Conflict Resolution & Challenging Behaviour Policy

Conflict Resolution & Challenging Behaviour Policy Document Number HS-002 Version V2 Ratified By and Date Health and Safety Sub-Committee 5 May 2016 Name of Approving Bodies and 17.09.15 Health and Safety Policy Review Dates Group 25.02.16 Health and Safety Policy Review Group 24.09.2015 Health and Safety Sub- Committee Job Title of Document Author Security Manager / Local Security Management Specialist Name of Responsible Committee Health and Safety Sub-Committee Executive Director Director of Finance and Resources / Security Management Director Date Issued 30 August 2016 Expiry Date (Maximum Two Years) 30 August 2018 Target Audience All staff This document may be made available in a different format By contacting the Author of the Document 1

Version Control - Review and Amendment Log Version Type of Change Date Description of Change V2.1 This is a review of an existing policy. September 2015 Review against NHS Protect Standards V2.2 Consultation with Health and Safety Policy Review Group 17. 09.15 Amendments completed as per minutes of the meeting. Policy name change to reflect V2.3 Amendments as per Policy Review Group Minutes of 25 th February 2016 V2.4 Consultation with Divisional Business Meetings current standards. 22.03.16 Mental Health Act definition included and minor amendments and consistency issues. 16/01/16 Consultation for information to DBMs - attendees from these are to forward any comments to Ops reps (includes staff side and Ops) V2.5 Chair s Approval 14/07/16 For any Policies approved as above but did not go to DBMs or your view that on a particular meeting there was insufficient difference in attendance at the group & sub-committee these could have a Chairs approval from me in these instances to move forward 2

DOCUMENT SUMMARY Document Title Conflict Resolution and Challenging Behaviour Policy Document Status New Revision X Date of Publication Key Points The Conflict Resolution and Challenging Behaviour Policy supersedes the Violence & Aggression Policy dated May 2013 and provides a framework for the management of challenging behaviour. The strategies promoted by the policy help identify, assess, understand, prevent and manage challenging behaviour. They may also help to and improve the quality of care delivered to individuals by preventing or minimising distress and ensuring that care is delivered within a safe environment, which protects staff, patients and service users. This policy includes strategies to improve the experience of: All individuals, many of whom may be vulnerable, who cause harm to themselves and / or others. Staff who deliver essential treatment and care, aftercare and rehabilitation. Other individuals who may also be vulnerable and disturbed. Relatives, carers and visitors involved in caring for other individuals or someone who is in distress. Available Support Security Manager / Local Security Management Specialist (LSMS) 3

Contents Page 1. Introduction 6 2. Purpose 6 3. Explanation of Terms and Definitions 7 4. Duties & Responsibilities 4.1 Chief Executive 4.2 Executive Directors 4.3 Director of Finance & Resources / SMD 4.4 Associate Director of Estates and Facilities 4.5 Security Manager / LSMS 4.6 Chief Operating Officers 4.7 Managers and Team Leaders 4.8 Employees 4.9 Others 5. Understanding Challenging Behaviour 5.1 Clinical Causes 5.2 Types of Behaviour 8 12 6. Managing Challenging Behaviour 6.1 Care Planning 6.2 De-escalation 13 7. 8. Risk Assessment Incident Reporting Reporting Requirements Incident Investigation and Review 14 15 9 Persistent Acts of Challenging Behaviour and Sanctions 6.3 Physical Assault 6.4 Non-Physical Assault 6.5 Sanctions 6.6 Verbal Warnings 6.7 Warning Letters 6.8 Failure to Comply with Warning Letters and Sanctions 6.9 Withholding of Treatment / Services 16 4

10. Training and Resource Implications 22 11. Consultation, Approval and Ratification Process 22 12. 13. 14. 15. Equality Analysis Summary Monitoring Compliance with the Policy References and Supporting Documents Policy Review 23 23 24 25 Appendices Appendix 1 Conflict Resolution and Challenging Behaviour Risk Assessment Appendix 2 Clinical Risk Assessment Patients with Challenging Behaviours Appendix 3 Verbal Warning File Note Appendix 4 Request for Police Assistance Flow Chart Appendix 5 - Equality Analysis Appendix 6 - Monitoring Compliance 5

Conflict Resolution & Challenging Behaviour Policy 1. Introduction Clinically related challenging behaviour is often a manifestation of a patient s distress and an attempt by them to communicate their unmet needs. It may result from an individual feeling threatened, fearful or anxious, suffering delusions or hallucinations, or it may be a response to a difficult situation, or a misinterpretation of the actions of other people. It may simply be a result of an individual trying to express that they are hungry, thirsty or in pain. Preventing challenging behaviour is concerned with understanding the reasons for a person s distress by recognising their vulnerability, anticipating their needs and designing care accordingly. This supersedes the previous NHS Protect Zero Tolerance Campaign and Partnership Trust Violence and Aggression Policy dated May 2013. 2. Purpose The Trust will proactively explore all options to deter violence linked to challenging behaviour and have in place measures to robustly prevent all forms of violence and aggression. The purpose of this policy is: To prevent, and protect staff from violence at work. To prevent and protect patients from other patients and visitors from acts of aggression To provide a safe and secure working environment for all employees and thereby help to increase morale and reduce absenteeism. To ensure that employees are confident that they will receive the necessary support, guidance and training to enable them to manage conflict that can lead to violence and aggression within the workplace. To provide the necessary support to those employees who have been involved in a violent or aggressive incident and guidance for Line Managers as to the action they must take to support victims. To ensure incidents of violence or aggression are properly recorded and that all necessary control measures are implemented and monitored for their effectiveness in reducing violence. To comply with relevant Health and Safety legislation. 6

The Trust will provide the necessary training for staff, following a multi-agency problem solving approach, highlighting trends and using sanctions against those who use aggression towards NHS staff in the case of non-clinical assault or other forms of violent behaviour. Incidents of violence, aggression or harassment between members of staff is not covered by this policy, any such incidents should be dealt with through the relevant HR policies and processes. 3. Explanation of Terms and Definitions For the purpose of this document, the following abbreviations and NHS definitions apply: Term LSMS SMD CRT QGC HSE RIDDOR NHSP SIRS Mental Capacity Explanation Local Security Management Specialist Security Management Director Conflict Resolution Training Quality Governance Committee Health and Safety Executive Reporting of Diseases and Dangerous Occurrences Regulations NHS Protect Security Incident Reporting System Capacity is the ability to make a specific decision at the time the decision needs to be made. Ability to make a decision is informed by, for example, a persons ability to understand the decision and why it needs to be made. For further information see the Trust Policy Mental Capacity Act 2005 Policy and Guidance GNQ-020. Challenging Behaviour - Any non-verbal, verbal or physical behaviour exhibited by a person which makes it difficult to deliver good care safely. Violence and Aggression - Any incident, in which a person is verbally abused, threatened or assaulted by another person including patient, in circumstances arising out of the course of his / her employment. Assault: Physical - The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort Non-Physical Assault - The intentional use of inappropriate words or behaviour causing distress and / or constituting harassment. 7

Physical and Non-physical Assault Sub Categories for determining appropriate actions: Clinical (not deliberate) - meaning a person did not have the capacity of knowing what they were doing at the time of the incident e.g. dementia, mental health illness, as a result of treatment administered or recovering from anaesthetic. Non Clinical (deliberate) meaning a person did have the capacity of knowing what they were doing at the time of the incident. Weapon - This can mean any item, whether intended or adapted to cause injury, to threaten staff or other individuals. This would include recognised weapons, e.g. knives, axes, batons / sticks, guns and non-recognised weapons such as furniture or equipment, e.g. chairs, sharps or vessels of any kind. Risk Assessment - the process that helps organisations to understand the range of risks they face, the level of ability to control those risks, their likelihood of occurrence and their potential impacts. 4. Duties & Responsibilities 4.1 Chief Executive The Chief Executive has overall responsibility for the strategic and operational management of the Trust, including ensuring that the Trusts procedural documents comply with all legal, statutory and good practice requirements. The Chief Executive is responsible for ensuring that there are safe and effective systems in place to deliver high quality care to those who use Trust services and to reduce where it is reasonably practicable the risk of violence within the Trust. Additionally as the Accountable Officer, the Chief Executive has the ultimate responsibility for ensuring compliance with the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999. 4.2 Executive Directors The Executive Directors are responsible for ensuring that work is undertaken in accordance with this Policy and that it is promoted within their Directorates thus encouraging a joint approach to addressing risks to staff. 4.3 Director of Finance and Resources / Security Management Director (SMD) The Director of Finance and Resources is the appointed SMD. This appointment demonstrates that board level responsibility has been clearly defined. 8

The SMD will ensure there are appropriate security management services and specialist advice available within the Trust and ensure the LSMS has the necessary resources and support available to carry out their role effectively. The SMD will, subject to any contractual and legal restraints, ensure that all staff, and particularly those responsible for human resources, cooperate with the LSMS and disclose information which arises in connection with any matters (including disciplinary matters) which may have implications for the investigation, prevention or detection of security breaches and violence and aggression incidents. Furthermore the SMD assisted by the LSMS is responsible for the promotion and realisation of a pro-security culture throughout the Trust. 4.4 Associate Director of Estates and Facilities The Associate Director of Estates and Facilities will ensure that Trust sites and buildings are conducive to personal safety, where reasonably practicable, and do not contribute or exacerbate the potential for violent or aggressive situations. 4.5 Security Manager / Local Security Management Specialist (LSMS) The Security Manager / LSMS reports to the Associate Director of Estates and Facilities and is the active lead for all security risk management matters, the development of a Security Management Strategy including the management of conflict and challenging behaviours, and advising managers on the implementation of this policy. The LSMS will aim to provide a comprehensive, inclusive and professional security management service for the Trust and work towards the creation of a pro-security culture where incidents are reported and fully investigated in accordance with the Trust s Adverse Incident Reporting Policy. The Security Manager / LSMS will specifically: Ensure the SMD is informed promptly of all incidents involving serious physical assault or those that involve the use of a weapon. Monitor all violence and aggression incidents to ensure that appropriate actions are taken at a local level and where necessary liaise with the Police, NHS Protect and other relevant parties to obtain sanctions where appropriate. Ensure that all reported incidents involving a physical assault are additionally reported through SIRS via NHSP to inform the National Statistics on Physical Assaults. Support managers to ensure effective risk assessments are undertaken and action plans are developed where deficiencies have been identified or following an incident. 9

Monitor CRT as directed by the Trust to enable all front line staff to manage and reduce confrontational situations that may result in violent or aggressive behaviour. In conjunction with line managers co-operate with NHSP in any investigation or subsequent action which is considered appropriate. Report employee absences in connection with assaults to the HSE under RIDDOR Regulations as appropriate. Produce information reports to enable the Trust to monitor performance against the Policy. Ensure the Trust continues to improve the security management arrangements in accordance with the NHSP Security Management Standards. Distribute NHSP Security Alerts in respect of known perpetrators of aggression against NHS staff and property. Develop an Annual Security Work Plan and Report. Audit the implementation of this policy and report the findings to the Health and Safety Sub-Committee. 4.6 Chief Operating Officers Chief Operating Officers have a responsibility to ensure that all employees working within their services are aware of this Policy and its requirements. They are also responsible for ensuring local procedures are developed for monitoring incidents within their area and ensuring appropriate action is taken. 4.7 Managers & Team Leaders In order for the Trust to discharge its responsibilities under the Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999 and in particular Regulation 3 which places a responsibility on employers to undertake Risk Assessments, the Trust delegates responsibility to Managers and Team Leaders to implement safe working practices within their areas of responsibility. In particular they will be responsible for: Implementing Trust Policies and Procedures within their areas developing local procedures as appropriate. Ensuring the potential for violence and aggression is risk assessed for the teams that they control, implementing control measures where risks are identified and monitoring these for effectiveness (Appendix 1 Conflict Resolution & Challenging Behaviour Risk Assessment). Routinely reviewing risk assessments and updating them following an incident or change in circumstance or process. Developing Action Plans in connection with identified risks and escalating these to the Risk Register in accordance with the Risk Management Policy. 10

Ensuring that lone workers duties are fully risk assessed and protective measures are implemented. Further information and guidance can be found in the Policy for the Protection of Lone Workers. Maintaining records of violent or aggressive incidents and ensuring they are reported via the Trust Incident Reporting System Safeguard documenting where appropriate Police Crime Reference numbers. Ensuring that all criminal acts are reported promptly to the police and LSMS. Reporting all physical assaults or threats involving the use of a weapon to the police. Ensuring that all incidents are investigated and that learning is shared and Risk Markers applied where appropriate. Implementing appropriate security measures when known perpetrators of aggression are required to use services. Ensuring patient care plans for behaviour are completed and include actions specific to behavioural management for those patients that have demonstrated aggression (Appendix 2 Clinical Risk Assessment Form). Issuing verbal warnings to the perpetrators of incidents in accordance with this policy and documenting the actions taken and agreements obtained (Appendix 3 Verbal Warning File Note). Informing the victim on the progress of an investigation. Informing the LSMS of staff absences in connection with assaults thus ensuring those exceeding 7 days are reported to the HSE under RIDDOR Regulations. Ensuring staff who have been involved in incidents are appropriately supported and have access to Occupation Health Services including Counselling services where appropriate. Promoting employee self-referral to Staff Counselling Services where employees have been involved in incidents. Ensuring an appropriate level of de-brief is provided to individuals or teams involved in serious or protracted incidents. Ensuring that all patient facing staff / front-line staff attend Conflict Resolution Training in accordance with the Training Needs Analysis. It is recognised that situations will arise from time to time that could not have been predicted and it is important that Managers and Team Leaders seek advice from the Security Manager / LSMS and escalate issues in such circumstances at the earliest opportunity. 4.8 Employees It is the employee s duty to follow guidance, processes or systems implemented in the workplace in the course of providing services to NHS and Social Care patients and service users. All front line (service / patient facing) employees are required to attend mandatory Conflict Resolution Training (CRT). 11

Employees who have been issued with Lone Working devices must ensure that they are used in accordance with the risk assessment and manufacturer s instructions, and that the device is fully charged and operational at all times. In addition all employees are responsible for: Ensuring they are conversant with and comply with all policies and procedures designed to reduce the risk of violence and aggression within the workplace. Reporting any potential risk or actual incidents of physical or non-physical acts of violence on Safeguard. Co-operating with all risk assessments and actions plans. 4.9 Others Anyone accessing the Trust s facilities and services, including staff from external organisations and agencies, should at all times conduct themselves so as to minimise the risk of violence against themselves, or others, who may be affected by their acts or omissions. In the case of contractors / providers of services, failure to adhere to this Policy will cause the Trust to require their immediate removal from Trust premises. 5. Understanding Challenging Behaviour 5.1 Clinical Causes Individuals who manifest challenging behaviour often have some degree of cognitive impairment, either chronic (e.g. dementia or a learning disability) or acute (e.g. delirium, head or brain injury, drug or alcohol intoxication). It may also be seen in other mental health conditions such as psychosis or personality disorder. Care is needed to ensure that the behaviour is not as a result of an underlying illness or injury which needs urgent attention. 5.2 Types of Behaviour Challenging behaviour may describe many kinds of deliberate or nondeliberate non-verbal, verbal or physical behaviour. Some of these behaviours e.g. staring, crying and shouting may represent legitimate expressions of distress, it can also include behaviours which may be less risky, such as apathy, lethargy, fatigue, hyperactivity, hypo activity, being non-compliant or withdrawn. Such behaviours can present risks to staff, patients and service users when staff are required to intervene in the course of providing care or treatment. There are three common types of behaviour: 12

Non Verbal Agitation Wandering, pacing, following Intimidating facial expressions, staring Intimidating body posture Cornering, invading personal space Offensive gestures Interference with equipment or property Being withdrawn, extreme passivity, refusal to move Verbal Shouting Swearing Crying Screaming Repetitive statements or questions Personal comments or questions Racist, sexist, offensive speech Bizarre, psychotic content, not based on known reality Physical Scratching Grabbing, hair pulling Biting Hitting, slapping, punching Pinching Spitting Kicking Pushing, shoving, knocking into someone Striking or throwing furniture or objects Inappropriate touching (self or others) Urinating, smearing Undressing Self harm Absconding Removal of lines, masks, catheters, dressings, incontinence pads Non-compliance, resistive behaviour (e.g. refusing medication, blood tests) 6. Managing Challenging Behaviour 6.1 Care planning Risk assessment and management should inform the care plan as to whether specific interventions are required to manage challenging behaviour. The risk assessment documentation should sit alongside the care plan and should be cross referenced and updated accordingly if new risks emerge. 13

6.2 De-escalation If prevention has failed, is failing or has never had a chance to work, staff need to be skilled in de-escalation. This is based around highly developed communication skills, fostering good relationships, empathy, calming, nonconfrontation, minimising threat, negotiation, compromise, agreeing to any reasonable requests, distraction activities and changes of staffing. The risk of injury to members of staff is greater when challenging behaviour has not been de-escalated which may result in an incident becoming physical. 7. Risk Assessment Risk assessment is concerned with assessing the likelihood and consequences of challenging behaviour and implementing appropriate measures to avoid, mitigate or control the risks. Protective factors, such as greater collaboration with other colleagues and services, and family involvement should also be emphasised. All teams are required to assess the risks associated with their service using the Conflict Resolution and Challenging Behaviour Risk Assessment at Appendix 1. A formal risk assessment for individual patients will not always be possible in fast paced workplaces such as Minor Injuries Units, Walk-in-Centres and some clinics. In these settings there is little or no lead up to situations and sometimes limited or no observation time or the person does not necessarily have a history of challenging behaviour, or at least one that is readily accessible by staff. Where possible a Clinical Patient Risk Assessment should be completed (Appendix 2 Clinical Risk Assessment Patients with Challenging Behaviours). All security related workplace risk assessments must be undertaken in accordance with the processes established in the Risk Management and Security Management Policies. This will facilitate the identification, assessment, reporting and minimising of all risks to the physical security of premises, assets and staff. Monitoring of risk assessments and the resulting action plans must be undertaken in accordance with the Risk Management Policy and communicated to all staff in the team and shared with new starters at local induction. Generic risk assessments are not appropriate for different areas or departments but may be appropriate where similar services/functions are the same. Advice should be sought from the Security Manager / LSMS in these instances. The Security Manager / LSMS on behalf of the SMD will monitor completed risk assessments during the Health and Safety Audit process. Any identified 14

trends highlighting gaps in control measures will be reported to the Health and Safety Sub-Committee. An organisational overview of audited risk assessments will be presented to the Health and Safety Sub-Committee annually. 8. Incident Reporting 8.1 All violent or aggressive incidents MUST be reported in accordance with the Trusts Incident Reporting Policy via SAFEGUARD. It is important that incidents reported on Safeguard include factual detail of what happened or was observed, noting the behaviour of the offender, what they said (actual words including expletives), what they did plus any crime reference number given by the police. Line managers must ensure that all incident reports are investigated, risk assessments reviewed following an incident and appropriate risk reduction measures implemented. 8.2 Acts of physical violence and other acts of non-consensual violence to a person at work that result in death, a major injury or being incapacitated for over seven days are reportable to the HSE under RIDDOR. Line Mangers must inform the Security Manager / LSMS or the Health Safety and Security Manager of any employee absence over 7 days resulting from an incident. A physical injury inflicted on one employee by another during a dispute about a personal matter, or an employee at work injured by a relative or friend who visits them at work about a domestic matter, is not reportable. 8.3 Incident Investigation and Review All incidents MUST be reported on the Safeguard system immediately or as soon as possible after the incident has occurred. All additional reviews and documentation such as warning letters, GP letters should be completed when reasonably practicable after the incident has concluded. Following an incident of physical or non-physical aggression it is important to identify aggravating and causal factors in order to prevent the event from recurring and if it cannot be prevented then at least steps taken to minimise the likelihood of recurrence and risks to staff in the future. Post-incident reviews and / or reviews of near misses are invaluable in identifying lessons to be learnt and should be conducted in accordance with the Adverse Incident Reporting Policy. A post incident review will only be effective if it is documented and shared with everyone involved in delivering care for that individual. 15

9. Persistent Acts of Challenging Behaviour and Sanctions 9.1 Any patient (with capacity), visitor, relative or other member of the public refusing to remain calm while on Trust premises or when communicating with Trust employees either in person or over the telephone may be subjected to certain sanctions imposed on them by the Trust if they continue to behave in a disorderly manner. 9.2 Physical Assault Physical assaults on NHS staff are defined as: "The intentional application of force to the person of another without lawful justification, resulting in physical injury or personal discomfort. An assault meeting this definition should be reported to the police by either the individual who was assaulted or their line manager or a colleague on their behalf. The exception to this is in those cases where a clinical condition exists or is suspected. Clinical Condition - where clinical opinion indicates that the assault was unlikely to have been intentional as the assailant did not know that what they had done was wrong due to a medical illness (including confusion), mental ill health, a severe learning disability or as a result of treatment administered Each incident must be considered on a case by case basis in light of all the available facts. Where the police are involved and attend an incident, every effort should be made to ascertain if the police intend to take action against the assailant. The details of the police officers involved should be recorded and passed on to the Security Manager / LSMS to assist in their role in monitoring the progress of such cases. Reports of physical assault received by the Security Manager / LSMS can typically be divided into two categories: 1. Those which are being pursued by the police and require monitoring by the Security Manager / LSMS 2. Those which require investigation by the Security Manager / LSMS. Where the police have attended an incident, the Security Manager / LSMS or Investigating Officer will contact the Police Officer who attended the incident to ascertain what action they intend to take. Where the police are continuing action, the Security Manager / LSMS will arrange to be kept appraised of the progress and outcome. Where the police decline to investigate the incident, the Security Manager / LSMS will consider investigating further to see whether or not a private 16

prosecution by the Trust or other action, such as a civil injunction is necessary and / or achievable. If following an investigation it is considered that there is sufficient evidence to support a prosecution, the matter will be referred to the Legal Protection Unit (LPU) of NHS Protect for legal advice and further action as appropriate. Irrespective of whether a legal sanction is pursued or not, the Service Lead or Manager, in conjunction with the Security Manager / LSMS should always consider whether additional action such as warning letters about future conduct should be sent. If the incident is particularly serious in nature or is repeated behaviour and there are concerns that staff, patient and or public safety could be at risk, the Security Manager / LSMS will provide the SMD and Chief Executive with all the evidence to consider the appropriate steps to be taken which could include withholding treatment. 9.3 Calling the Police You should always call 999 (9 999 from Trust land lines) when it is an emergency, such as when a crime is in progress, someone suspected of a crime is nearby, when there is danger to life or when violence is being used or threatened. In all other circumstances where Police support is required they should be contacted on 101 (9 101 from Trust land lines). A Flow Chart to support staff decision making is included at Appendix 4. 9.4 Non Physical Assault Non-physical assaults on NHS staff are defined as: The use of inappropriate words or behaviour causing distress and / or constituting harassment. It is difficult to provide a comprehensive description of all types of incidents, which are covered under non-physical assault, examples covered by this policy are listed below, however this list is not exhaustive and advice should be sought from the Security Manager / LSMS if in doubt: Offensive language, verbal abuse and swearing which prevents staff from doing their job or makes them feel unsafe Loud and intrusive conversation Unwanted or abusive remarks Negative, malicious or stereotypical comments Invasion of personal space Offensive gestures 17

Threats or risk of serious injury to a member of staff, fellow patients or visitors Bullying, victimisation or intimidation Stalking Alcohol or drug fuelled abuse Unreasonable behaviour and non-cooperation such as repeated disregard of hospital visiting hours; or any of the above which is linked to destruction of or damage to property. It is important to note that the any of the above behaviour can take place in person, by telephone, letter or e-mail or other form of communication including graffiti on NHS property. Taking action is appropriate where non-physical assault or abusive behaviour is likely to: Prejudice the safety of staff involved in providing the care or treatment Lead the member of staff providing care to believe that he or she is no longer able to undertake their duties properly as a result of fearing for their safety Prejudice any benefit the patient might receive from the care or treatment Prejudice the safety of other patients Result in damage to property inflicted by the patient, relative, visitor or as a result of containing their behaviour. The following is a list of possible aggravating factors which should be considered when deciding to report an incident to the police and is by no means exhaustive: The effect on the victim and / or others present The assailant s behaviour is motivated by hostility towards a particular group or individual on the grounds of race, religious belief (or lack of), nationality, gender, sexual orientation, age, disability or political affiliation A weapon, or object capable of being used as a weapon, is brandished or used to damage property The incident was an attempted, incomplete or unsuccessful physical assault The incident involves action by more than one assailant The incident is not the first to involve the same assailant(s) There is an indication that a particular member of staff or department / section is being targeted There is serious concern that any threats made will be carried out There is a concern that the individual s behaviour may deteriorate. 18

9.5 Sanctions It must be emphasised that the clinical condition of the assailant should always be considered when investigating an incident and when considering which course of action is to be taken. A wide range of measures can be taken by the Trust depending on the severity of the physical and non-physical assault. These sanctions may assist in the management of unacceptable behaviour by seeking to reduce the risks and demonstrate acceptable standards of behaviour, they include: Verbal warnings Written warnings Exclusion / Restriction on attending NHS premises Withholding treatment Civil injunction Criminal prosecution Civil compensation claim All of the above with the exception of a verbal warning must be initiated by the Security Manager / LSMS in consultation with the SMD who will be the signatory for any letters sent on behalf of the Trust. Throughout any of these processes the Trust is committed to developing and continuing to work with the Police, the Crown Prosecution Service and NHS Protect to ensure the best possible response and action which is appropriate to the circumstances. 9.6 Verbal Warnings Verbal Warnings are a method of addressing unacceptable behaviour with a view to achieving realistic and workable solutions. Verbal warnings are not a method of appeasing difficult patients, relatives or visitors in an attempt to modify their behaviour, or to punish them, but should be used to determine the cause of their behaviour so that the problem can be addressed or the risk of it reoccurring minimised. It is important that patients, relatives and visitors are dealt with in a fair and objective manner. However, whilst staff have a duty of care, this does not include accepting abusive behaviour. Every attempt should be made to deescalate a situation as it unfolds, where this fails the patient, relative or visitor should be warned of the consequences of future unacceptable behaviour. Where a verbal warning is issued a file note must be made on the patient s record using the template at Appendix 3. Where it is deemed appropriate to speak to a patient, relative or visitor in respect of their behaviour it should be done where practicable in private and at a time when all parties involved are composed. 19

The aim of the verbal warning process is twofold: 1. To ascertain the reason for the behaviour as a means of preventing further incidents or reducing the risk of it reoccurring 2. Ensure that the patient, relative or visitor is aware of the consequences of further unacceptable behaviour. 9.7 Warning Letters Where de-escalation and verbal warnings have not achieved the intended outcome and unacceptable behaviour has continued, consideration will be given to sending a formal warning letter to the perpetrator of the incidents. The letter will set out the Trust s expectations and conditions for continuing to provide services or care to an individual whilst maintaining the safety of Trust employees. The letter will specify a list of acts or behaviours in which an individual (patient, relative or visitor) has been involved, with a view to obtaining their agreement and cooperation for them not to continue their inappropriate or unacceptable behaviour All formal warning letters issued by the Trust will be signed by the SMD in consultation with the Security Manager / LSMS and will be sent through the post by recorded delivery with a stamped addressed envelope for the return of the signed acknowledgment to abide by the conditions set out in the letter. Cultural and ethnic sensitivities should be borne in mind in order to ensure that all possible aggravating factors are excluded at the outset. Warning letters are not linked to criminal proceedings and it is important that the greatest care is taken to ensure this is not misinterpreted as such, although they will make clear the Trusts intention to take further action if the recipient continues to behave in an inappropriate manner. The following issues should be covered: An explanation as to why the identified behaviour is unacceptable A clear explanation that such behaviour must stop The consequences of continued unacceptable behaviour; and Details of the mechanism for seeking a review. 9.8 Failure to Comply with Warning Letters and Conditions In order for Warning letters to be effective it is essential that staff continue to report further incidents or violations of the conditions set out in the letter. Where a patient, relative or visitor fails to comply with the terms outlined in the Warning Letter consideration should be given to alternative procedural, civil or criminal action. The NHS Protect Legal Protection Unit (LPU) will provide specialist assistance in specific cases, should this be necessary. In the case of mental health, any 20

action which may or may not include legal action must be made in conjunction with clinical opinion. 9.9 Withholding of Treatment / Services The withholding of treatment raises a number of ethical as well as clinical issues for clinicians and managers. However, where policies and procedures for withholding treatment have been introduced within the NHS, there is a clear indication that they can act as a deterrent to potentially violent patients and visitors and ensure that those who work hard to deliver quality patient care and services can do so in a safe environment. The process for withholding treatment must be clear that it should only be applied where appropriate and always as a last resort. Any decision to withhold treatment must be based on a clinical assessment and the advice of the patient s consultant, GP or senior member of the medical team on a case-by-case basis. Under no circumstances should it be inferred or implied to a patient that treatment may be withheld without appropriate consultation taking place. The withholding of treatment should always be seen as a last resort and only ever following legal advice from NHS Protect Legal Protection Unit (LPU) via the Security Manager / LSMS. Consideration to withhold treatment will only be considered when all other options covered by this policy have been exhausted. Before withholding of treatment is instigated, a final written warning should be issued to the patient by the Trust Chief Executive or SMD and must be copied to the patient s consultant and GP. The written warning should: Explain the reasons why withholding of treatment is being considered (including relevant information, dates and times of incidents); Explain that the behaviour demonstrated is unacceptable; Explain that appropriate sanctions will apply to violent or abusive patients; Give details of the mechanism for seeking a review of the issue, e.g. via local patient complaints procedures; and Explain that the patient s GP and consultant will be sent a copy of the letter. In exceptional circumstances there may be instances where the nature of the assault is so serious that the Trust, having obtained legal advice, can decide to withhold treatment immediately. Where it is decided that a patient should be excluded from Trust premises and treatment withheld, a written explanation for the exclusion must be provided. This letter must state: The reason why treatment is being withheld (including specific information, dates and times of incidents); 21

The period of the exclusion (the period of exclusion should normally not exceed 12 months, after which the decision must be reviewed); Details of the mechanism for seeking a review of a decision to withhold treatment; The action that the Trust intends to take if an excluded individual returns to Trust premises for any reason other than a medical emergency Each case is judged on its own merits to ensure that the need to protect and ensure the safety of staff is properly balanced against the need to provide health care to individuals; and That their GP and consultant will be notified in writing of the decision. 10. Training & Resource Implications Mandatory Conflict Resolution Training must be undertaken by patient facing (front line) staff to assist them in managing confrontational situations to reduce the potential for these to escalate to a violent incident. The training covers the aims and objectives of NHS Protect national syllabus as identified within the Trust s overall mandatory training needs analysis. Additional breakaway training is provided to healthcare staff employed in Offender Health and to other staff groups identified through risk assessment. The Trust is committed to providing support to all its employees and service users involved in violent or aggressive incidents. Further information / support can be accessed by line managers through the LSMS, Human Resources (HR), Training Department and Occupational Health Department. 11. Consultation, Approval and Ratification Process 11.1 Consultation The draft of this policy document has been shared with all members, of the Health and Safety Sub-committee to ensure that it is complete, correct and acceptable as a working policy. In addition the policy has been reviewed through the Health and Safety Policy Review Group. All comments received have been fully considered by the author and where necessary amendments made. 11.2 Trust Board 22

The Board is responsible for setting the strategic context in which the organisational policy and procedural documents are developed. The Board will approve strategies for implementation and where appropriate may also be asked to ratify underpinning policy or procedural documents. The Board delegates approval of the documents to its Committees and their associated groups and sub-groups. The sub-groups include for example the operational and working groups, and also specialist groups. The approving Sub-Committee for the Violence and Aggression Policy is the Health and Safety Sub-Committee. 12. Equality Analysis Summary All public bodies have a statutory duty under The Equality Act 2010 (Statutory Duties) Regulations 2011 to provide, evidence of the analysis it undertook to establish whether its policies and practices would further, or had furthered, the aims set out in section 149(1) of the [Equality Act 2010] ; in effect to undertake a written record of equality analysis and due regard on all procedural documents and practices. The Trust considers how the decision it makes affects people who share different protected characteristics (race, disability, sex, gender re-assignment, religion/belief, sexual orientation, age, marriage and civil partnership, pregnancy and maternity). The Trust also recognises that there are groups/communities that are recognised at a local level within society as excluded or disadvantaged in addition to those listed as protected groups above and this document is inclusive to these groups also for example, young teenage parents, homeless people etc. A completed Equality Analysis Summary is attached at Appendix 5. 13. Monitoring Compliance with the Policy The practical application of this policy will be monitored through routine review of incident trends and statistics, and review of preventive and corrective actions taken as a response to reported incidents by the Health and Safety Sub-Committee. Additionally the Health and Safety Sub-Committee: Has responsibility for monitoring all aspects of health and safety and security risks including violence and aggression. Will provide reports and assurance to Quality Governance Committee that security and violence and aggression risks are being identified and mitigated appropriately. Meets quarterly to consider all health and safety, risk and security matters across the Trust. 23

The Health and Safety Sub-Committee and Quality Governance Committee will receive and review the LSMS Annual Work plan and will oversee the implementation and delivery of the objectives. The Health and Safety Sub-Committee, and Quality Governance Committee, will receive and review the LSMS Annual Report. The Report will be sent to NHS Protect as required. Any security and violence and aggression risks will be recorded on the Trust Risk Register in accordance with the Risk Management Policy. The data collected from the monitoring process will be available for inspection by the NHS Litigation Authority and other appropriate external agencies. The outcome of the monitoring will be reported to Health & Safety Sub Committee, Divisional Business Meetings and Quality Governance Committee at least twice per year. Where changes to monitoring methods are made, the Trust policy must be reviewed and approved. 14. References and Supporting Documents 14.1 References NHS Protect Security Management Standards for Providers 2015/16 NHS Protect Guidance on Tackling Violence and Aggression in the NHS NHS Protect Guidance on Reducing Distress Health & Safety at Work Act 1974 Mental Capacity Act 2005 14.2 Supporting Documents This Policy and all direction and guidance included in it, should be read in conjunction with all Trust Policies & Procedures but is particularly relevant to the following Policies: Policy for the Protection of Lone Workers Adverse Incident Reporting Policy Security Management Strategy Security Management Policy Mental Capacity Act 2005 Policy & Guidance Risk Management Strategy and Policy Customer Relations & Complaints Policy and Procedures Policy for the Lockdown of a Trust Site or Premise Health and Safety Organisational Policy CCTV Policy 24

Personal Protective Equipment Policy Disciplinary Policy Training Needs Analysis Equality Analysis 15. Policy Review This policy will be reviewed two years from ratification or sooner if the necessity arises. 25

APPENDIX 1 CONFLICT RESOLUTION & CHALLENGING BEHAVIOUR RISK ASSESSMENT Department/Specialty: Location:..Date of Assessment:.. Assessment Serial No: ACCESS YES NO COMMENTS/ACTION REQUIRED Is access appropriately restricted to members of the public (including patients visitors and relatives)? Do all restricted areas have a secure physical barrier to prevent unauthorised people access? PROCEDURES (complete for all areas) YES NO COMMENTS/ACTION REQUIRED Are staff aware of the procedure to follow when an actual or potential incident occurs (including who to call for help)? Is incident report system readily available to all staff? Are the departments referring victims of violent or aggressive incidents to support counselling if required? If panic alarms are in place, are Staff aware of actions to take when the alarm sounds? Is there a mechanism to alert staff to people known to be violent or aggressive? Are incidents of violence & aggression discussed with the staff that are involved within the department? Are violence & aggression incidents discussed at Trust level? TRAINING YES NO COMMENTS/ACTION REQUIRED Have the staff s violence & aggression training needs been established? Is attendance at the mandatory conflict resolution training monitored? Are all staff aware of de-escalation skills? 26

WAITING AREAS YES NO COMMENTS/ACTION REQUIRED Is the entrance monitored by CCTV? Is there sufficient seating for the number of people waiting? Are there sufficient, easily accessible and clearly marked facilities e. g. toilets, drinks machine, telephone? Is there a system to ensure that facilities that are broken/out of order are reported and attended to promptly? Have all objects that could be used as a weapon been identified and actions taken to remove or secure them? Are visitors provided with sufficient information regarding waiting times etc? Does the appointment system minimise the need for patients and visitors to wait for long periods? TREATMENT AREAS YES NO COMMENTS/ACTION REQUIRED Is access controlled out of hours? Have all objects that could be used as a weapon been identified and actions taken to remove or secure them? Is the room/furniture arranged in a way to allow rapid escape by staff if necessary? Is there a mechanism for communicating with other staff in an emergency (e.g. panic alarm)? Are staff escorted where the patient/relative is known to be potentially violent or aggressive? DIFFICULT/SENSITIVE DISCUSSIONS YES NO COMMENTS/ACTION REQUIRED If difficult/sensitive issues need to be discussed, is there a private room/area available? During difficult/sensitive discussions, is there a protocol for ensuring staff safety (e.g. escort, communication)? WORKING ALONE/ISOLATED YES NO COMMENTS/ACTION REQUIRED Is the need for staff to work alone or in an isolated situation 27

absolutely essential? Are additional measures in place to increase their security to an acceptable level (e.g. locked doors, use of escorts, and ring in system)? COMMUNITY WORK YES NO COMMENTS/ACTION REQUIRED Is there a system to ensure that the manager is aware of the whereabouts of their community staff at all times? Is there a procedure informing managers/staff of the actions to take if there are concerns for the safety of the member of staff in the community? Are escorts provided for situations that have the potential for violence and aggression, or might pose other threats to personal security? Is there a system in place to alert staff to patients/relatives known to be violent or aggressive? Is there a protocol that allows for the service to be delivered on hospital premises where the risk of violence or aggression appears unacceptable? HANDLING MONEY/VALUABLES YES NO COMMENTS/ACTION REQUIRED Are procedures in place to ensure that the handling of money/valuables is the minimum necessary? If handling of money/valuables is carried out regularly, is there a system to ensure that the activity is varied (eg member of staff, time of day)? 28

To establish the Risk Rating, multiply Likelihood by the Impact Managers name (Block Capitals):. Managers signature:... Date:. 29