High Risk Patients - Their Management at Broadmoor Hospital

Size: px
Start display at page:

Download "High Risk Patients - Their Management at Broadmoor Hospital"

Transcription

1 Policy: H4 High Risk Patients - Their Management at Broadmoor Hospital Version: H4/03 Ratified by: Broadmoor SMT Date ratified: December 2013 Title of originator/author: Clinical Director High Secure Services Title of responsible Director Executive Director of High Secure Services Date issued: 19 th May 2014 Review date: December 2015 or earlier if directions require Target audience: All staff at Broadmoor Hospital Disclosure Status B Can be disclosed to Patients and the Public Embedded Documents EIA/Sustainability Implementation Plan N/A G:\Trust Policies and Procedures\2011 & 20 West London Mental Health NHS Trust Page 1 of 22

2 Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 22

3 H4 - High Risk Patients - Their Management at Broadmoor Hospital Version Control Sheet Version Date Title of Author Status Comment H4/01 Sep 11 Clinical Director High Secure Services H4/02 Nov 11 Clinical Director - High Secure Services Draft Revised Policy to be presented to SMT Sep 2011 for approval to go to consultation. Revised following consultation process Ratified at Broadmoor SMT 25 November th July 2013 Re-issued to reflect Organisation and Department name changes. No changes to content. H4 / 03 October 2013 Clinical Director High secure Services Revised and updated as per periodic review For consideration at Broadmoor SMT October 2013 and subsequently consultation if required Approved at Broadmoor SMT, Dec 2013 subject to minor amendments. Issued on the Exchange West London Mental Health NHS Trust Page 3 of 22

4 H4 - High Risk Patients - Their Management at Broadmoor Hospital Content Page 1. Flowchart 5 2. Introduction 9 3. Scope Definition Responsibilities Systems & Recording The process for identifying high risk patients Managing high risk patients Monitoring telephone calls Locking a high risk patient in his room at night Reviewing patients High Risk status Incompatible patients Monitoring and review Training References Glossary of Terms/Acronyms Appendices: 1 High Risk Identification algorithm 2 Decision Tree & Management strategies 3 Procedure for identification 4 Notification form 5 Discontinuation form West London Mental Health NHS Trust Page 4 of 22

5 H4 - High Risk Patients - Their Management at Broadmoor Hospital 1.0 DECISION TREE FOR RISK MANAGEMENT OF HIGH RISK PATIENTS (including decisions about locking them in their rooms at night to manage risk) West London Mental Health NHS Trust Page 5 of 22

6 Management Strategies Supporting the Decision Making for the Risk Management of High Risk Patients Box 1 High Risk Suicide / Self Harm specific treatment focussed on suicide/self harm for the individual reduced access to risk items enhanced levels of observation (refer to the enhanced engagement & observation policy) enhanced emotional support occasionally a suicidal/self harming patient is also violent and assaultative and in this situation the patient may be locked in their room at night in conjunction with enhanced levels of observation 3 Box 2 High Risk of Being Assaulted enhanced levels of observation (refer to the hospital s observation policy) geographical manipulation i.e. consider moving the patient away from individual(s) posing risk or restrict access to such individual(s) voluntary locking into room for periods of day or night. Many of these patients will co-operate with measures to enhance their safety, including agreeing to remain in their rooms for specified periods. But consideration must be given to the patient s ability / willingness to protect themselves. Voluntary exit from rooms should be maintained if possible but locking into room for identified high risk periods only (e.g. night time) 3 may be considered Box 3 High Risk of Escape locking into room for identified high risk periods (e.g. night time) 2 3 geographical manipulation i.e. consider moving the patient to a higher staffed location, or restrict access to a more confined area of the ward1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits1 enhanced monitoring of mail and telephone calls 1 enhanced precautions for leave of absence from hospital (refer to policy) 1 enhanced escorting (to be specified precisely) for movement within hospital s secure perimeter 1 enhanced levels of observation 1 (refer to the hospital s observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 1,2,3 etc: see notes page 8 West London Mental Health NHS Trust Page 6 of 22

7 Box 4 High Risk of Immediate Harm to Others (continued) locking into room until judged safe to end such locking in in accordance with seclusion policy locking into room for identified high risk periods only (e.g. night time) 2 3 Longer term segregation should be considered if the risk is continuous and other management strategies are not considered sufficient to manage the risk geographical manipulation i.e. consider moving the patient to a higher staffed location or away from provocation, or restrict access to a more confined area of the ward 1 enhanced levels of observation 1 (refer to the enhanced engagement & observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits 1 Box 5 High Risk of Subverting Security locking into room for identified high risk periods (e.g. night time) 2 3 geographical manipulation i.e. consider moving the patient to a higher staffed location, or restrict access to a more confined area of the ward1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits 1 enhanced monitoring of mail and telephone calls 1 enhanced precautions for leave of absence from hospital (refer to policy) 1 enhanced escorting (to be specified precisely) for movement within hospital s secure perimeter1 enhanced levels of observation 1 (refer to the hospital s observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 Box 6 Corridor Supervision at Night Corridor supervision can be enhanced by the use increased levels of staff and this should be considered as part of risk management. Consideration should also be given to deploying technology to enhance corridor supervision. Appropriate technology would include CCTV monitoring of corridors, Video motion detectors, infra red detectors, and door alarms. These can all be used to give early warning of untoward patient movement. West London Mental Health NHS Trust Page 7 of 22

8 (continued) NOTE 1 if these measures do not reduce the risk of escape in the view of the clinical team and security department, then locking in for high risk periods will be necessary (see Broadmoor Hospital Night Time Confinement Policy and paragraph 33 & 35 of the Directions). NOTE 2: a decision not to lock a patient in his room at night in accordance with the protocol should be clearly documented in the notes. NOTE 3: locking patients in their rooms at night should be supervised (see Broadmoor Hospital Night Time Confinement Policy ) West London Mental Health NHS Trust Page 8 of 22

9 2. INTRODUCTION 2.1 The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 recognise there is a group of patients in the High Security Hospitals who may pose a higher risk than the majority and therefore, require increased levels of security. The Directions require that increases in both physical and procedural security be considered for those patients identified as high risk. 2.2 This policy provides a structured algorithm for the identification and management of patients identified as significantly higher risk than the majority of high secure patients. 2.3 The purpose of this document is to describe the procedures whereby these High Risk patients are identified and the enhanced procedural security arrangements that they may be subject to. 3. SCOPE This policy is applicable to all clinical staff working in Broadmoor High Security Hospital. 4. DEFINITIONS 4.1 For the purposes of this specific policy the term ' "High Risk" patients' refers to those patients who have been assessed as High Risk in accordance with direction 33 of The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 (herein referred to as the Directions ). 4.2 This policy will be applied to all patients, enabling the identification of those who present high levels of risk in specific areas and the safe management of the risks they present. 5. RESPONSIBILITIES 5.1 Chief Executive The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations. 5.2 Executive Director of High Secure Services The Executive Director of High Secure Services is the responsible Director for this policy and has overall responsibility for ensuring that policy and practice within the High Secure Service adheres to the legislative requirements of the High Security Psychiatric Services Directions (2013) and the Clinical Security Framework. West London Mental Health NHS Trust Page 9 of 22

10 5.3 Clinical Director High Secure Services The Clinical Director is accountable to the Director of High Secure Services in relation to this policy for ensuring that the effectiveness of the policy is monitored through the High Risk Monitoring Group and for conducting annual audits of compliance with the policy and its effectiveness. The Clinical Director is also responsible for ensuring the maintenance of a contemporary High Risk Register of identified patients as defined by this policy. 5.4 Responsible Clinicians / Clinical Teams Clinical Teams are responsible for ensuring that every patient under their care is appropriately assessed using the prescribed tools in this policy and in line with the minimum time intervals described in this policy (or more frequently as indicated), and where those patients are identified as high risk that appropriate management plans are documented and followed in order to address the identified areas of risk. 5.5 All Staff This policy applies to all staff working within Broadmoor Hospital 6. SYSTEMS & RECORDING When patient assessed and decision is high risk Notification form completed Where recorded on High Risk database maintained by PA to Clinical Director Recorded by - Security Liaison Nurse When recorded notified when decision made Circulated to: - Clinical lead Site management Control room Clinical director Deputy Director of Nursing Director of Security West London Mental Health NHS Trust Page 10 of 22

11 7. THE PROCESS FOR IDENTIFYING "HIGH RISK" PATIENTS 7.1 Clinical Teams will use the operational pro-forma (Appendix 1) to identify those patients who should be considered as high risk. As a minimum, this should be undertaken before admission, (or within 6 hours of admission if it is not practicable to do so before) at every CPA, on transfer between wards and when a significant untoward incident* requires reassessment of risk. *including: Where a patient commits or threatens to commit an act of self harm, Where a patient is the victim of actual or threatened violence, Where a patient has used or threatened violence towards another patient, or a member of staff, Any act, or the receipt of any intelligence, relating to escape or unauthorised absence of the patient, or Any action, or threat of action, by the patient which would subvert security, In relation to a risk management plan, by the dates specified in the plan 7.2 A comprehensive multi-disciplinary risk assessment will be undertaken and recorded to ensure that all risks are identified. These fall into five main categories: Immediately harming others Committing suicide or self harming; Being assaulted Escaping Subverting safety and security, or organizing action to subvert safety or security 7.3 Any type of risk may range in magnitude from minimal to high We have attempted to operationalise the identification of high risk using the pro-forma at appendix 1. This has a scoring system which is inclusive of both historical and current evidence to improve consistency in identifying the level of risk in each category (see embedded presentation document below, for further details on use). IDENTIFYING.ppt 7.4 The Clinical Team (including the Security Liaison Nurse) must consider whether each patient presents an identified risk of harmful behaviour which is greater than can be managed by the ward s regime which normally contains or manages the risk(s) presented by its other patients. 7.5 Associated management strategies (appendix 2) have been designed to standardise the development of risk management plans for each identified risk. The use of this and the decisions made will be documented in the patient s MDT notes. 7.6 Appendix 3 of this policy outlines the procedure for notifying relevant parties of the identification of "high risk" patients and appendix 4 contains the appropriate notification form. West London Mental Health NHS Trust Page 11 of 22

12 8. MANAGING "HIGH RISK" PATIENTS 8.1 The management of the identified high risk patients must include the development of a multi-disciplinary High Risk management Plan (this is incorporated in the assessment tool at Appendix 1), as a key component of risk reduction is the effective treatment of the patient s mental disorder. Management strategies to support the decision making for the care and management of high risk patients are contained in Appendix The management plan for each identified risk may include enhanced security procedures e.g. enhanced mail monitoring (refer to policy M6 Patients Mail & Postal Packets), increased supervision of visits, stricter monitoring (recording) of telephone calls (refer to T2 Telephone Calls by Patients), locking the patient in their room at night (refer to Broadmoor Hospital Night Time Confinement Policy). 8.3 Where a patient is identified as high risk in one or more of the above categories the Security Liaison Nurse must be present in the meeting drawing up the resulting risk management plan(s). 9 MONITORING TELEPHONE CALLS 9.1 If a patient is assessed, by the clinical team to be at high risk of escaping or subverting safety and security or organising action to subvert safety or security, or where there is a need to protect the safety of the patient (or others), the Clinical Team shall consider including in the risk management plan, arrangements to monitor the patient s telephone calls. 9.2 Details of the procedures to be followed for recording and monitoring patients telephone calls and the patient s right to have the decision reviewed are included in the Trust s policy Telephone Calls by Patients. 10 LOCKING A "HIGH RISK" PATIENT IN HIS ROOM AT NIGHT 10.1 One of the enhanced security procedures that may be appropriate for managing high risk patients is to lock them in their room for identified high-risk periods only (e.g. at night). The decision to authorise locking-in must be recorded in the High Risk management plan and any period of locking in will be recorded in accordance with the Broadmoor Hospital Night Time Confinement Policy which includes Procedural Guidelines for the care of a "high risk" patient locked in their room. 11 REVIEWING PATIENTS' "HIGH RISK" STATUS 11.1 For Each Individual Patient Review dates will be agreed and documented for each identified risk and its associated management plan. In some instances the review frequency will be determined by the policies governing the specific interventions deployed. West London Mental Health NHS Trust Page 12 of 22

13 11.2 The risk assessment protocol (appendix 1) will be used to assess the patient before, or on admission and, thereafter, as a minimum at each CPA review but frequencies must be set for individual patients in the light of their clinical condition and security intelligence. A further risk assessment will be required when a significant incident* occurs and similarly, events leading to a change of ward will also trigger a review of risk acknowledging either reduced risk if the ward move has been progressive or increased risk if the move has been retrogressive. *including: Where a patient commits or threatens to commit an act of self harm, Where a patient is the victim of actual or threatened violence, Where a patient has used or threatened violence towards another patient, or a member of staff, Any act, or the receipt of any intelligence, relating to escape or unauthorised absence of the patient, or Any action, or threat of action, by the patient which would subvert security, In relation to a risk management plan, by the dates specified in the plan 11.3 In implementing any enhanced security procedures for a high risk patient, it is important to have clearly prescribed periods for them, and agreed review dates. However, it is necessary for the Clinical Team to define, and be alert to, any triggers that may indicate the need for a review, in advance of the agreed date As good practice, details of all enhanced security measures should be shared (as far as is appropriate) with the patient, ensuring they understand the reasons for their implementation and the arrangements and timescales for their review If it is deemed upon review the patient no longer requires "high risk" status then the "discontinuation of high risk status" form must be completed by the Clinical team (Appendix 5). When the "high risk" status has been reviewed and discontinued all other agencies that were aware of the patients "high risk" status must be informed. 12. INCOMPATIBLE PATIENTS 12.1 On occasion Clinical Teams may identify that two (or more) patients are incompatible. Meaning that, at the present time, they pose such a risk / are at such risk to / from identified individual(s) within the Hospital that the Clinical Team(s) decide that contact between the identified individuals must be prevented, or safely managed*. (*requiring interventions that extend beyond the normal operational procedures of a ward/area) 12.2 Placing a patient(s) on the incompatibility list must not be viewed as a resolution of the identified problem and must prompt interventions designed to address the identified issue(s) The process for signposting individuals incompatibility with each other is to add their names to the incompatibility list. In order to do this the Responsible Clinician, Clinical Nurse Manager, or Security Liaison Nurse should inform the Security West London Mental Health NHS Trust Page 13 of 22

14 Intelligence Office, by submitting a Security Information Report detailing the reasons why the patient(s) need to be added to the list and if contact between the patients can be managed or should be prevented In some cases (i.e. where a patient has disclosed fear of another patient or having been victimised), whether the patient explicitly requests it or not, the CTM may decide that the information should be kept confidential from the third party identified by the patient. In this case this must be clearly indicated in the SIR that is submitted, in order that the Security Intelligence Office can annotate the incompatibility list indicating that this information is not to be disclosed The Security intelligence Office maintains a contemporary list of all incompatibilities within the Hospital. The list is published on the exchange Possible reasons for patients to be added to the incompatibility list include the following: Threats of violence to an identified other Actual violence Evidence of having collaborated to subvert safety or security, or information that suggests collaboration Information that suggests others are at risk Bullying Predatory behaviour Inappropriate sexual activity It should be noted that the above list is, by no means, exhaustive. It should also be noted that evidence of the above behaviours does not mean that a patient should be automatically added to the incompatibility list, but it is an option that the Clinical Team may wish to consider as a short term measure for managing the identified risk(s) When incompatibility issues are identified Clinical Teams must consider all aspects of the patients care and management including High Risk assessment / management, care planning and where appropriate, safeguarding vulnerable adults Once a patient has been added to the incompatibility list Clinical Teams should seek to identify appropriate methods for resolution, i.e. mediation, 1-1 support, safeguarding vulnerable adults interventions, High Risk management plan, etc The decision to place a patient on the incompatibility list must be made by the Clinical Team and reviewed as a minimum at each CPA where the default is that the incompatibility lapses unless actively reinstated by the Team. The Team must ensure that appropriate steps are made to remove patients from the list wherever the risks have been mitigated to levels that can be managed by the clinical teams. The Security Intelligence Office must be informed of any changes in order that the incompatibility list may be updated. Where it is decided to remove a patient from the incompatibility list a Security Information Report should be submitted detailing how the original issue has been resolved Where patients from different wards have been placed on the incompatibility list, all of the appropriate Clinical Teams must be in agreement for the names to be removed from the list. West London Mental Health NHS Trust Page 14 of 22

15 13. MONITORING AND REVIEW 13.1 The High Risk Register will be reviewed monthly in the Directorate Management Team meetings by the Service Director and the Clinical Lead who may seek assurance from the Responsible Clinician, Ward Manager and Security Liaison Nurse regarding the status of any patient The High Risk Monitoring Group will meet quarterly to review the number of patients within the Hospital who are (or have been, during the period in question) designated High Risk, and a summary of the risk(s) they pose (or have posed). The group will have oversight take an overview of the distribution of high risk patients around the hospital and consider any new security information which has a bearing on the safe management of wards The Clinical Director will report to the Performance Manager at NTDA in accordance with the performance review framework for High Secure Hospitals The High Risk Identification Framework will be subject to monitoring across the three High Secure Hospitals at the Clinical and Security Practice Forum The High Risk Monitoring Group will also consider any patients classified at exceptionally high risk of escape or causing harm to others for all Leave of Absences. - See Leave of Absence Policy L2 paragraph (j). Depending on the nature of the leave of absence, Thames Valley Police may deploy and manage police resources in addition to those identified within the patient High Risk Management Plan Compliance with this policy is subject to external audit on an annual basis by the National Offender Management Service (NOMS) audit team. 14. TRAINING Role Specific training is provided for Responsible Clinicians and Security Liaison Nurses as part of Secondary Induction 15. REFERENCES This policy should be read in conjunction with the following: The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 (and accompanying Guidance) National & Local Clinical Security Frameworks Leave of Absence Policy L2 (paragraph (j) Telephone Calls by Patients at Broadmoor T2 Night Time Confinement Broadmoor N5 Patients Mail at Broadmoor M6 West London Mental Health NHS Trust Page 15 of 22

16 16. GLOSSARY OF TERMS/ACRONYMS ACRONYMS CPA MDT CCTV NOMS CTM NHS SMT SIR NTDA DESCRIPTION Care Plan Approach Multidisciplinary Team Closed-circuit Television National Offenders Management Service Clinical Team Manager National Health Service Senior Management Team Security Incident Report National trust Development Authority West London Mental Health NHS Trust Page 16 of 22

17 HIGH SECURE HOSPITAL HIGH RISK REGISTER Appendix 1 PATIENT NAME: RIO NUMBER: MHA SECTION: WARD: DATE: REASON FOR UPDATE: DOB: NHS NUMBER: DOA: RC: CPA / WARD TRANSFER / RECENT EVENT / ADMISSION A patient should be placed on the high risk register if there is historical evidence (scoring 1) as well as current evidence (scoring 1), i.e. in the last six months, of significant risk. Current evidence of risk may be due to (a) chronic risks that have not reduced (e.g. because pharmacological or psychological interventions have not been effective) or (b) new behaviours. In exceptional circumstances current evidence alone, if sufficiently serious, may warrant inclusion on to the high risk register by scoring 2. IMMEDIATELY HARMING OTHERS1 (consider: sex offending; arson, hostage taking; harm to children; weapon use) Historical Evidence: Score (0,1) Current Evidence: Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN COMMITTING SUICIDE OR SELF-HARM Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN 1 If a patient is held under terrorist legislation or detained under suspicion of terrorist activity, they are automatically placed on the high risk register (i.e. scoring 2) as immediate harm to others. Such patients are kept on the high risk register until the clinical team are directed otherwise. West London Mental Health NHS Trust Page 17 of 22

18 BEING ASSAULTED / RISK FROM OTHERS (consider: very high profile patients) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN ESCAPING (consider: escaping and absconding) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN SUBVERTING SECURITY (includes: concerted indiscipline) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN Review Date Changes or Amendments Signed by Responsible Clinician on behalf of MDT West London Mental Health NHS Trust Page 18 of 22

19 APPENDIX 2 "HIGH RISK" PATIENTS THEIR MANAGEMENT IN BROADMOOR HOSPITAL PROCEDURE FOR IDENTIFYING "HIGH RISK" PATIENTS The following procedure will be applied in identifying all high risk patients within the hospital. 1 Introduction 1.1 The Clinical Team should review all patients as part of the regular Clinical Team Meeting and identify those patients who pose a high risk (see Policy Section 2). These fall into 5 main categories: Risk of harm to self (suicide or self injury) Risk of harm to others Risk of escape Risk of being assaulted (ie high vulnerability) Risk of subverting safety and security, or organizing action to subvert safety or security 1.2 The purpose of this document is to set out the process of notification to relevant parties of any patient identified as "high risk" as per this policy in order to ensure there is an up-to-date central record of all high risk patients in the hospital. 2 Notification 2.1 When a patient has been assessed as high risk by their Clinical Team. This decision will be Recorded in the patient s clinical notes Communicated by to the Clinical Lead Site Management Control Room Clinical Director 2.2 The Responsible Clinician (or delegated member of the clinical team) will complete the attached notification form (appendix 3) and send it to the: Clinical Lead Site Management Control Room Clinical Director 2.3 The P.A to the Medical Director will maintain a hospital-wide list of "high risk" patients, which will be maintained up-to-date as amendments occur. This information will be copied to the Director of High Secure Services and the Director of Security. West London Mental Health NHS Trust Page 19 of 22

20 Appendix 3 "HIGH RISK" PATIENTS THEIR MANAGEMENT IN BROADMOOR HOSPITAL "HIGH RISK" PATIENTS NOTIFICATION FORM Ward Responsible Clinician Patient Identified risk category(s) Care plan(s) in place to address identified risk(s)? yes / no Telephone monitoring required? yes / no Patient's room to be locked at night? yes / no Review date When completed, please forward to Clinical Director Site Management Control Room Security Liaison Mental Health Act Office MDT Notes West London Mental Health NHS Trust Page 20 of 22

21 Appendix 4 DISCONTINUATION OF "HIGH RISK" STATUS FORM Ward Responsible Clinician Patient Commencement date of High Risk Status Date discussed at CTM Date Discontinued Form Completed by RC or appointed Deputy: Signature: Name (PRINT): Date: When completed please forward to: Clinical Director Site Management Office Control Room MDT File (Section 4) Service Director Mental Health Act Office West London Mental Health NHS Trust Page 21 of 22

22 APPENDIX 5 POLICY / PROCEDURE: MONITORING TEMPLATE H4 - High Risk Patients - their Management at Broadmoor Hospital. MONITORING TEMPLATE WHO (which staff/team/dept) National Offender Management Service (NOMS) - external High Risk Monitoring Group (HRMG) - clinical director, dep dir nursing, director of security WHAT / TYPE (Audit/process/report - list details) AUDIT - standards and baseline targets to be agreed by the 3 HSHs Review the number & distribution of patients who have been placed on the high risk register, including a review of a summary of the risks they do/have posed. HOW MANY (No of records/%) No. of records to be agreed by 3 HSHs Summaries of all patients currently on the high risk register FREQUENCY (monthly/quarterly/annual) Annual Monthly WHERE REVIEWED (which meeting/committee) Security Committee HSS SMT Trust Board Safety & Safeguarding Governance Group OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Action plans are prepared by the Director of Security / Director of High Secure Services and submitted to the Trust Board HRMG may recommend action where the identification of patients appears anomalous, where distribution of high risk patients needs to be addressed, or where policy is being inconsistently applied. West London Mental Health NHS Trust Page 22 of 22

Policy: A4 Alcohol and Illicit Drugs Procedure (Broadmoor Hospital only)

Policy: A4 Alcohol and Illicit Drugs Procedure (Broadmoor Hospital only) Policy: A4 Alcohol and Illicit Drugs Procedure (Broadmoor Hospital only) Policy relates to: D2 Dual Diagnosis policy Version: A4/08 Ratified by: Policy Review Group Date ratified: 24 th September 2015

More information

Policy: I3 Informal Patients

Policy: I3 Informal Patients Policy: I3 Informal Patients Version: I3/05 Ratified by: High Secure Senior Management Team Date ratified: 25 th April 2013 Title of Author: Executive Director of High Secure Services Title of responsible

More information

West London Forensic Services Handcuffs Policy

West London Forensic Services Handcuffs Policy Policy: H5SF West London Forensic Services Handcuffs Policy Version: H5SF / V01 Ratified by: Trust Management Team Date ratified: 11 th September 2013 Title of Author: Head of Women s Forensic Services

More information

Informing Patients of their Rights under Section 132

Informing Patients of their Rights under Section 132 Policy: I9 Informing Patients of their Rights under Section 132 Version: I9/05 Ratified by: Trust Management Team Date ratified: 12 June 2013 Title of Author: MHA Office / Health Records Manager Title

More information

Reports Protocol for Mental Health Hearings and Tribunals

Reports Protocol for Mental Health Hearings and Tribunals Reports Protocol for Mental Health Hearings and Tribunals Reports Protocol for Mental Health Hearings and Tribunals Document Type Clinical Protocol Unique Identifier CL-037 Document Purpose This policy

More information

Policy Document Control Page

Policy Document Control Page Policy Document Control Page Title: Section 17 (Leave of Absence) Policy Version: 9 Reference Number: CL7 Supersedes Supersedes: Section 17 (Leave of Absence) Policy V8 Description of Amendment(s): Updated

More information

Central Alerting System (CAS) Policy

Central Alerting System (CAS) Policy Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray

More information

Policy for the use of Leave under Section 17 of the Mental Health Act 1983 (as amended) Version: 9

Policy for the use of Leave under Section 17 of the Mental Health Act 1983 (as amended) Version: 9 SH CP 52 Policy for the use of Leave under Section 17 of the Mental Health Act 1983 (as amended) Version: 9 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: Policy for

More information

Open Door Policy (replacing policy no. 030/Clinical)

Open Door Policy (replacing policy no. 030/Clinical) A member of: Association of UK University Hospitals Open Door Policy (replacing policy no. 030/Clinical) THIS POLICY IS CURRENTLY UNDER REVIEW WITH THE POLICY AUTHOR POLICY NUMBER 138/Clinical POLICY VERSION

More information

Policy: L5. Patients Leave Policy (non Broadmoor) Version: L5/01. Date ratified: 8 th August 2012 Title of originator/author:

Policy: L5. Patients Leave Policy (non Broadmoor) Version: L5/01. Date ratified: 8 th August 2012 Title of originator/author: Policy: L5 Patients Leave Policy (non Broadmoor) Version: L5/01 Ratified by: Policy Review Group Date ratified: 8 th August 2012 Title of originator/author: Consultation Psychiatrist Title of responsible

More information

Independent Investigation Action Plan for Mr L STEIS Ref No: 2014/7319. Report published: NHE to complete

Independent Investigation Action Plan for Mr L STEIS Ref No: 2014/7319. Report published: NHE to complete Independent Investigation Action Plan for Mr L STEIS Ref No: 2014/7319 Statement from Oxleas NHS Foundation Trust The Trust would like to offer sincere condolenses to the family and friends of Mr Parsons.

More information

Document Title Clinical Risk Assessment and Management Policy. Electronic Systems Development & Training Consultant Risk and Assurance Facilitator

Document Title Clinical Risk Assessment and Management Policy. Electronic Systems Development & Training Consultant Risk and Assurance Facilitator Document Title Clinical Risk Assessment and Management Policy Document Description Document Type Policy Service Application Trust Wide Version 1.2 Policy Reference no. POL 025 Lead Author(s) Name Bob Yardley

More information

Continuing Healthcare Policy

Continuing Healthcare Policy Continuing Healthcare Policy 1 SUMMARY This policy describes the way in which Haringey Clinical Commissioning Group (HCCG) will make provision for the care of people who have been assessed as eligible

More information

SECTION 17 LEAVE POLICY MENTAL HEALTH ACT 1983

SECTION 17 LEAVE POLICY MENTAL HEALTH ACT 1983 SECTION 17 LEAVE POLICY MENTAL HEALTH ACT 1983 Version: 3 Ratified by: Senior Managers Operational Group Date ratified: July 2014 Title of originator/author: Mental Health Legal Strategies Lead Title of

More information

Plymouth Community Healthcare CIC. Observation Policy ( Mental Health Wards and Plymbridge ) Version 2.3

Plymouth Community Healthcare CIC. Observation Policy ( Mental Health Wards and Plymbridge ) Version 2.3 Plymouth Community Healthcare CIC Observation Policy ( Mental Health Wards and Plymbridge ) Version 2.3 Notice to staff using a paper copy of this guidance The policies and procedures page of Healthnet

More information

Non Attendance (Did Not Attend-DNA ) Policy. Executive Director of Nursing and Chief Operating Officer

Non Attendance (Did Not Attend-DNA ) Policy. Executive Director of Nursing and Chief Operating Officer Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Non Attendance (Did Not Attend-DNA) NTW(C)06 Executive Director of Nursing and Chief Operating Officer Ann Marshall

More information

PROVISION OF NORTH CUMBRIA FORENSIC OUTREACH CLINICS FOR CUMBRIA PARTNERSHIP NHS FOUNDATION TRUST

PROVISION OF NORTH CUMBRIA FORENSIC OUTREACH CLINICS FOR CUMBRIA PARTNERSHIP NHS FOUNDATION TRUST PROVISION OF NORTH CUMBRIA FORENSIC OUTREACH CLINICS FOR CUMBRIA PARTNERSHIP NHS FOUNDATION TRUST Document Summary To ensure that practitioners within Cumbria Partnership NHS Foundation Trust are aware

More information

VIP Visitors Policy. Purpose of Agreement. Document Type. Policy SOP Guideline. Version Version 1. Operational Date July 2015

VIP Visitors Policy. Purpose of Agreement. Document Type. Policy SOP Guideline. Version Version 1. Operational Date July 2015 VIP Visitors Policy Please be aware that this printed version of the Policy may NOT be the latest version. Staff are reminded that they should always refer to the Intranet for the latest version. Purpose

More information

Regional Guideline on the Use of Observation and Therapeutic Engagement in Adult Psychiatric Inpatient Facilities in Northern Ireland

Regional Guideline on the Use of Observation and Therapeutic Engagement in Adult Psychiatric Inpatient Facilities in Northern Ireland Regional Guideline on the Use of Observation and Therapeutic Engagement in Adult Psychiatric Inpatient Facilities in Northern Ireland November 2011 1 Contents 1. Introduction 3 2. Aims of Guideline 4 3.

More information

Visiting Celebrities, VIPs and other Official Visitors

Visiting Celebrities, VIPs and other Official Visitors Visiting Celebrities, VIPs and other Official Visitors Who Should Read This Policy Target Audience Healthcare Professionals Executive Team Version 1.0 May 2016 Ref. Contents Page 1.0 Introduction 4 2.0

More information

Hospital Discharge and Transfer Guidance. Choice, Responsiveness, Integration & Shared Care

Hospital Discharge and Transfer Guidance. Choice, Responsiveness, Integration & Shared Care Hospital Discharge and Transfer Guidance Choice, Responsiveness, Integration & Shared Care Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique

More information

SM-PGN 01- Security Management Practice Guidance Note Closed Circuit Television (CCTV)-V03

SM-PGN 01- Security Management Practice Guidance Note Closed Circuit Television (CCTV)-V03 Security Management Practice Guidance Note Closed Circuit Television (CCTV)-V03 Date Issued Issue 7 Sep 17 Issue 8 Dec 17 Issue 9 Mar 18 Planned Review September- 2018 SM-PGN 01- Part of NTW(O)21 Security

More information

MULTIDISCIPLINARY MEETINGS FOR COMMUNITY HOSPITALS POLICY

MULTIDISCIPLINARY MEETINGS FOR COMMUNITY HOSPITALS POLICY MULTIDISCIPLINARY MEETINGS FOR COMMUNITY HOSPITALS POLICY (To be read in conjunction with Handover Policy) Version: 3 Ratified by: Date ratified: August 2015 Title of originator/author: Title of responsible

More information

ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS

ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS ALLOCATION OF RESOURCES POLICY FOR CONTINUING HEALTHCARE FUNDED INDIVIDUALS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE Date of Issue:- Version

More information

Mental Health Commission Rules

Mental Health Commission Rules Mental Health Commission Rules Reference Number: R-S69(2)/02/2006 RULES GOVERNING THE USE OF SECLUSION AND MECHANICAL MEANS OF BODILY RESTRAINT 1 st November 2006 PREAMBLE Section 69(2) of the Mental Health

More information

Lone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead

Lone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead Document level: Trustwide (TW) Code: GR33 Issue number: 3 Lone worker policy Lead executive Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead 01244 397618

More information

Section 136: Place of Safety. Hallam Street Hospital Protocol

Section 136: Place of Safety. Hallam Street Hospital Protocol MENTAL HEALTH DIVISION Section 136: Place of Safety Hallam Street Hospital Protocol 1. Introduction 2. Purpose 3. Section 136: Place of safety 4. Exclusion Criteria 5. Reception at Place of Safety 6. Initial

More information

HILLSROAD SIXTH FORM COLLEGE. Safeguarding Policy. Date approved by Corporation: July 2017

HILLSROAD SIXTH FORM COLLEGE. Safeguarding Policy. Date approved by Corporation: July 2017 HILLSROAD SIXTH FORM COLLEGE Safeguarding Policy Date approved by Corporation: July 2017 Interim update with non-substantive changes approved by the Principal March 2016 Post of member of staff responsible:

More information

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss

More information

Informal Patients to take Leave from Adult Mental Health Inpatient Wards. Standard Operating Procedure

Informal Patients to take Leave from Adult Mental Health Inpatient Wards. Standard Operating Procedure Informal Patients to take Leave from Adult Mental Health Inpatient Wards Standard Operating Procedure DOCUMENT CONTROL: Version: 1 Ratified by: Quality Committee Date ratified: 16 June 2016 Name of originator/author:

More information

Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy

Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy SUPERVISED COMMUNITY TREATMENT AND COMMUNITY TREATMENT ORDERS (S17(A)) POLICY Document Type Policy Unique Identifier CL-010

More information

NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST. PATIENT ACCESS MANAGEMENT POLICY (Previously known as Waiting List Management Policy) Documentation Control

NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST. PATIENT ACCESS MANAGEMENT POLICY (Previously known as Waiting List Management Policy) Documentation Control NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST PATIENT ACCESS MANAGEMENT POLICY (Previously known as Waiting List Management Policy) Documentation Control Reference CL/CGP/026 Approving Body Senior Management

More information

Christopher Newport University

Christopher Newport University Christopher Newport University Policy: Campus Violence Prevention Policy Policy Number: 1055 Executive Oversight: President s Office, Chief of Staff Contact Office: Director of Human Resources Vice President

More information

APPROVED CLINICIAN (AC) POLICY FOR MEDICAL STAFF

APPROVED CLINICIAN (AC) POLICY FOR MEDICAL STAFF APPROVED CLINICIAN (AC) POLICY FOR MEDICAL STAFF Version: 1 Ratified by: Date ratified: August 2015 Title of originator/author: Title of responsible committee/group: Date issued: August 2015 Review date:

More information

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed:

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed: Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Cleaning Policy NTW(O)71 James Duncan Deputy Chief Executive / Executive Director of Finance Steve Blackburn Deputy

More information

Mental Health Commission

Mental Health Commission Code of Practice Code of Practice on the Use of Physical Restraint in Approved Centres Issued Pursuant to Section 33(3)(e) of the Mental Health Act 2001. October 2009 VISION Working Together for Quality

More information

Performance and Quality Committee

Performance and Quality Committee Title: NHS Continuing Health Care Choice Policy (addendum to Cornwall Wide Patient Choice, Equity and Fair Access Policy) Developed by: Document type: Policy library: NHS Kernow Policy Policies Sub Section:

More information

Safeguarding & Wellbeing Policy

Safeguarding & Wellbeing Policy Safeguarding & Wellbeing Policy 4.0 June 17 June 19 (unless an earlier review is required by legislative changes) All Midland Staff, Contractors and Volunteers Rebekah Newton, Director of Retirement Living

More information

Policy: P15 Physical Healthcare Policy

Policy: P15 Physical Healthcare Policy Policy: P15 Physical Healthcare Policy Version: P15/04 Ratified by: Trust Management Team Date ratified: 15 th April 2015 Title of originator/author: Director of Primary Care Title of responsible Director

More information

Executive Director of Nursing and Chief Operating Officer

Executive Director of Nursing and Chief Operating Officer Document Title Arrangements for Managing Patients Mental and Physical Health Needs across NTW and the Acute Hospital Trusts Reference Number Lead Officer Author(s) (name and designation) Ratified by NTW(C)15

More information

Child Protection/Safeguarding Policy Lettings Policy E-Safety Policy Fire Safety Manual First Aid Policy. Minibus Policy Physical Intervention Policy

Child Protection/Safeguarding Policy Lettings Policy E-Safety Policy Fire Safety Manual First Aid Policy. Minibus Policy Physical Intervention Policy Page 1 of 12 Document Title Security Policy Current Version V1-09/16 Authors Kathrin Williams, Business Manager Chris Teague, Premises Manager Related Policies Administration of Medicines Policy Child

More information

THE STATE HOSPITALS BOARD FOR SCOTLAND. The Care Programme Approach (CPA) A policy for the care and treatment planning of patients.

THE STATE HOSPITALS BOARD FOR SCOTLAND. The Care Programme Approach (CPA) A policy for the care and treatment planning of patients. THE STATE HOSPITALS BOARD FOR SCOTLAND The Care Programme Approach (CPA) A policy for the care and treatment planning of patients. Policy Reference Number Lead Author Contributing Authors CP12 Issue: 2

More information

ISLE OF MAN MENTAL HEALTH REVIEW TRIBUNAL GUIDANCE

ISLE OF MAN MENTAL HEALTH REVIEW TRIBUNAL GUIDANCE ISLE OF MAN MENTAL HEALTH REVIEW TRIBUNAL GUIDANCE Issued by the Chairmen of the Isle of Man Mental Health Review Tribunal on 19 June 2017 after Consultation with the High Bailiff, HM AG for the IoM, IoM

More information

Wandsworth CCG. Continuing Healthcare Commissioning Policy

Wandsworth CCG. Continuing Healthcare Commissioning Policy Wandsworth CCG Continuing Healthcare Commissioning Policy Document Control Title Originator/author: Approval Body Wandsworth CCG Continuing Healthcare Commissioning Policy Alison Kirby / Munya Nhamo Wandsworth

More information

GUIDELINES ON SECTION 17 LEAVE OF ABSENCE MHA (1983)

GUIDELINES ON SECTION 17 LEAVE OF ABSENCE MHA (1983) GUIDELINES ON SECTION 17 LEAVE OF ABSENCE MHA (1983) Document Summary All in-patients detained under the Mental Health Act 1983 within Cumbria Partnership NHS Foundation Trust may only be granted Leave

More information

Policies, Procedures, Guidelines and Protocols

Policies, Procedures, Guidelines and Protocols Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure

More information

Leaflet 17. Lone Working

Leaflet 17. Lone Working Leaflet 17 Lone Working Contents 1. Introduction 2. Purpose 3. Definitions 4. Risk Assessment 5. Environment 6. Communication 7. Monitoring & Effectiveness Appendix 1 - Environmental Precautions Appendix

More information

Sample CHO Primary Care Division Quality and Safety Committee. Terms of Reference

Sample CHO Primary Care Division Quality and Safety Committee. Terms of Reference DRAFT TITLE: Sample CHO Primary Care Division Quality and Safety Committee Terms of Reference AUTHOR: [insert details] APPROVED BY: [insert details] REFERENCE NO: [insert details] REVISION NO: [insert

More information

A Case Review Process for NHS Trusts and Foundation Trusts

A Case Review Process for NHS Trusts and Foundation Trusts A Case Review Process for NHS Trusts and Foundation Trusts 1 1. Introduction The Francis Freedom to Speak Up review summarised the need for an independent case review system as a mechanism for external

More information

Positive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care

Positive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Positive and Safe Management of Post incident Support and Debrief NTW(C)13 Ron Weddle Deputy Director, Positive

More information

Absent Without Leave Policy

Absent Without Leave Policy March 2009 Page 1 of 19 Title Reference Number AdultMHD09/001 Implementation Date March 2009 Review Date March 2009 Responsible Officer Director of Adult Mental Health and Disability Services Page 2 of

More information

Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer

Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer Document Title Reference Number Security Management Policy NTW(O)21 Lead Officer Author(s) (name and designation) Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience

More information

Resource Library Banque de ressources

Resource Library Banque de ressources Resource Library Banque de ressources SAMPLE POLICY: STAFF SAFETY Sample Community and Health Services Keywords: high risk, safety, home visits, staff safety, client safety, disruptive behavior, refusal

More information

LONE WORKER POLICY. Policy Number: Version: 2.0 NHS Southend CCG Governing Body Date Ratified: Name of Sponsor: Linda Dowse, Chief Nurse

LONE WORKER POLICY. Policy Number: Version: 2.0 NHS Southend CCG Governing Body Date Ratified: Name of Sponsor: Linda Dowse, Chief Nurse LONE WORKER POLICY Policy Number: CP14 Version: 2.0 Ratified by: NHS Southend CCG Governing Body Date Ratified: Name of Sponsor: Linda Dowse, Chief Nurse Name of originator/author: Date Issued: November

More information

SAFEGUARDING CHILDEN POLICY. Policy Reference: Version: 1 Status: Approved

SAFEGUARDING CHILDEN POLICY. Policy Reference: Version: 1 Status: Approved SAFEGUARDING CHILDEN POLICY Policy Reference: Version: 1 Status: Approved Type: Clinical Policy Policy applies to : All services within SCH Serco Policy applies to (staff groups): All SCH Serco staff Policy

More information

Procedure for the Management of a Patient being Absent without Leave (Absconding) from a Hospital Environment

Procedure for the Management of a Patient being Absent without Leave (Absconding) from a Hospital Environment Procedure for the Management of a Patient being Absent without Leave (Absconding) from a Hospital Environment Name of Procedure: Purpose of Procedure: Directorate responsible for Procedure Name & Title

More information

Computer Aided Dispatch (CAD) Markers Policy

Computer Aided Dispatch (CAD) Markers Policy Computer Aided Dispatch (CAD) Markers Policy Document Status Approved Version 1.0 DOCUMENT CHANGE HISTORY Initiated by Date Author Review of historic document February 2015 Gary Morgan, Regional Head of

More information

Safeguarding Alerts Policy and Procedure

Safeguarding Alerts Policy and Procedure Safeguarding Alerts Policy and Procedure Document Title: Safeguarding Alerts Policy and Procedure Version number: 2 First published: 27 th March 2014 Updated: 29 June 2015 Prepared by: The NHS Commissioning

More information

The Prevention and Control of Violence & Aggression Policy CONTROLLED DOCUMENT

The Prevention and Control of Violence & Aggression Policy CONTROLLED DOCUMENT CONTROLLED DOCUMENT The Prevention and Control of Violence & Aggression Policy CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document

More information

Procedure for Discharge from Inpatient Units including 48 hour Follow Up. (Wotton Lawn only)

Procedure for Discharge from Inpatient Units including 48 hour Follow Up. (Wotton Lawn only) Procedure for Discharge from Inpatient Units including 48 hour Follow Up (Wotton Lawn only) Version: Version 3 Consultation: Ratified by: Date ratified: Name of originator/author: Date issued: July 2012

More information

LOCKED DOORS AND DOOR CONTROL POLICY

LOCKED DOORS AND DOOR CONTROL POLICY LOCKED DOORS AND DOOR CONTROL POLICY Version: 3 Ratified by: Senior Managers Operational Group Date ratified: November 2013 Title of originator/author: Mental Health Legal Strategies Lead Title of responsible

More information

Policy 3.19 Workplace Violence and Threat Assessment Team

Policy 3.19 Workplace Violence and Threat Assessment Team Policy 3.19 Workplace Violence and Threat Assessment Team Purpose John Tyler is concerned about the safety, health and well-being of all of its students, faculty and staff. In adherence to Virginia Code

More information

Conveyance of Patients S6 Mental Health Act (Replaces Policy No. 182.Clinical)

Conveyance of Patients S6 Mental Health Act (Replaces Policy No. 182.Clinical) (Replaces Policy No. 182.Clinical) POLICY NUMBER TPMHA&MCA/103 VERSION NUMBER V.4 RATIFYING COMMITTEE Pan Sussex MHA Monitoring Committee DATE OF EQUALITY & HUMAN 01 August 2015 RIGHTS IMPACT ASSESSMENT

More information

Health Information and Quality Authority Regulation Directorate

Health Information and Quality Authority Regulation Directorate Health Information and Quality Authority Regulation Directorate Compliance Monitoring Inspection report Designated Centres under Health Act 2007, as amended Centre name: Centre ID: Centre county: Type

More information

Policies, Procedures, Guidelines and Protocols

Policies, Procedures, Guidelines and Protocols Title Policies, Procedures, Guidelines and Protocols Document Details Trust Ref No 2078-28878 Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approved by (Committee/Director)

More information

DRAFT - NHS CHC and Complex Care Commissioning Policy.

DRAFT - NHS CHC and Complex Care Commissioning Policy. DRAFT - NHS CHC and Complex Care Commissioning Policy. 1. Introduction 1.1 This policy describes the way the following Clinical Commissioning Groups (CCGs) NHS Wirral Clinical Commissioning Group, NHS

More information

Learning from Deaths - Mortality Report

Learning from Deaths - Mortality Report Learning from Deaths - Mortality Report NHS Improvement and the National Quality Board have requested all NHS Trusts to publish a review of mortality by. This is our Trust report. 1. Background In line

More information

MEDICINES FOR HUMAN USE (CLINICAL TRIALS) REGULATIONS Memorandum of understanding between MHRA, COREC and GTAC

MEDICINES FOR HUMAN USE (CLINICAL TRIALS) REGULATIONS Memorandum of understanding between MHRA, COREC and GTAC MEDICINES FOR HUMAN USE (CLINICAL TRIALS) REGULATIONS 2004 Memorandum of understanding between MHRA, COREC and GTAC 1. Purpose and scope 1.1 Regulation 27A of the Medicines for Human Use (Clinical Trials)

More information

Observation and Therapeutic Engagement of Mental Health Inpatients in Holywell Hospital and Ross Thomson Unit Reference Number:

Observation and Therapeutic Engagement of Mental Health Inpatients in Holywell Hospital and Ross Thomson Unit Reference Number: This is an official Northern Trust policy and should not be edited in any way Observation and Therapeutic Engagement of Mental Health Inpatients in Holywell Hospital and Ross Thomson Unit Reference Number:

More information

CLINICAL HANDOVER AT NURSE SHIFT CHANGES

CLINICAL HANDOVER AT NURSE SHIFT CHANGES TRUST-WIDE CLINICAL DIVISION POLICY DOCUMENT CLINICAL HANDOVER AT NURSE SHIFT CHANGES Policy Number: Scope of this Document: SD49 All clinical divisions Recommending Committee: Ratifying Committee: Divisional

More information

CONTINUING HEALTHCARE POLICY

CONTINUING HEALTHCARE POLICY BEFORE USING THIS POLICY ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION CONTINUING HEALTHCARE POLICY 1 SUMMARY This policy describes the way in which the five Primary Care Trusts in NHS North

More information

The Royal College of Emergency Medicine. A brief guide to Section 136 for Emergency Departments

The Royal College of Emergency Medicine. A brief guide to Section 136 for Emergency Departments The Royal College of Emergency Medicine A brief guide to Section 136 for Emergency Departments December 2017 Summary of recommendations 1. When a patient is brought to the ED under section 136 of the Mental

More information

Hospital Managers Appeal and Renewal Hearings

Hospital Managers Appeal and Renewal Hearings Standard Operating Procedure 10 (SOP 10) Hospital Managers Appeal and Renewal Hearings Why we have a procedure? It is the Hospital Managers (Managers) who have the power to detain patients who have been

More information

Corporate. Visitors & VIP s Standard Operating Procedure. Document Control Summary. Contents

Corporate. Visitors & VIP s Standard Operating Procedure. Document Control Summary. Contents Corporate Visitors & VIP s Standard Operating Procedure Document Control Summary Status: Version: Author/Owner: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date:

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Placing a Risk of Violence Alert on Patient Records

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Placing a Risk of Violence Alert on Patient Records The Newcastle upon Tyne Hospitals NHS Foundation Trust Placing a Risk of Violence Alert on Patient Records Version No: 1.0 Effective From: 26 September 2013 Expiry Date: 1 April 2016 Date Ratified: 14

More information

Kings Crisis and Critical Incident Management Policy

Kings Crisis and Critical Incident Management Policy Kings Crisis and Critical Incident Management Policy All Kings policies will be ratified by the Board of Directors and signed by the Chairperson. Each policy will be co-signed by the principal of each

More information

Reservation of Powers to the Board & Delegation of Powers

Reservation of Powers to the Board & Delegation of Powers Reservation of Powers to the Board & Delegation of Powers Status: Draft Next Review Date: March 2014 Page 1 of 102 Reservation of Powers to the Board & Delegation of Powers Issue Date: 5 April 2013 Document

More information

MULTI AGENCY PUBLIC PROTECTION ARRANGEMENTS EXTENSION OF MANAGEMENT OF OFFENDERS ETC (SCOTLAND) ACT 2005 TO RESTRICTED PATIENTS

MULTI AGENCY PUBLIC PROTECTION ARRANGEMENTS EXTENSION OF MANAGEMENT OF OFFENDERS ETC (SCOTLAND) ACT 2005 TO RESTRICTED PATIENTS MULTI AGENCY PUBLIC PROTECTION ARRANGEMENTS EXTENSION OF MANAGEMENT OF OFFENDERS ETC (SCOTLAND) ACT 2005 TO RESTRICTED PATIENTS HEALTH SERVICE GUIDANCE Introduction 1. Arrangements to ensure appropriate

More information

Care Programme Approach Policies and Procedures. Choice, Responsiveness, Integration & Shared Care

Care Programme Approach Policies and Procedures. Choice, Responsiveness, Integration & Shared Care Care Programme Approach Policies and Procedures Choice, Responsiveness, Integration & Shared Care Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose:

More information

INDEPENDENT NON-MEDICAL PRESCRIBING (NMPs) POLICY. Suffolk GP Federation Board

INDEPENDENT NON-MEDICAL PRESCRIBING (NMPs) POLICY. Suffolk GP Federation Board INDEPENDENT NON-MEDICAL PRESCRIBING (NMPs) POLICY Version: 1.0 Policy owner: Ratified by: Clinical Governance Lead Chief Executive Date approved: 28 th November 2014 Approved by: Suffolk GP Federation

More information

Agenda item 3.3 Appendix 4 MANDATORY TRAINING POLICY

Agenda item 3.3 Appendix 4 MANDATORY TRAINING POLICY Agenda item 3.3 Appendix 4 MANDATORY TRAINING POLICY Reference No: Issued by Policy Manager Version No: 1 Previous Trust / LHB Ref No: n/a Documents to read alongside this Policy Study Leave Guidelines

More information

Title. Title: Section 132, 132A & 133 Provision of Information to detained patients & Nearest Relatives

Title. Title: Section 132, 132A & 133 Provision of Information to detained patients & Nearest Relatives Policy Document Control Page Title Title: Section 132, 132A & 133 Provision of Information to detained patients & Nearest Relatives Version: 4 Reference Number: CL36 Keywords: (please enter tags/words

More information

Patient Observation Policy

Patient Observation Policy Policy No: MH03 Version: 5.0 Name of Policy: Patient Observation Policy Effective From: 25/08/2015 Date Ratified 24/07/2015 Ratified by Mental Health Act Committee Review Date 01/07/2017 Sponsor Associate

More information

Mental Health Commission Code of Practice

Mental Health Commission Code of Practice COP- S33/01/2008 Version 2 Mental Health Commission Code of Practice Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting January 2008 Preamble The Mental Health

More information

Clinical Supportive Observation, Intervention and Engagement of Service Users Policy

Clinical Supportive Observation, Intervention and Engagement of Service Users Policy Clinical Supportive Observation, Intervention and Engagement of Service Users Policy Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or

More information

HEALTHCARE INSPECTORATE WALES SAFEGUARDING AND PROTECTING CHILDREN IN WALES:

HEALTHCARE INSPECTORATE WALES SAFEGUARDING AND PROTECTING CHILDREN IN WALES: HEALTHCARE INSPECTORATE WALES SAFEGUARDING AND PROTECTING CHILDREN IN WALES: A Review of the arrangements in place across the Welsh National Health Service ACTION PLAN - UPDATED August 2010 RECOMMENDATION

More information

Mental Health Act Policy. Board library reference Document author Assured by Review cycle. Introduction Purpose or aim Scope...

Mental Health Act Policy. Board library reference Document author Assured by Review cycle. Introduction Purpose or aim Scope... Mental Health Act Policy Board library reference Document author Assured by Review cycle P041 Associate Director of Governance, Quality and Regulatory Compliance Quality and Standards Committee 1 Year

More information

EXECUTIVE SUMMARY OF THE INDEPENDENT INVESTIGATION INTO THE MENTAL HEALTH CARE AND TREATMENT OF PATIENT E COMMISSIONED BY THE FORMER NORTH EAST

EXECUTIVE SUMMARY OF THE INDEPENDENT INVESTIGATION INTO THE MENTAL HEALTH CARE AND TREATMENT OF PATIENT E COMMISSIONED BY THE FORMER NORTH EAST EXECUTIVE SUMMARY OF THE INDEPENDENT INVESTIGATION INTO THE MENTAL HEALTH CARE AND TREATMENT OF PATIENT E COMMISSIONED BY THE FORMER NORTH EAST STRATEGIC HEALTH AUTHORITY 1 Contents Page The Panel 3 1

More information

CONTINUING HEALTHCARE (CHC) CHOICE & EQUITY POLICY

CONTINUING HEALTHCARE (CHC) CHOICE & EQUITY POLICY CONTINUING HEALTHCARE (CHC) CHOICE & EQUITY POLICY Ref: Version: Supersedes: Author (inc Job Title): Ratified by: (Name of responsible Committee) Date ratified: To be completed by Corporate Team To be

More information

Quality and Governance Committee. Terms of Reference

Quality and Governance Committee. Terms of Reference Quality and Governance Committee Terms of Reference 1. Constitution 1.1 The Clinical Commissioning Group s Governing Body hereby resolves to establish a Committee of the Governing Body known as the Quality

More information

Safeguarding of Vulnerable Adults. Annual Report

Safeguarding of Vulnerable Adults. Annual Report of Vulnerable Adults Annual Report 2011-2012 April 2012 DOCUMENT CONTROL Version Author Date Change V0.1 Veronica Flood 20 April 2012 First draft V0.2 Mary Sexton 24 April 2012 Second Draft V0.3 Mary Sexton

More information

PREVENTION OF VIOLENCE IN THE WORKPLACE

PREVENTION OF VIOLENCE IN THE WORKPLACE POLICY STATEMENT: PREVENTION OF VIOLENCE IN THE WORKPLACE The Canadian Red Cross Society (Society) is committed to providing a safe work environment and recognizes that workplace violence is a health and

More information

Ensuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS

Ensuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS Ensuring our safeguarding arrangements act to help and protect adults TERMS OF REFERENCE AND GOVERNANCE ARRANGEMENTS April 2017 Contents Page 1. Purpose 2 2. Key Functions 2 3. Governance and Administrative

More information

1. Workplace Violence Employee Survey 2010

1. Workplace Violence Employee Survey 2010 1. Workplace Violence Employee Survey 2010 1. Do you feel safe at work? 2. Do you think you are prepared to handle a violent situation, threat, or responsive and escalating behaviours exhibited by clients

More information

Buckinghamshire County Council and the Longcare Homes (First Term of Reference)

Buckinghamshire County Council and the Longcare Homes (First Term of Reference) Independent Longcare Inquiry Summary, Main Conclusions and Recommendations Origin of Inquiry Terms of Reference General Conclusions Buckinghamshire County Council and the Longcare Homes (First Term of

More information

Brief guide: the use of blanket restrictions in mental health wards

Brief guide: the use of blanket restrictions in mental health wards Brief guide: the use of blanket restrictions in mental health wards Context and policy The Mental Health Act Code of Practice defines blanket restrictions as rules or policies that restrict a patient s

More information

ADMITTING YOUNG PEOPLE UNDER 18 TO ADULT MENTAL HEALTH WARDS POLICY

ADMITTING YOUNG PEOPLE UNDER 18 TO ADULT MENTAL HEALTH WARDS POLICY ADMITTING YOUNG PEOPLE UNDER 18 TO ADULT MENTAL HEALTH WARDS POLICY Version: 2 Ratified By: Date Ratified: August 2015 Title of Originator/Author Title of Responsible Committee/Group Senior Managers Operational

More information

Staff with responsibilities under Section 17 of the Mental Health Act. Section 17, Mental Health Act, authorisation, leave, detained, patients

Staff with responsibilities under Section 17 of the Mental Health Act. Section 17, Mental Health Act, authorisation, leave, detained, patients Policy: Section 17 Mental Health Act - Authorisation of Leave (Detained Patients) Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke, Executive Director

More information

Campus and Workplace Violence Prevention. Policy and Program

Campus and Workplace Violence Prevention. Policy and Program Campus and Workplace Violence Prevention Policy and Program SECTION I - Policy THE UNIVERSITY AT ALBANY is committed to providing a safe learning and work environment for the University s community. The

More information

WORKPLACE VIOLENCE PREVENTION. Health Care and Social Service Workers

WORKPLACE VIOLENCE PREVENTION. Health Care and Social Service Workers WORKPLACE VIOLENCE PREVENTION Health Care and Social Service Workers DEFINITION Workplace violence is any physical assault, threatening behavior, or verbal abuse occurring in the work setting A workplace

More information