Clive Gibson: Lead Nurse: Elderly Assessment Team Policy to be followed by (target staff) All MEHT staff. Policy

Transcription

1 Adult Patient Safer Restraint Policy Policy Register No: Status: Public Developed in response to: Best Practice Contributes to Care Quality Commission: Outcome 7 Consulted With Post/Committee/Group Date Rabina Tindale Divisional Nurse Manager for Medicine 28 September 2014 Carin Charlton Director of Estates and Facilities & SMD Dr Ronan Fenton Medical Director 28 September 2014 Cathy Geddes Chief Nurse 28 September 2014 Helen Clarke Clinical Audit / NHSLA Lead 28 September 2014 Dr Anser Qureshi Clinical Director for Care of the Elderly 28 September 2014 Lyn Hinton Deputy Director of Nursing 28 September 2014 Sandra Morton Nance Hospital Liaison Nurse for Learning Disabilities 28 September 2014 Helen Ali Lead Nurse for Clinical Operations 28 September 2014 James Day Trust Board Secretary 28 September 2014 Emma Rougier-Pirie Adult Safeguarding Clinical Nurse Specialist 28 September 2014 Eric Carter Head of Portering 28 September 2014 Julie Green Dementia Specialist 28 September 2014 Professionally Approved By Cathy Geddes, Chief Nurse 28 September 2014 Version Number 2.0 Issuing Directorate Nursing Ratified by: Document Ratification Group Chairmans Action by James Day Ratified on: 10th October 2014 Executive Management Group November 2014 Implementation Date 10th October 2014 Next Review Date September 2016 or earlier as required Author/Contact for Information Doug Smale: Local Security Management Specialist Clive Gibson: Lead Nurse: Elderly Assessment Team Policy to be followed by (target staff) All MEHT staff Distribution Method Intranet and Website Related Trust Policies (to be read in conjunction with) Adult Safeguarding Policy Mandatory Training Policy (Training Needs Analysis) Mental Capacity Act (2005) Policy Incident Policy Mental Capacity Act Deprivation of Liberty Safeguards (2009) Policy Clinical Record Keeping Policy Violence and Anti-Social Behaviour Policy Mental Health Policy Management of Delirium in Older People policy Dementia policy Consent to Treatment and Examination policy Security policy Being Open Support for staff involved in a traumatic incident, compliant or claim policy Absconding and Missing Patient Policy Document Review History Review No Reviewed by Review Date 1.0 Clive Gibson 27th October Consultation Group outlined above. 10 th September 2014 I Page 1 of 18

2 Index 1.0 Purpose 2.0 Introduction 3.0 Scope 4.0 Duties 5.0 Definition 6.0 Purpose of Restraint 7.0 Personal Safety 8.0 Risk Assessment 9.0 Common Law and Criminal Law 10.0 Restraint 11.0 Positional Asphyxia 12.0 Weapons 13.0 The Mental Health Act (1983) 14.0 The Mental Capacity Act (2005) 15.0 Deprivation of Liberty Safeguards (2009) 16.0 Medication 17.0 Learning Disabilities 18.0 Training 19.0 Documentation 20.0 Post Incident Management 21.0 Counselling, Assistance and Compensation for Staff 22.0 Staff exempt from assisting with restraint 23.0 Assistance from non-clinical staff and other agencies 24.0 Equality and Diversity 25.0 Complaints 26.0 Communication and Implementation 27.0 Monitoring and Audit 28.0 References Appendix 1 Equality Impact Assessment Page 2 of 18

3 1.0 Purpose of Policy 1.1 The purpose of this policy is to provide guidance for staff on the circumstances where restraint may be appropriate, the approved methods of restraint and how these methods can be used safely. The policy also aims to ensure actions taken are consistent with all legislative and professional obligations. 1.2 Patients may become disturbed as a result of a physical illness or deterioration in their mental state. Others may be under the influence of drugs or alcohol. Where an individual presents a risk of harm to themselves or others this policy will provide staff with guidance towards meeting their responsibilities. 1.3 Any restraint used must be reasonable and proportionate to the identified risk. Recognising that circumstances are often complex, it is imperative that all other means of preventative action are explored before physical restraint is applied. Any restraint must be for the minimum time. This is determined through an ongoing assessment of the person and their non-verbal cues whilst in restraint. 1.4 The Trust aims to maintain a balance between its Duty of Care to patients and its responsibility to support employees when harassed or under threat. This policy recognises this and is designed to provide additional guidance to staff on the management of disturbed patients. The Trust undertakes to provide staff with appropriate training and, in the event of an incident, make available appropriate support where staff have acted lawfully and in good faith. 1.5 The Trust has a legal obligation (Health and Safety at Work Act etc.1974, Human Rights Act, 1998) to ensure that there is adequate staffing to deal with potential violence. Staffing levels must be based on anticipated future events, therapeutic staff/patient ratios and any recent adverse events. 2.0 Introduction 2.1 The philosophy for the implementation of safer restraint by the Trust is based on the definition by Emerson et al (1988) Behaviour of such intensity and frequency of duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to and use of ordinary community facilities. 2.2 The safer restraint of patients is a complex area of practice which is bound by legislation including the Mental Capacity Act (MCA) 2005; Deprivation of Liberty Safeguards (DoLS) 2009, the Mental Health Act (MHA) 1983 NICE guidelines on Violence (2005) & Criminal Law Act (1967), the Human Rights Act and common law. Staff should also refer to Positive and Proactive Care: reducing the need for restrictive interventions (Department of Health 2014) guidance. 2.3 Staff have a duty of care to their patients and must be aware of their responsibilities in relation to any situation which requires a patient to be restrained. Trust Security staff are certified to provide physical restrictive interventions on the direction of clinical staff. Page 3 of 18

4 2.4 The Trust has a duty to staff to provide guidance and training in relation to restraint in order to comply with health and safety legislation and reduce the risk of harm to both patients and staff. 2.5 This policy will provide the framework for staff and their managers to comply with relevant legislation regarding the restraint of patients over the age of 18 years and enable staff to fulfil the requirements of their role safely and competently. 2.6 This policy takes into consideration the NHS constitution and reference to the right for patients to refuse treatment and examination when they are assessed as having mental capacity. 2.7 Professionals working with vulnerable people have a duty of care to recognise the need to avoid actions that may harm others, and to ensure the agencies they work for always act in the best interest of the service user. By preventing behaviours which challenge the service user, it may be possible to minimise the extent to which physical interventions are employed. 3.0 Scope 3.1 This policy applies to all staff across the Trust working with adults. Restraint of children (under the age of 18 years) is beyond the scope of this policy and should not be considered. All staff includes temporary staff, contracted staff, volunteers and employees of Trust, students or employees of other external organisations that provide services to the Trust. 4.0 Duties 4.1 Lead Clinicians, Clinical Directors, Heads of Departments and Head Nurses must ensure that members of their teams understand their responsibilities within this document. 4.2 Individual professionals have the duty to implement the requirements of this document within their area of responsibility in accordance with their professional code of conduct and complete all appropriate documentation. 4.3 Within the Trust, clinical staff should raise concerns and seek clinical advice with the CNS Adult Safeguarding and/or the Elderly Assessment Team (within working hours) or the Clinical Operations Managers (out of hours). The medical team and the Heads of Nursing must also be notified of any physical or chemical restraint via the clinical incident reporting system. The nurse in charge is responsible for completing the datix incident reporting form. 4.4 Security staff have a duty to respond as required to clinical staff s request for assisting in restrictive practice. 4.5 The Executive Board (EB) will ensure the Trust applies the principles outlined in this policy. The EB is also responsible for maintaining and being accountable for overarching restrictive intervention reduction programmes in line Department of Health (2014) guidance. Page 4 of 18

5 5.0 Definitions 5.1 Physical restraint Stopping an individual s movement by the use of equipment that is not specifically designed for that purpose e.g. bed rails, belts, tables or chairs. 5.2 Physical intervention Refers to the direct action by one or more members of staff restricting or blocking the persons movement or mobility to stop them going where they wish during a time when the person initiates dangerous or harmful contact to themselves or others. The aim of physical intervention is to redirect, limit or deny free bodily movements as a last resort and should not be confused with interventions such as guiding and prompting that are intended to support the person. 5.3 Mechanical restraint This is restraint that is applied by the use of a specific piece of equipment to control activity for the safety of the person or others. This includes the use of mittens, belts, arm cuffs, splints or helmets to limit movement to prevent selfinjurious behaviour or harm to others. It is generally accepted that mechanical restraint will only be used as a planned response by multi disciplinary team when no other alternative can be found. 5.4 Environmental restraint Environmental restraint is where a patient regardless of legal status is kept confined within an area and maybe segregated from others and prevented from leaving at will Designing the environment to limit people s ability to move as they might wish, for example, locking doors, poor lighting or heating, preventing the patient from leaving the hospital and the use of bed rails and low riser beds. Positioning of table in front of chair to prevent person from getting up is not appropriate restraint Environmental restraint can be used in an acute situation to PREVENT or MINIMISE: Emotional/physical injury to other persons The person being a danger to themselves 5.5 Chemical restraint In certain situations, the use of drugs and prescriptions may be indicated as a method of chemical restraint to change or moderate peoples behaviour. Medication must only be administered under medical advice and must not be used as a routine method of managing difficult behaviour. Page 5 of 18

6 5.5.2 When rapid tranquillisation is used for the purpose of quickly calming the severely agitated patient in order to reduce the risk of imminent & serious violence or harm to self or others and not for the purpose of treating the underlying condition or inducing sleep. Please refer to the Management of Delirium in Older Patients Policy. 5.6 Cultural restraint This can be the result of constantly telling people not to do something or that doing what they want to do is not allowed, is illegal or too dangerous. 5.7 Medical restraint This includes the fixing of medical interventions (such as a catheter to the bed) to deliberately restrict the patients movement. 5.8 Positional asphyxiation Restraining an individual in a position that compromises the airway or expansion of the lungs (i.e. in the prone position).this may seriously impair an individual s ability to breathe and can lead to asphyxiation. This includes pressure to the neck region, restriction of the chest wall and impairments of the diaphragm. 5.9 Physical Violence The intentional application of a force without lawful justification, resulting in physical injury or personal loss (Cited in Response to Directions from the Secretary of State for health to Deal with Violence and Aggression against NHS staff SMS) Minimum force An amount of force not exceeding what is required to complete the task without causing injury or discomfort to the individual or patient. Any method of restraint which involves excessive force or is continued to be used after the immediate crisis is over, is not justified under common law Common law That part of the English law not embodied in legislation. It consists of rules of law based on common custom and usage and on judicial (court) decisions Non-pain compliance technique All Trust staff must work in accordance with the guidance in chapter 15 of the Mental Health Act Code of Practice (2008) in the use of safe, ethical, dignified control and restraint methods which does not induce pain to the individual or patient. Page 6 of 18

7 6.0 Purpose of restraint 6.1 To ensure that acceptable action is taken in accordance with this policy and related procedures in response to those situations where any de-escalation; deflection; breakaway or restraint has been used. In order: To take immediate control of a dangerous or potentially dangerous situation to self and/or others. To end or reduce significantly harm to self and/or others for the period necessary to do so (Mental Health Act, 1983, Code of Practice). 6.2 Risk to property is not an indicator for restraint staff should withdraw from a situation and observe from a safe distance to see if the patient is calming-down or if the situation is escalating. 7.0 Action and Personal Safety 7.1 Staff should report concerns to the person in charge of the area who will be responsible for informing the CNS Adult Safeguarding and/or the Elderly Assessment Team (within working hours) or the Clinical Operations Managers (out of hours). Where support is required for those patients with a Learning Disability please contact the Learning Disability Lead Nurse for support and advice. 7.2 Staff should consider whether it is necessary, possible or safe to move other patients away from the vicinity. 7.3 Staff are not to place themselves at unnecessary levels of risk when attempting to control or restrain a patient. Staff must ensure they have received adequate information and training on forms of control and restraint before attempting any methods. Failure to ensure this could result in harm to the staff or patient and harm to the organisation. 7.4 Security staff are fully trained in control and physical restraint and should always be called in the event that any control or restraint techniques are required. Do not attempt any techniques if you have not received training. 7.5 All staff have a duty of care to themselves and others and should avoid creating a high risk incident likely to cause harm to themselves and others. 7.6 Where appropriate an individualised support plan, incorporating a Behaviour Support Plan will be implemented to support the patient and staff members. These will be instigated and supported by the Local Security Management Specialist/Health. For our patients with Learning Disabilities the Learning Disabilities Lead Nurse will support with behavioural strategy techniques on deescalation, diffusion and distraction. Page 7 of 18

8 8.0 Risk assessment 8.1 All Managers are responsible to ensure the safety of their staff and patients is paramount. They should ensure that adequate risk assessments have been undertaken. 8.2 A formal assessment of the risks that exist either by the environment or person/s which exist at the time of the incident. 8.3 Where an incident arises all risk assessments should be reviewed post-incident to ensure that these still meet the requirements of the Ward/Department. 8.4 When a person behaves in an unexpected way that has not been foreseen by a risk assessment the member of staff retain their duty of care to ensure any response is proportionate to the circumstances of the situation. 8.5 All staff have a duty of care for their own health and safety and that of their immediate colleagues. They must adhere to all relevant policies and procedures and comply with risk assessments that have been put in place to reduce risks. 8.6 Where restraint methods have had to be applied a Datix Incident Report Form must be completed using the category security, a sub category of physical and chemical restraint will then need to be identified. 9.0 Common Law and Criminal Law 9.1 Common law recognises that there are many circumstances in which one person may use force upon another without committing a crime (e.g. sporting contests). Included in common law is a person s right to protect themselves from attack and to act in the defence of others. 9.2 If no more force is used than reasonable to repel the attack, such force is not unlawful and no crime is committed. Furthermore, a person about to be attacked does not have to wait for his or her assailant to strike the first blow. Certain circumstances may justify you making the first strike if it is in the safest interests of that person. 9.3 These laws are interpreted according to the following guidelines: minimum use of force proportionality of force used seriousness of evil to be prevented right to self defence 9.4 In accordance with Section 3, Criminal Law Act 1967, 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 persons unlawfully at large. Page 8 of 18

9 9.5 The key word in the legislation is reasonable and this issue is a question of fact to be decided in each individual case, remembering that going too far is a criminal offence Restraint 10.1 Restraint may take many forms and may vary in degree but should comply with the minimum force required. The essence of restraint is to contain or limit another person s freedom Any use of physical force must be reasonable, necessary and proportionate to both the behaviour of the individual to be controlled and the nature of the harm they may cause. The minimum necessary force should be used at all times and in all circumstances (DOH: 2014) Staff attending a violent incident will have to make the decision as to what level of restraint is required. The number of staff required to resolve a violent incident directly should be the reasonable number necessary to restrain the individual, whilst minimising the risk of injury to all parties. One member of staff should lead the team and assume control of the person being restrained throughout the process. He/she should ensure that the restrained person s head and neck is appropriately supported and protected and airway and breathing are not compromised Pain compliance technique is not therapeutic and must only ever be used to prevent a greater harm occurring. The Trust supports the use of Non-pain Compliant Techniques Any patient who requires physical or chemical restraint must be referred to the Elderly Assessment Team, Local Security Management Specialist/Health and Safety Management and Security Manager within normal working hours or the Clinical Operational Managers outside of working hours Positional Asphyxia 11.1 Restraint positions that increase the risk of positional asphyxiation for example, prone restraint, must only be used if safer methods (e.g. seated and supine) are likely to fail. Prone restraint must only be used for the shortest time possible to manage the situation presenting and the patient s physical state (including airway management, breathing and circulation) must be monitored both during and after such intervention Weapons 12.1 If it is thought that a patient may be carrying a weapon, DO NOT attempt to disarm the patient. Those present should attempt to keep the situation contained. Staff should ask the individual to surrender the weapon and move to another vicinity. If the individual will not put the weapon down, staff should evacuate themselves and others to a safe area and dial 999 for police attendance. Never ask someone to hand a weapon to you directly as this may Page 9 of 18

10 result in injury. Police will be equipped appropriately with shields and vests for their protection The Mental Health Act (1983) 13.1 Patients detained under Section 2 or 3 of the Mental Health Act 1983 may be given emergency treatment under Section 62. Patients being held for assessment under Section 5.2 have not been formally detained and therefore can be treated under the Common Law in an emergency situation, for the safety and protection of themselves and others (see Appendix 1 & 2). If patients are attending the hospital under a Section 136, staff should refer to the Mental Health Policy Patients who have not been assessed under the Mental Health Act can also receive emergency treatment under Common Law, including restraint and sedation. Once the emergency has been resolved, at the earliest possible time after the legal status of the patient must be reviewed and if appropriate, an assessment under the Mental Health Act must be undertaken The Mental Capacity Act (2005) 14.1 The assessment of a patient s capacity to make a decision about his or her own medical treatment is a matter of clinical judgement, guided by current professional practice and subject to the Mental Capacity Act (2005) Code of Practice It is the responsibility of the decision maker proposing treatment to determine whether the patient is capable of understanding what is intended and competent to decide to proceed i.e. give a valid consent To determine if a patient lacks capacity to make particular decisions, the MCA sets out a two-stage test of capacity: Stage 1: requires proof that the person has an impairment of the mind or brain. This can be a permanent condition (e.g. head trauma, dementia, and significant learning disabilities) or a temporary condition (e.g. delirium, sepsis, hypo-natraemia or drug and alcohol use/withdrawal). Stage 2: the impairment means that the person is unable to make a specific decision when they need to. A person is unable to make a decision for him/herself if he/she is unable: To understand the information relevant to the decision To retain that information To use or weigh that information as part of the process of making a decision or To communicate their decision (whether by talking, using sign language or any other means) Page 10 of 18

11 14.4 Lack of ability in any of these four areas means the person lacks the capacity to make this decision Evidence must be documented on the mental capacity assessment form 2 (MCA2) that both stages of the assessment indicate that the person does or does not have capacity The 5 key principles of the MCA 2005 are: a person is assumed to have capacity unwise decisions do not necessarily mean lack of capacity people must be helped to make decisions decisions must be taken in the person s best interests decisions must entail the least possible restriction of freedom 14.7 According to the MCA restraint can legally occur when the person lacks capacity and it will be in the person s best interests and it is reasonable to believe that it is necessary to restrain the person to prevent harm to them and any restraint is a proportionate response to the likelihood of the person suffering harm and the seriousness of that harm Please refer to the MEHT Mental Capacity Act Policy for further guidance Deprivation of Liberty Safeguards (2009) 15.1 Circumstances where a patient who may lack capacity to make a decision for themselves, repeatedly expresses a wish to leave the clinical area or is resisting treatment and requires either physical restraint or chemical restraint (i.e. sedation) would amount to a deprivation of liberty. A formal assessment of the patients capacity and request for urgent and standard authorisation to continue to deprive the patient of his or her liberty must be made accompanied by a mental capacity assessment (MCA2) evidencing the patient lacks the capacity to make decisions for him or herself. Please refer to the Trust Mental Capacity Act Policy and Deprivation of Liberty Safeguards Policy for guidance Medication 16.1 Control of a patient s behaviour by chemical restraint (i.e. sedation) requires careful consideration. It must be clear that it is given in the patient s best interest or of those affected by his/her actions. This must be clearly evidenced and documented accordingly. This will be on a MCA2 should the patient lack capacity to consent. It must be reviewed prior to any and every subsequent dose given. Non-pharmacological interventions must be attempted first and documented All sedatives may cause delirium, especially those with anticholinergic side effects such as chlorpromazine. The use of sedatives and antipsychotics Page 11 of 18

12 should therefore be kept to a minimum. Many older patients with delirium have hypoactive delirium (quiet delirium) and do not require sedation. Early identification of delirium and prompt treatment of the underlying cause may reduce the severity and duration of delirium Medication may be required in the following situations: In order to carry out essential investigations, medication or prevent removal of life saving equipment under the mental capacity act To prevent individuals from endangering themselves or others To relieve distress in a highly agitated or hallucinating patient Under the advice of mental health practitioners for those patients refusing medication under mental health section Only when all other remedies have been attempted and as a last resort 16.4 Sedation must not be administered simply due to staff shortages. Sedation is likely to significantly increase length of stay and risk of complications. Hence one to one nursing is often not only more effective and appropriate, but more cost effective The aim of sedation should be to calm the individual and avoid over sedation. Hence challenging behaviour must be managed without the prescription of high doses or combinations of drugs, especially for people with dementia, the elderly and frail. Refer to the Trust Management of Delirium in Older People policy for guidance It must be recognised that challenging behaviour is often a person s only method of communication and we must seek to understand the message the person is trying to convey. Staff should monitor and examine behaviour using the Antecedant, Behaviour & Consequence chart (see Appendix A) If patients are requiring physical and chemical restraint it may be necessary to consider a Behavioural Support Plan (please refer to DoH guidance 2014). Advice should be sought from the Local Security Management Specialist to determine if this is indicated Learning Disability 17.1 People who behave in ways which are considered dangerous, socially inappropriate or disruptive can make special demands on the service. The behavioural challenges presented by a small number of adults and children with learning disabilities and/or autism, special educational needs or emotional and behavioural difficulties mean that we are presented with the challenge of responding to their needs in order to assisting them to lead valued lives in spite of their problematic behaviours Occasionally, the use of some form of physical intervention may be unavoidable. When a patient with Learning Disabilities (LD) requires medical assessment/investigation involving invasive procedures, which results in the use of planned physical interventions then there is a need to ensure that such Page 12 of 18

13 interventions are carried out within a legal and ethical framework that sets out explicit safeguards for the person with a learning disability and for staff Where indicated, clinicians have a responsibility to make a referral to the Learning Disabilities Clinical Nurse Specialist or the Elderly Assessment Team/Clinical Operational Managers if unavailable De-escalation Techniques The aim of de-escalation is to intervene before the person has the opportunity to display the undesirable behaviour, by diffusing the situation and thereby averting a crisis The primary focus is on early recognition and prevention and therefore clinicians have a responsibility to make an early referral to the Learning Disabilities Clinical Nurse Specialist in order that all reasonable adjustments can be made Where the Learning Disability CNS is unavailable contact the Elderly Assessment Team/Clinical Operational Managers or Community Learning Disability Services for further advice Training 18.1 Training (initial awareness) is delivered to staff in accordance at Trust Induction Restraint information will be included on Level 3 Dementia training, Risk Management, Conflict Resolution training, MCA and DOLS training. Specific training on breakaway techniques will be provided to staff identified in the Training Needs Analysis as working in an area where this is required. Full physical restraint techniques will only be provided to the Security/Porters. Training can be accessed via the Learning and Development Team Documentation 19.1 When any event of a restraint technique is used this should be documented in the patient s notes giving specific reference to the technique and the rationalisation for the method being used, i.e. breakaway; deflection; deescalation; physical; environmental; chemical; mechanical including whether this was planned or unplanned as well as the name of the person this has been escalated to A Clinical Incident (Datix) Risk Event form should be completed to report any incident of physical and/or chemical restraint Both the datix and patient notes should provide details on what communication and information the patient and their families (as appropriate) have received following restraint implementation. For further information on why this is essential please refer to the Trust s Being Open policy. Page 13 of 18

14 20.0 Post Incident Management 20.1 All staff should be involved in debriefing. The nurse in charge is responsible for ensuring this takes place The debriefing session should be facilitated by someone with appropriate experience & training Review of the incident should not be seen as an exercise to apportion blame Those involved should be given the opportunity to discuss their version of what happened The debriefing can be used to identify how things might be improved 20.4 Feelings should be acknowledged It should be understood that feeling emotional distress after an incident is a normal response Risk management measures should be identified to minimise or prevent recurrence of similar incidents An Incident Report should be produced for serious incidents, to facilitate action plans and review at Directorate level in accordance with the Incident Policy and the Serious Incident Requiring Investigation Policy Any damage to property should be repaired as soon as possible Damage to personal property should be recompensed as soon as possible i.e. damage to staff clothing, spectacles etc Counselling, Assistance and Compensation for Staff 21.1 Where a member of staff is suffering severe distress following an incident they should be allowed paid time off at the manager s discretion. The advice of Human Resources should be sought and a referral made to Occupational Health Counselling is available to all employees and can be accessed via Occupational Health or the psychotherapy team In some cases and at the discretion of the relevant line manager in consultation with Human Resources, employees shall be given the opportunity of suitable alternative employment within the Trust on a temporary or permanent basis The individual may be entitled to compensation through the Criminal Injuries Compensation Authority (CICA). You should report the incident to the police and contact the CICA without delay Staff may also choose to contact Victim Support. Page 14 of 18

15 21.6 Refer to the Support for Staff Involved in a Traumatic Incident, Compliant or Claim Policy Staff Exempt from assisting with restraint Staff who have been failed by a recognised instructor on a course provided by or commissioned by the Trust, until such time that they have successfully repeated the course. Staff who are pregnant. The employee should inform their line manager of their pregnancy as soon as possible. DO NOT wait for an incident to arise before declaring your pregnancy. Staff with a diagnosed medical condition which prevents them from undertaking restraint. Staff with a diagnosed medical condition which may worsen if they undertake restraint. Staff seeking exemption on medical grounds should be referred to Occupational Health for an assessment to support their claim Assistance from non-clinical staff and other agencies 23.1 Assistance from non-clinical staff such as porters and security guards or other agencies such as the police may be required. This should be sought as early as possible before a violent situation can escalate. Staff must liaise with the helpers as they arrive and be clear about what help is required from them Equality & Diversity 24.1 Black and Minority Ethnic groups (BME) can experience problems in health care as acknowledged by MIMHE report Inside Outside (2003) These problems may include an over-emphasis on institutional and coercive care. BME patients are more likely to be subject to prescription of anti-psychotic medication, restraint and seclusion There is evidence that supports the view that service providers over-predict dangerousness in black people: When assessing for risk of the disturbed/violent behaviour, care needs to be taken not to make negative assumptions based on ethnicity. Staff members should be aware that cultural morass may manifest as unfamiliar behaviour that could be misinterpreted as being aggressive. The assessment should be objective, with consideration being given to the degree which the perceived risk can be verified in line with NICE Guidance CG To summarise the points above for justification of the policy an equality impact assessment listed as appendix 1 of this policy Complaints 25.1 Any complaint made against staff as a result of violent incidents will be investigated under the Trust Complaints procedure. Staff are also advised to Page 15 of 18

16 consult their own defence organisation, professional association or trade union for advice Communication and Implementation 26.1 This policy will be launched in the Trust s Staff Focus news letter and made available to staff and the public on the Trust s intranet site and website The Local Security Management Specialist and the Adult Safeguarding Named Nurse will ensure that all Clinical Directors, Divisional Nurse Managers and Ward Sisters are informed of this policy Monitoring and Audit 27.1 Individual incidents will be reviewed by the appropriate clinical, nursing or Risk lead upon receipt to ensure that the management of incidents met the requirements of this policy A further measure of compliance will be continual communication with external stakeholders by the Health, Safety & Security Manager to ensure that all available endeavours are met Heads of Nursing are responsible for ensuring all incidents requiring methods of restraint are reported via the clinical incident reporting system. The Risk Management Team will provide quarterly figures to the Local Security Management Specialist and the lead for adult safeguarding for review The Local Security Management Specialist together with the lead for adult safeguarding will review these quarterly figures (27.3) in conjunction with completed Behavioural Support Plans and these will be presented annually to the Board within the annual security report References Human Rights Act 1998 Health and Safety at Work Act etc S2, S3 and S4 Management of Health and Safety at Work Regulations 1999 Reg 7. British Institute of Learning Disabilities Code of Practice (2006) BILD Physical Interventions: A Policy Framework (2008) DOH, (2002) Guidance for Restrictive Physical Intervention: How to provide safe services for people with learning disabilities and Autistic Spectrum Disorder Mental Health Act (2007) NICE Guidelines on Violence (2005) The Criminal Law Act (1967) Positive and Proactive Care: reducing the need for restrictive interventions DoH 2014 Page 16 of 18

17 Appendix 1 Equality Impact Assessment (EIA) Title of document being impact-assessed: Safer Restraint Policy Equality or human rights concern. (see guidance notes below) Does this item have any differential impact on the equality groups listed? Brief description of impact. How is this impact being addressed? Gender Equality Neutral The Trust strive to meet the same sex accommodation standards. The wards consist of single sex bays and all staff are aware that it is not acceptable to mix these bays. Bathrooms also have appropriate gender signs. Where risks have been highlighted patients can be allocated side rooms in order to ensure individuals are treated with dignity and respect. Race and ethnicity Disability It is recognised that people from black, minority ethnic groups are more likely to be subject to prescription of anti-psychotic medication, restraint and seclusion. Language may be seen as a barrier for some patients. It is recognised that people with cognitive impairment, learning disability; physical and sensory disability and/or mental health issues maybe more likely to have restraint (physical, environmental and chemical) applied. Monitoring will be undertaken by Lead Nurses within Divisions to ascertain if research findings match experiences within the Trust and submit evidence to Adult Safeguarding Named Nurse. Interpreters are made available when required either face to face or via language line. All staff attend in-house training courses on equality and diversity in order to raise awareness of cultural issues. All wards have a communication resource folder which includes easy read and picture mediums. The Trust promotes that all staff treat carers as an equal partner in the care of the patient. Monitoring will be undertaken by Lead Nurses within Divisions to ascertain if research findings match experiences within the Trust and submit evidence to Adult Safeguarding Named Nurse. The Elderly Assessment Team; Dementia CNS (RMN) and Learning Disability CNS (RN-LD) are available to offer advice to ensure consideration of restraint is as a last resort using a time limited approach in order to achieve effective harm reduction. Learning Disability CNS provides Staff training on Diffusion, Distraction and De-escalation techniques as well as providing advice on alternative methods of Communication and making reasonable adjustments. Part of the clinical role for the Learning Disability CNS (RN- LD) is to co-ordinate the patient with LD journey from preadmission through to post discharge. Page 17 of 18

18 Religion, faith and belief Sexual orientation Age Transgender people Equality Neutral Equality Neutral It is recognised that cognitive impairment and, physical disability is more prevalent in the elderly and people with learning disabilities and therefore these groups are more likely to have restraint (physical, environmental and chemical) applied. Equality Neutral All wards have a communication resource folder which includes easy read and picture mediums. The Trust promotes that all staff treat carers as an equal partner in the care of the patient. There is access to the chaplaincy team who are available to offer support and advice for staff, patients, and relatives and/or carers. It is possible to access multi-faith leaders when required. All staff attend in-house training courses on equality and diversity in order to raise awareness of cultural issues. Monitoring will be undertaken by Lead Nurses within Divisions to ascertain if research findings match experiences within the Trust and submit evidence to Adult Safeguarding Named Nurse. The Elderly Assessment Team; Dementia CNS (RMN) and Learning Disability CNS (RN-LD) are available to offer advice to ensure consideration of restraint is as a last resort using a time limited approach in order to achieve effective harm reduction. This policy is adult specific. The Trust does not condone restraining of children. Community based Specialist Children s services will offer flexible support which is personalised to the needs and circumstances of individual Families and Carers. All staff attend in-house training courses on equality and diversity in order to raise awareness of cultural issues. Social class Equality Neutral All staff attend in-house training courses on equality and diversity in order to raise awareness of cultural issues. Carers. Equality Neutral The Trust has an advocate from Action for Family Carers available to support relatives and or carers. The Trust promotes that all staff treat carers as an equal partner in the care of the patient. A Support for Carers Information Leaflet is available on request from LD CNS. Date of assessment: September 2014 Names of Assessor Sandra Morton Nance: CNS Learning Disabilities John McLellan: Equality & Diversity Advisor Page 18 of 18