g., medication, alcohol or drug abuse, changes in behaviour or mood Patients, their relatives, visitors or members of the public who have a previous history of abusive behaviour are being transferred from one department to another Domiciliary visits are made to patients with a known or suspected history of aggressive or violent behaviour. 6.8 Electronic Alert System Where Red and Yellow cards and ASBOs ( Anti Social Behaviour Orders) are issued or there are incidents reported or intelligence to suggest that a patient or visitor is likely to be violent, aggressive or disruptive the LSMS will ensure that a marker is placed on CERNER to alert staff to the likely risk that the patient or visitor causes. The LSMS will forward any requests for markers to be placed on CERNER to the Deputy Divisional Manager, Emergency Department who will arrange for the markers to be placed on the system. The alerts will be as follows: Red and Yellow Cards and ASBOs Refer to Operational Bed Bureau Intelligence or Incidents to Suggest Violence or Aggression Refer to Security Any other Information or Complex Issue Refer to Patient Notes A record of any alerts placed on CERNER will be kept by the LSMS and reported in the Quarterly Security Report and monitored via the Security Steering Group. 7 Considerations Specific to Individuals Below 16 Years of Age When considering action to be taken in response to violent and abusive behaviour from individuals who are less than 16 years of age, carefully planning is essential and needs to take into account the following: The best interests of the child should be a primary consideration when any action involves a child Children should not routinely be separated from their parents unless this is necessary in the best interest of the child. If this is necessary then an alternative carer may need to accompany the child. Children should be protected from abuse or neglect Parents retain parental responsibility for their child (unless this is legally removed) and are actively encouraged to remain with their child throughout their admission Children under 10 years are exempt from criminal responsibility. Children between 10 and 14 years are also exempt unless it can be established that they can distinguish between right and wrong. Wirral University Teaching Hospital NHS Foundation Trust Page 7 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

11 The Safeguarding Team should be informed of any situation in which a child or young person behaves in a violent or abusive manner. For policy guidance on restraint of individuals below 16 years of age refer to the following link: Positive Handling/Physical Intervention of Children & Young Persons 8 Managing Aggressive Behaviour 8.1 Informal Stage Non Physical The management of aggressive behaviour should, as far as the situation allows, remain informal and be non-physical. Where the relatives or friends of the aggressor are available, they should be asked to support staff to defuse the situation. In adopting a non-physical approach to the management of aggressive behaviour, staff should: Ensure that one member of the team assumes control of the incident Ensure that colleagues are aware of the situation Be aware of the sources of help available if required Ask other patients or persons not involved to leave the area quietly Approach the aggressor where possible and seek their agreement to stop the behaviour or to comply with the request. Offer the aggressor the opportunity to explain their actions Explain to the individual(s) concerned the consequences of refusing to adopt appropriate behaviour (i.e. that they may be asked to leave the hospital) When violent or abusive behaviour occurs involving children, young people and parents there must be a multi-disciplinary approach to ensure safe appropriate care can be delivered. In the event of unacceptable behaviour, it is the responsibility of the Ward Manager to co-ordinate a multi-disciplinary meeting with the child (if appropriate), their family, the Ward Manager, Consultant and Social Worker and a member of the Safeguarding Team. The multi-disciplinary meeting s purpose is to set out an agreed contract of expected standards of behaviour, reasons for this and the sanctions that will be instigated in the event of non-compliance. A record of this meeting including those present should be made in the medical or nursing notes. Members of the multi-disciplinary team should be informed of the agreement. 8.2 Informal Stage Physical Staff should call Security. Physical intervention is not encouraged and should only be undertaken as a last resort, by staff that have been trained and assessed as competent in restraint techniques. Where non-physical methods have failed or the incident is sufficiently serious, the person in control may decide to restrain the aggressor physically. In so doing the person in control: must have been trained and assessed as competent in physical intervention procedures or delegate this task to someone who has been trained and is up to date with their mandatory training requirements Wirral University Teaching Hospital NHS Foundation Trust Page 8 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

12 should make a visual check for weapons or any other object that can be used to cause harm should nominate staff members to assist, control and allocate each a specific task. A small number of competent, well-trained staff are more likely to be more effective in managing the situation. A large number of staff attempting to restrain an individual is unacceptable practice A web based incident form must be completed in the event of physical intervention/restraint being undertaken. This form must be completed by the security personnel who carried out the restraint and the clinician who overseen the procedure. Incident report forms are located on the intranet and should be completed in conjunction with an Incident/Near Miss report Form. If the security staff have not already been asked to attend the ward / department and any member of staff thinks that a situation is beyond their control and there is a threat to their own safety or that of others, the Security Staff should be summoned via the Switchboard Operator (Dial 300) or by a panic alarm where sited, i.e. the ELPAS system. The Switchboard Operator will rapid bleep security and rapid bleep the Hospital Co-ordinator. Following the initial incident, Security Officers should not remain in the ward or clinical area without consultation with a Nurse or Manager in Charge of the Ward/ Department at the time of the event or consultation with the Hospital Co-ordinator. In non-urgent situations, Security staff may be contacted via: Bleep Arrowe Park 2046 Clatterbridge 4314 Phone Arrowe Park 2695 Clatterbridge 4312 Wirral University Teaching Hospital NHS Foundation Trust Page 9 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

13 ACTUAL INCIDENT CONTROL MEASURES INCIDENT OCCURS IMMEDIATE/IMMINENT DANGER No INITIAL INCIDENT DEALT WITH YES 1. Notify Clinical Bleep-Holder/Nurse Manager. Primary Tasks: 1. Utilise de-escalation/individual safety techniques/evacuate 2. initiate emergency security assistance via telephone extension 300 (for any use of physical intervention (PI) /restraint) 3. Contact Police (Dial 300) Secondary Tasks: Notify: a) Clinical Bleep Holder/Nurse Manager b) Doctor/Consultant c) Safeguarding Team d) LSMS Identify a PI trained clinical lead to coordinate the incident and supervise the PI response team. 2. Notify Safeguarding Team/Specialist Nurse 3. Complete incident form via safeguard web incident report system 4. Contact LSMS. Begin a Post-Incident Review: 1. Medical analysis (Consultant/Doctor/ Safeguarding Team) 2. Environmental risk assessment (Nurse Manager/Clinical Bleep Holder/Nurse Specialist) 3. Security assessment (LSMS) plus investigation were appropriate 4. Provisions for appropriate counselling/support or training for staff or other individuals affected by incident (Lead Facilitator for CRT/PI) 5. Follow up of all witnesses to the incident 6. Carry out a risk assessment and include a full training needs analysis PI response team to assist in control of the immediate situation until resolved 1. Initiate post-incident review 2. Complete incident form via safeguard web incident report system. Provide feedback on effectiveness of the processes/systems that have been put in place together with any identified weaknesses and lessons learned. Trust Incident Review Group post incident analysis. Wirral University Teaching Hospital NHS Foundation Trust Page 10 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

14 8.3 Formal Stage Trust Sanctions for Patients Under the Care of the Trust Instigation of Yellow Card Patients Before consideration can be given to any formal sanctions a medical or mental capacity reason for the behaviour must be excluded. To rule out medical reasons for such behaviour a careful review of the patient by a senior member of the individual s clinical team (or the on-call team out-of-hours) must be undertaken. It is important to note that for children or young person under the age of 16 the multidisciplinary team must be informed at all stages of the procedure including the appropriate social worker. Consideration must be given to the most appropriate environment for the child (open bay or cubicle; child or adult ward) and the level of supervision. If medical reasons for the behaviour can be excluded, following any incident, the person in charge of the ward or a consultant will explain to the patient that their behaviour is unacceptable and expected standards to be observed in the future. Consideration should be given to having security staff present or nearby in case an emergency situation arises. If the behaviour continues, the responsible manager or clinician will give a verbal warning about the possible consequences of any further repetition. For children or young persons under the age of 16 this discussion must involve the parents or carers. Failure to subsequently comply with expected standards of behaviour may result in the application of the Procedure for Care of Individuals who are Violent or Abusive (known as issuing a Yellow Card ). This is a formal written warning of the consequences of such behaviour.this situation must be discussed with a member of senior staff by the immediate manager or consultant. The appropriate senior staff who can decide that a yellow card is appropriate are the Matron, Associate Directors of Nursing, Assistant Divisional General Manager (ADGM), the Clinical Director or equivalent in the Corporate Departments. Out of hours this should be discussed with the Hospital Co-ordinator who will contact the Senior Manager on Call. It is the senior member of staff s responsibility to undertake the following: Take full details of the incident and the concerns of the staff involved, document them in the medical or nursing notes and decide whether a Yellow Card is required. Inform the patient of the concerns of the staff in the presence of a suitable member of staff (medical staff or registered nurse or equivalent in the Corporate Departments) and fully explain the policy regarding Managing Violent and Abusive Behaviour, ensuring that there is no confusion as to the standard of behaviour required or the possible consequences of failure to comply i.e. that the individual may be excluded from Trust premises. Consideration should be given to having security present or nearby in the event of an emergency. Complete all of the patient details on the Yellow Card Form. Wirral University Teaching Hospital NHS Foundation Trust Page 11 of 23 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Working)

15 Ask the patient to sign the form. If the patient refuses to sign, this should be documented on the form but it should be explained to the patient that the document will be valid with or without their agreement. Sign and date the form and ask the witness to do the same. Give the patient a copy of the policy and the Yellow Card form; send a copy of the form to the Director of Nursing and Midwifery. Prepare a copy of the standard letter for issue to the patient s GP. Prepare a copy of the standard letter for issue to the patient Explain to the patient that if they comply with the terms of the Yellow Card they can expect the following: o Their clinical care will not be affected in any way. o Where substance abuse has been identified, appropriate assistance will be provided. o That a copy of the Yellow Card form will be sent to the Director of Nursing and Midwifery. o The WUTH Security Manager, LSMS and relevant managers will be informed. o The Trust will fully investigate all valid concerns raised by the patient. o The Yellow Card will expire after a period of one year. The patient must be informed that they may request an immediate review of the yellow card by the ADO or on call Senior Manager. Give the paperwork to the ADO who will check that the procedure has been applied correctly. It is the responsibility of the Associate Directors of Nursing to notify the Clinician involved in the care of the patient that a Yellow Card has been instigated. They will sign and issue the GP letter. They will also send a copy of the Policy to the GP. They will forward the letter for the patient to the Director of Nursing and Midwifery for signature. They will also send copies of the Yellow Card form to the LSMS, Security Manager, the Hospital Co-ordinators, Safeguarding Team and A & E for awareness. Link to yellow card process and letter templates Yellow Card Process Instigation of Red Card Patients Failure by the patient to behave in an appropriate manner following the receipt of a Yellow Card will, at the request of the relevant ADO or CHD (or in their absence their nominated deputies) result in the exclusion of the patient from the Trust once alternative care arrangements have been made. This exclusion is documented in the medical notes only. Letters of confirmation are sent to the patient and their GP. If a Red Card is issued it does not preclude the clinician discharging a patient who no longer requires in-patient care in the normal manner. It is the senior member of staff s responsibility to undertake the following: Document full details of the incident(s) and the concerns of the member of staff in the medical notes including the rationale for the Red Card Wirral University Teaching Hospital NHS Foundation Trust Page 12 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)

16 Inform the patient of the concerns of the staff in the presence of a suitable member of staff (medical staff or registered nurse or equivalent for corporate departments) and fully explain the policy regarding Managing Violent and Abusive Behaviour. Explain to the patient that their behaviour is unacceptable, that they are being issued a Red Card and what form of sanction this will take i.e. that as soon as alternative care can be arranged they will be transferred or that specific restrictions will be placed on their presence in the hospital e.g. presence of security staff whilst on site. Explain to the patient that future emergency treatment would not be affected but that unless the situation was an emergency then the alternative care arrangements will apply. Consideration should be given to having security present or nearby in the event of an emergency. Confirm the content of the discussion with the patient in the medical or nursing notes and sign and date the entry. Ask the witness to do the same. Give the patient a copy of the policy. Inform the patient that they may challenge exclusion via the established complaints procedure and give the patient a copy of the Trust s complaints leaflet. Prepare a copy of the standard letter for issue to the patient. Prepare a copy of the standard letter for issue to the patient s GP. Give a copy of these to the ADO who will check that the procedure has been applied correctly. It is the responsibility of the Associate Director of Operations to notify the Clinician involved in the care of the patient that a Red Card has been instigated and that a record has been placed in the medical notes. They will liaise with the Director of Nursing and Midwifery who will sign and issue the letters. A copy of the Policy will be attached and sent to the GP. If the situation involves children or young persons under the age of 16 then Health Visitor or School Nurse and Social Worker must be informed in addition to the GP. The ADO will also send copies of the Red Card letter to the patient to the LSMS, Security Manager, Hospital Co-ordinators, Consultants and A & E for awareness. A Red Card exclusion will last one year, subject to alternative care arrangements being made. These arrangements must be made by the relevant Consultant and the patient s GP will be notified. If the patient is ready for discharge the arrangements for future alternative care will be made in conjunction with the patient s GP. In the event of an excluded individual presenting at the Accident and Emergency Department for emergency treatment, they will be treated and stabilised with, if necessary, security staff in attendance. Where possible, they will then be transferred immediately. However, if admission is unavoidable, security staff will, if necessary, remain in attendance. The need for security attendance will be determined by manager or clinician responsible for the patient. If an excluded individual returns in any circumstances other than a medical emergency, security staff should be called immediately. The Trust will subsequently seek legal redress to prevent the individual from returning to Wirral University Teaching Hospital premises. Wirral University Teaching Hospital NHS Foundation Trust Page 13 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)

17 Link to red card process and letter templates Red Card Process 8.4 Formal Sanctions Relatives or Visitors (Anyone who is not a Patient) Relatives or visitors who are violent or abusive on more than one occasion will be asked to stop and offered the opportunity to explain their actions. They must be warned that failure to comply with the required standard of behaviour may result in removal from Trust premises. A single offence may be considered serious enough to warrant formal action; this must be discussed with a senior staff member e.g. Assistant Divisional General Manager, Lead Nurse, Matron or Consultant (Out-of-hours Hospital Co-ordinator). If the Senior Member of Staff considers that the relative or visitor should be removed then security should be called and the offending individual will be escorted from the premises and advised that although they can return into the hospital the following day following a cooling off period that if the required standard of behaviour falls below what is required again then there is the potential that they will be excluded from the hospital for a temporary period, permanent period or have restrictions placed upon their entry into the hospital. If the relative or visitor then fails to comply with the required standard of behaviour, the situation must be discussed the relevant Associate Director of Operations, Clinical Head of Division (CHD) or equivalent for Corporate Departments or the Director of Nursing and Midwifery who may decide to continue to exclude any individual removed from the premises or restrict their visiting only to specific times and, if necessary, under escort by security staff. This will occur if a repeated pattern of violent or abusive behaviour occurs or if a single offence is serious enough to warrant this measure. If the relative or visitor is on hospital premises to visit a child then the child will be informed in age appropriate language what has happened and the reason why. Every reasonable attempt should be made to arrange for another appropriate adult to remain with the child if this is considered to be necessary. If there is an agreement that the relative or visitor should be excluded then one of the senior staff members must explain the Trust policy for dealing with violent or abusive behaviour. The individual should be given a copy of the Violent & Abusive Behaviour Policy. A yellow or red card form is not issued to a relative or visitor but the senior staff member must make it clear why the decision has been made to exclude the relative or visitor, how long the exclusion will last and if presence on Trust premises is permitted with certain restriction a clear explanation of the restrictions which apply must be made. Permanent exclusions may be considered necessary. This will be confirmed in writing by the Director of Nursing and Midwifery. Permanent exclusions may be considered necessary. Any relative or visitor behaving in a violent or aggressive manner to Trust staff, property or assets will be reported to the police. The offending individual must be notified of this by the senior member of Trust staff. The relative or visitor must be informed that they may request an immediate review of the Yellow Card by the Associate Director of Operations (ADO) or On Call Senior Manager. Wirral University Teaching Hospital NHS Foundation Trust Page 14 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)

18 If the relative or visitor has dealings with a patient in the hospital then the event and the action should be documented in the patient s medical notes. 9 Reporting Violent and Abusive Behaviour and Lone Working Incidents As soon as possible after the incident has occurred, a Trust incident form must be completed via the Safeguard web based reporting system. This system must be used to record physical and non-physical assaults / incidents as well as any incident where verbal aggression or restraint has occurred. In addition, all assaults are reported nationally to NHS Protect via the Risk Management Incident Reporting, and are automatically sent to SIRS (Security Incident Reporting System) at NHS Protect to be placed on the national database. Link to Safeguard Incident Report System: Web Incident Reporting Link Link to Incident / Near Miss Report Form (If unable to access web based system due to downtime ONLY) Incident Near Miss Reporting Form - Word The Director of Nursing and Midwifery, Security Manager, Safeguarding Team, Lead Trainer for PI/CRT, LSMS together with Risk Management receives the report. 10 Support for Staff The Trust acknowledges that its staff may be affected physically or emotionally following a violent incident. Managers need to be aware therefore that individuals will need active support and counselling, especially after the incident and on resuming or returning to work. This is particularly important given the potential impact of stress on the employee s current or future health. The Hospital Co-ordinators will act as an immediate debriefs for staff as and when these incidents occur. Once the incident has been logged, the Security Manager and LSMS will be contacted to ensure that follow-up action is taken. The Security Manager with the assistance of key stakeholders will alert staff of persons who have previous history of violence via the Cerner System. The respective line manager will send out a letter of support to each member of staff who is involved in a conflict situation giving contact details for support mechanisms. It is therefore essential that the line manager conducts a full debriefing of all staff involved in a violent episode. This should include the arrangement of professional counselling, if required, via their GP or Occupational Health. However, in group/specialist situations appropriate specialist support should be sought for all those who wish to avail themselves of it. Wirral University Teaching Hospital NHS Foundation Trust Page 15 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)

19 The manager should also arrange a follow-up meeting within two weeks of the debriefing. The Trust will work actively with the member of staff, NHS Protect and the Crown Prosecution Service in regard to prosecutions and individual support mechanisms. Trust policies on the Management of Stress and Supporting Staff Involved in an Incident, Complaint or Claim provide further guidance. 11 Training 11.1 Identification of Staff requiring Aggression Management Training All staff will receive Conflict Resolution training on commencement of employment as part of the Initial Mandatory Training Programme delivered as part of the corporate programme. It will also be delivered every 3 years as part of Refresher Mandatory Training for staff who work in high risk areas. The process for identifying required attendees, booking training, checking that staff complete the relevant training, recording attendance, following up non attendees and monitoring compliance with training is described in the Mandatory Training Policy. Other specialist training is available; Adult Physical Intervention, Physical Intervention Overseers Course, Individual Safety Techniques (IST), Lone Worker Training, Dealing with Telephone Abuse, Behavioural Support for Dementia Patients Knowing Me, CSW Core Skills Patient Safety Training. Details of these training programmes can be found in the Trust s HR/OD portfolio which can be found on the HR/OD essential training section of the intranet Identification of Lone Workers requiring training Staff will be identified following departmental risk assessment and as part of their annual individual review Lone Worker Training Requirements Lone Worker Training is now classed as Essential Training for all staff who, with their managers who have been identified as lone workers as part of their departmental risk assessment and Individual Review/Appraisal (Performance and Development Review) processes. Staff identified as lone workers should refer to the essential training matrix with Trust Policy 180- Learning and Development Policy for training requirements Management of Training Records Attendance and non attendance training records will be recorded in the Oracle Learner Management (OLM) System by the HROD Department. Staff who fail to attend a booked training course will be alerted to the individual s line manager and the appropriate charge made in line with the Learning and Development Policy Compliance Reporting and Recording Compliance with the requirements for completing Lone Worker Training should be checked at the annual Individual Performance and Development Review by managers Wirral University Teaching Hospital NHS Foundation Trust Page 16 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)

20 with their staff. Line managers are responsible for notifying the HR&OD department of dates of Individual Reviews/Appraisals that have been completed. This is incorporated into the reviewee s record and is used to calculate the End Date of Compliance for Individual Review / Appraisals Compliance with all essential training is monitored through the Individual Performance and Development Review process. Non Compliance will be reported as follows: Board Dashboard Quarterly Traffic light report Workforce and Communication Group and Clinical Governance Group Quarterly Performance Report Divisional Management Teams Quarterly Performance Report Line Managers Quarterly Performance and Alert Report It is the Manager s responsibility to monitor completion and compliance with Individual Reviews / Appraisals. In order to provide a control and assurance mechanism, the HR & Organisational Development Department, using the Electronic Staff Record (ESR), records/tracks attendance/compliance with Individual Reviews / Appraisals. HR & OD is responsible for producing Performance and Alert Reports. Managers receive a Quarterly Performance and Alert Report for their area, linked to mandatory training alert reports, to facilitate planning for Review/appraisal activity and to validate records. Managers are responsible for ensuring that staff have an annual review and non compliance will be identified within the alert report. Divisional Management Teams (DMT) receive Quarterly Performance and Alert Reports linked to mandatory training alert reports highlighting current non compliance levels and potential non compliance during the next quarter. DMTs are expected to provide an action plan to deal with noncompliance over the agreed target as part of the Quarterly Divisional Review Evaluation of Training All training will be evaluated and the results will be shared at the Mandatory and Essential Lead Trainers (Melt) meetings, Clinical Governance Group meetings, and Health and Safety Partnership Team meetings as well as service heads to ensure it is meeting identified needs. 12 Definitions 12.1 Physical Assault The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort Non-Physical Assault The use of inappropriate words or behaviour causing distress and or constituting harassment Lone Worker A Lone Worker is defined as any employee who works on their own without close or direct supervision or contact with colleagues. Where employees have to work alone, personal safety must be a priority consideration and the Trust has a duty to ensure that lone workers are made aware of all necessary steps to avoid putting themselves at risk either from the work itself or the work environment. After assessing the risks, a Wirral University Teaching Hospital NHS Foundation Trust Page 17 of 24 Policy 068 Managing Violent & Abusive Behaviour (Including Lone Worker)