Therapeutic Observation and Positive Engagement Policy

SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 Summary: The purpose of supportive observation is to ensure the safe and sensitive monitoring of the persons behaviour and mental wellbeing, enabling a rapid response to change, whilst at the same time fostering positive therapeutic engagement between staff and the individual. Keywords (minimum of 5): (To assist policy search engine) Observation, Therapeutic engagement, Risk assessment. Maintain safety and respect dignity. Care and Comfort checks. Target Audience: All clinical and medical staff working within Southern Health NHS Foundation Trust Mental Health, Learning Disabilities and Older People s Mental Health inpatient units involved in observation Next Review Date: August 2020 Approved & Ratified by: AMH Quality & Safety Meeting OPMH Governance Meeting Date issued: September 2017 Date of meeting: 24 August 2017 6 September 2017 Author: Sponsor: Laura Pemberton Head of Nursing specialised Services, Liz James, Head of Nursing AMH Carole Adcock Associated Director of Nursing AMH SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 1

Version Control Change Record Date Author Version Page Reason for Change April 14 Anne Leitch 2 Revised to incorporate learning from Critical Incidents November 2014 Tim Coupland 2 Clarity relating to observations within seclusion section 5.3.3 Within eyesight observations Additional information related to observation at night- section 5.3.5 - Night time observations April 2015 Tim Coupland 2 10, 20 Amendment to training requirements and addition of forms in appendix 3 August 2016 Louise Hartland 2 10 Amendment to training and assessment of competence process (section 8.2) 26/4/17 Review date extended from April to June 2017 May 2017 December 2016 Liz James Laura Pemberton 2 All Revised to incorporate learning from serious incidents: 5.1 Details of discussion with service user and carer/relative to be documented in RiO Clarification regarding different levels of observation over the 24 hour period 5.3.2 Added assessed risk as well as need The exact time of the checks must be documented on the observation record 5.3.5 Added checks should be at irregular intervals in a pattern that cannot be predicted Observation recording sheets updated to enable timings to be entered. Appendix 1 Change in observations RiO template Nice guidelines and updates required via incident learning. July 2017 Sept 2017 Laura Pemberton and Liz James Louise 3 all Change of focus of policy to be based within supportive and therapeutic care. Embedding NICE NG10 into the policy. Title change 4 All Review. Changes to students / agency staff. Hartland Sept 2017 Kathy Jackson 4 All Review. Typing errors. Sept 2017 John Stagg 4 All Review. Typing errors. 23/10/17 4 20 Appendix 3 - Addition of 5 minute observation sheet Reviewers/contributors Name Position Version Reviewed & Date Matrons (MH/SS inpatient units) Jan- April 2014 Consultation with Staff- Snap Survey 26 responses (25 MH, 1LD) January 2014 Sarah Leonard specific input on best practice and training Acute Care Pathway Manager Southern Health NHS Foundation Trust February 2014 MH/LD forum discussion on night time observation Heads of Nursing within AMH and Specialised Services April 2014 July 2017 SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 2

CONTENTS 1 Introduction 4 2 Scope 4 3 Definitions 4 4 Duties/responsibilities 5 5 Main policy 6 5.1 Principles 6 5.2 Implementing therapeutic engagement and supportive observation 7 5.3 Observation of babies during admission of Mother 7 5.4 Observation and engagement practice 7 5.5 General supportive observation 7 5.6 Intermittent supportive observation 8 5.7 Within eye sight supportive observation 8 5.8 Within arm s length supportive observation 9 5.9 Night time observations 9 5.10 Changing or amending observation levels 10 5.11 Who should carry out Observation? 10 6 Training Requirements 11 6.2 Guidance on training and assessment of competence 11 7 Monitoring Compliance 12 8 Reporting Incidents 12 9 Policy Review 12 10 Associated Documents 12 11 Supporting References 12 Page Appendices A1 Training Needs Analysis (TNA) 14 A2 Equality Impact Assessment (EqIA) 15 A3 Record of Observation forms 20 A4 Observation RiO Template 65 SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 3

Therapeutic Engagement and Supportive Observation Policy 1. Introduction 1.1 The primary aim of therapeutic engagement and supportive observation should be to engage positively with the service user to reduce risk and prevent harm. This involves a two-way relationship, established between a service user and staff member, which is meaningful, grounded in trust and therapeutic in nature. 1.2 Supportive observation is an important skill for all mental health professionals. It is a form of therapeutic engagement and intervention used in the prevention and management of suicide, self- harm and violence and to monitor mental health and evaluate against agreed planned care. 1.3 NICE guidelines (NG10, May 2015), Violence and aggression: short-term management in mental health, health and community settings provides clear guidance for the underpinning evidence of the development of this policy. It is recognised that not all supportive observation is used in the management of aggression, in addition it is used to reduce risk and prevent harm to service users in all areas of care and practice. Observation can be a restrictive intervention, therefore every effort should be made to use the least intrusive level of observation necessary, balancing the service user's safety, dignity and privacy with the need to maintain the safety of those around them. 1.4 The level of supportive observation agreed should ensure that the restriction is both appropriate and proportionate to the individual s presentation. 2. Scope 2.1 This policy applies to all permanent and non-permanent staff working within Southern Health NHS Foundation Trust (The Trust) Mental Health, Learning Disability and Older People s Mental Health inpatient units. 2.2 For particular services, local approaches may be agreed. The approaches reflect the type, scope and jurisdiction of the service. Any local approach must be formally agreed through Divisional Quality and Safety arrangements and noted as part of this policy as well as available on the Trust s policy section of the intranet. 2.3 All Service Users receiving in-patient care will be observed to low level intermittent observation as a minimum standard of once every 60 minutes. 3. Definitions 3.1 Observation A minimally restrictive intervention of varying intensity in which a member of the healthcare staff observes and maintains contact with a service user to ensure the service user's safety and the safety of others. 3.2 Positive engagement An intervention that aims to empower service users to actively participate in their care. Rather than 'having things done to' them, service users negotiate the level of engagement that will be most therapeutic. SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 4

3.3 Therapeutic engagement Compassionate therapeutic engagement is an essential aspect of supportive observation. The allocated and observing nurse should make appropriate and genuine attempts to build rapport with the service user and demonstrate a caring attitude. At the core of observation practice is the desire to engage with the person positively and proactively, using strength s based approaches. The staff member undertaking the observations should be able to convey that they are individually approachable. It is important to support the service user and help them feel valued. In particular listen to the service user s experience. 4. Duties / Responsibilities 4.1 Trust Board are accountable for ensuring that the Observation and Engagement Policy is in force and current and that it is reviewed regularly including following incidents and near misses. 4.2 Director of Nursing To ensure a policy is in place and reviewed regularly. 4.3 Associate Director of Nursing and Allied Health Professionals To ensure that the policy is reviewed within the time frame using national guidelines. 4.4 Head of Nursing and Quality To participate in the review and amendments of the policy and ensure that clinical staff are aware and adhere to the policy. 4.5 Responsible Clinician To work in collaboration with the service user, primary nurse and allied health professionals to assess the most appropriate level of supportive observation. The responsible clinician is responsible for the continued evaluation and effectiveness of the application of supportive observation. 4.6 Primary Nurse To work collaboratively with the service user to develop a patient safety care plan. This should be in collaboration with the responsible clinician and other allied health professionals. Where appropriate advanced directives/statements should be discussed with the service user and incorporated. Care plans should include any details regarding therapeutic engagement and supportive observation. 4.7 Allocated Member of staff The member of staff allocated to any observation duties should follow this policy and the service user specific care plans. They should use the documentation attached and complete all necessary checks. Whilst on allocated duties the staff member should be aware of the location of all service users. When handover of observations occurs the allocated member of staff should ensure that the next one is handed over to and any relevant documents signed to demonstrate this has occurred. SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 5

4.8 Nurse in Charge The nurse in charge of the ward is responsible for allocating registered and unregistered staff to undertake the therapeutic engagement and supportive observation, including the review of these. The nurse in charge needs to ensure that staff have the knowledge and competence to undertake this duty and free from other duties that could impede their ability to undertake the therapeutic engagement and supportive observation. At least once during each shift, the nurse in charge must set aside dedicated time for a healthcare worker to assess the mental state, and engage positively with, the service user. As part of the assessment the healthcare worker should evaluate the impact of the service user s mental state on the risk of violence and aggression, and record any risk in the electronic records/notes. The nurse in charge is responsible for handing over the services user s observation level each shift. 4.9 Ward Manager The ward manager is responsible for ensuring all staff have the opportunity to discuss and clarify the application of this policy, associated care planning and service user involvement, through the use of managerial and clinical supervision. The ward manager must ensure all staff have completed the competency level required and ensure that staff, maintain up-todate knowledge and skills. The ward manager is responsible for ensuring that the levels of staff are sufficient, and any improvement actions are completed relating to this area of practice on the ward. 4.10 Registered staff complete initial risk assessments and work collaboratively with the person (wherever possible) to develop observation care plans. The aim is to review plans and risk assessments on a regular basis and ensure these are implemented. 4.11 All clinical staff are responsible for familiarising themselves, adhering to and applying the Observation and Engagement Policy. Staff should be competent in undertaking observations. 5. Main policy 5.1 Principles The underpinning values supporting this policy are supported by the following Practice Principles: Recovery-oriented practice is the golden thread that runs through our services. It is not abandoned if the person experiences an acute period of illness, or if their capacity is compromised. There may be times when the balance of control between the individual and the service shifts, according to need, yet the principle of sharing the responsibility for managing risk will remain. This will include effective advance planning (e.g. use of collaborative crisis plans) and Services will work on the principle of nothing about me, without me. All aspects of CPA and care planning will be undertaken in collaboration with the individual. That includes assessing, planning, implementing and reviewing care. A shared responsibility, which places demands on both parties, will exist between the clinician and the individual to ensure this occurs SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 6

The practice of observation is about using skills to maintain privacy and dignity at all times Intrusion should be minimised and positive engagement with the person should take place The level of observation should be explained and discussed with the person unless it is felt that this would be detrimental to their mental health and (taking into consideration person confidentiality and capacity issues) their carer/relative whenever possible. Details of the discussion should be documented within the service users RiO progress notes Leaflet should be offered. It should be recorded in EPR the reason why a person and/or their carer/relative has not been involved completely in any change in observations The reason why a person requires a particular level of observation and under what specific circumstances it can be decreased must be recorded in their care plan i.e. the person must have met specific criteria which have been pre-determined and recorded in a care plan. Maintenance of observation levels will be in conjunction with the needs of the person and the decision to vary the level of observation should be determined in relation to the presentation of the individual At times, service users may have different levels of observation over the 24 hr period. For example someone may be on intermittent levels of observation during daytime hours, but a risk balance decision is made to observe on hourly observations whilst asleep to reduce the risk of them being disturbed by the checks. 5.2 Implementing therapeutic engagement and supportive observation Use supportive observation only after positive engagement with the Service User has failed to dissipate the risk to self and others. Recognise that service users can find observation intrusive, and it can lead to feelings of isolation and dehumanisation. Give the service user information about why they are under observation, the aims of the observation, how long it is likely to last and what needs to achieved for it to stop. If the service user agrees, tell their carer about the levels and aims of observation. 5.3 Observation of babies during admission of Mother Babies accompanying mothers on admission to the Mother and Baby Unit will be regarded as a dependent child A dependent child is not classified as being admitted, but is recognised as a child who has health and care needs, which cannot be met entirely by their mother (who is an inpatient). The safety and wellbeing of the baby is paramount at all times. Babies will be on a minimum of 15 minute observations 5.4 Observation and engagement practice NICE Guidelines 25 (2005) identifies different types of observation. The Trust quick reference guide (appendix 4) provides further definition as to how it applies for each type. 5.5 General supportive observation General supportive observation is the minimum standard for all in-patient units. The location of all service users should be known to staff and they should be observed a minimum of every 60 minutes, both day and night. Everyone on general intermittent supportive observation should have 1:1 time with staff on a shift by shift basis as a minimum. Southern Health focus general observation on ensuring the Care and Comfort of the person on an inpatient unit. SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 7

It is a fundamental expectation and standard that an hourly check is made on each individual within an inpatient service (informal or detained) over daytime and night time hours. Care and Comfort checks are regular checks to: o Interact and talk with the person about their well being o Objectively assess and review a person s mental state and general behaviours o Establish the whereabouts and activity of the person o To ensure personal comfort for the person o To ensure basic needs are met o To establish if the overall environment feels and looks safe 5.6 Intermittent supportive observation Is considered effective and appropriate where a person is potentially but not immediately at risk of disturbed/violent behaviour, suicide, self-harm and vulnerability. The observations will be recorded at intervals of 30 minutes or less depending on assessed need and risk. Observations and therapeutic engagement can be at irregular intervals in a pattern that cannot be predicted by the person. The exact time of the checks must be documented on the observation record. Anyone on intermittent observation should have an individualised care plan and an observation record (appendix 3) In addition to undertaking Care and Comfort checks a member of staff should set aside dedicated time at least once a shift to engage with the patient to assess their mental state. An evaluation of the patients mood and associated risks should be recorded on EPR 5.7 Within eye sight supportive observation Is considered effective when there is a significant risk of disturbed/violent behaviour, suicide, self-harm and vulnerability e.g. a person who could at any time make an attempt which could seriously harm themselves or others. They should be within eyesight at all times day and night. The level of observation should be explained and discussed with the person unless it is felt that this would be detrimental to their mental health and (taking into consideration person confidentiality and capacity issues) their carer/relative whenever possible. Searching of the person and their belongings may be necessary. This should be conducted sensitively and with due regard to legal rights and in keeping with Southern Health NHS Foundation Trust policy on personal searches. Anyone on within eye sight observation should have an individualised care plan and an observation record (appendix 3). The person s care plan and medical entry on the EPR should specify what the observing nurses are required to do to support the person during this time. Issues of comfort, privacy, dignity, gender and environmental dangers should be discussed and incorporated into the care plan. Consideration should be given to whether the person may be alone for short periods (to use the toilet, whilst sleeping or for other reasons of privacy and dignity observing them too closely would be detrimental to their mental health). This should be clearly documented within the care plan and discussed with the service user. At least once per shift a member of staff should set aside dedicated time to engage with the person to assess their mental state. An evaluation of the persons mood and associated risks should be recorded on EPR SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 8

The member of staff responsible for carrying out the prescribed observations must document a brief summary of the person s interactions, behaviour and mental state in the EPR. The nurse in charge must nominate a particular member of staff who has been trained to undertake observation practice to conduct observations of a particular person. Where possible that member of staff will perform those observations for no more than one hour Eye sight observation applies to incidences when a patient requires Seclusion. The following principles are stated in the seclusion policy (Please refer to SH CP 107 for specific procedural guidance) 5.8 Within arm s length supportive observation Should be used with care after discussion and agreement with the immediate team. This level should be used for persons at the highest levels of risk of harming themselves or others and should be supervised in close proximity of the staff member. The level of observation should be explained and discussed with the person unless it is felt that this would be detrimental to their mental health and (taking into consideration person confidentiality and capacity issues) their carer/relative whenever possible. Searching of the person and their belongings may be necessary. This should be conducted sensitively and with due regard to legal rights and in keeping with Southern Health NHS Foundation Trust policy on personal searches. Anyone on arm s length observation should have an individualised care plan and an observation record (appendix 3) The person s care plan and medical entry on the EPR should specify what the observing nurses are required to do to support the person during this time. Issues of comfort, privacy, dignity, gender and environmental dangers should be discussed and incorporated into the care plan. A designated member of staff will provide one to one intervention but there may be times when more than one staff member is required for reasons of safety. The staff member responsible for carrying out the prescribed observations must document hourly a brief summary of the person s interactions, behaviour and mental state in the EPR. The nurse in charge must nominate a particular member/s of staff to conduct observations of a particular person. Where possible that member of staff will perform those observations for no more than one hour 5.9 Night time observations When a person is on any level of observation there are some general principles that should be followed. The level of observation will have been risk assessed and reviewed by the MDT. The care plan will clearly state what the risks are and what staff should be mindful of when carrying out observations at night when the person is in their bedroom. Each person, no matter what their level of observation, should be checked hourly as a minimum Checks should be at irregular intervals in a pattern that cannot be predicted by the person. Staff will have discussed with the person the reason for the level of observation and how this will be undertaken over the 24hour period All staff on duty will have received a full handover of the people on the ward and understand the level of observations required Staff undertaking observation checks will have received the appropriate training The member of staff undertaking the observation should be able to clearly see that the person is breathing SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 9

If the staff member undertaking the observation is unable to see the person clearly they should enter the room to ensure there is no risk to the person The observer should be able to see the persons head and be assured that there is nothing impeding the person s breathing If there are any concerns about the person s mental state or physical wellbeing a top-toe check may be required to see if the person is moving freely and not restricted in anywaythis would be at the discretion of the nurse in charge who would refer to specific care plans or handover agreements about the type and nature of some observation at night Any exceptions to observation requirements at night must be agreed with the MDT, Risk Assessed on a daily basis and a Care Plan must be in place to reflect decisions that may deviate from the requirement 5.10 Changing or amending observation levels The prescribing of observation levels should, whenever possible, be the result of a joint multi-disciplinary (MDT) assessment, although a nurse/mental Health Practitioner can initiate a level of observation above general level on admission or following a rapid change in the person s mental state before a discussion with medical staff can take place Ward Permanent and non-permanent w staff can initiate and increase levels of observation should a person s mental state and circumstances change increasing their risk of disturbed/violent behaviour, suicide, self-harm and vulnerability. The decision to reduce the frequency of observations should normally be carried out following an MDT assessment and discussion. The risk assessment and rationale for all changes must clearly be documented in the care plan and clinical notes within the EPR The Observation Level Changes; RiO Template (appendix 4) can be used for this purpose Non-permanent staff can only undertake this role if they are a registered nurse and have been approved by the local management team as being competent to do so. This would need to be evidenced in the competency framework attached. In circumstances where it is felt by the medical practitioner that observation should not be reduced without medical consultation this should be clearly recorded on the care plan in the EPR, in the clinical notes and communicated verbally with the MDT Any person subject to levels of observation above General Observation should be reviewed at least once per day by at least two members of the MDT. At least once a week a full review of observation levels must take place by the MDT as indicated in the persons care plan and the discussion outcome recorded on the EPR 5.11 Who should carry out Observation? Observations should be carried out by a member of staff, permanent or non-permanent, who is competent Permanent staff, once deemed competent through completion of training requirements will be able to undertake all levels of observations Non-permanent staff; Students, once deemed competent through completion of training requirements and competency assessment will be able to undertake observations as detailed below; Year 1 students General Observations Year 2 students General and Intermittent Observations Year 3 students All levels of Observations SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 10

SHFT is committed to supporting students to develop their clinical skills in preparation for registration. It is the joint responsibility of the student, mentor and nurse in charge of each shift to make decisions on when a student will carry out observations. There may be clinical reasoning why a student may not undertake observations regardless of them having demonstrated competence. Non-permanent staff; Agency staff will be considered competent by SHFT, however during their induction their attention should be brought to this policy if this staff group are with certain services for long period of time the full competency paperwork can be undertaken. It is the responsibility of the nurse in charge to ensure that observations are carried out according to the agreed prescribed level within eyesight. 6. Training Requirements 6.1 Modern Matrons and Ward Managers are responsible for ensuring that staff are aware of and have read the Therapeutic Engagement and Supportive Observation Policy. The responsibility for medical staff lies with the Clinical Service Directors. Observation training and assessment of competency is a requirement for all staff identified in the Training Needs Analysis (Appendix A1). Other staff may be identified as requiring the training following a local risk assessment and these staff should complete the training and assessment of competency as set out below. Modern Matrons and Ward Managers must also ensure that new members of staff, Bank and Agency staff receive Observation training as part of the local induction programme 6.2 Guidance on training and assessment of competence All permanent and non-permanent staff should have the observation policy explained to them as part of the local induction process. All permanent and non-permanent staff must complete the trust approved therapeutic observation training and have been deemed competent to undertake therapeutic observations in accordance with the observation competency assessment prior to carrying out observations without supervision. The competency assessment involves two episodes of supervised practice before they can be considered competent; one in providing intermittent observation followed by at least one in providing within arm s length observation. If there is concern over their ability to undertake observations independently, they will be given further supervised practice until deemed competent. Assessment of competence for new starters must be completed by a band 5 or above nurse or mental health practitioner who has a minimum of 1 years post registration experience. The assessment of competence for all other staff must be completed by a qualified member of staff who is a minimum of one band above the person who is being assessed. Ward managers must ensure that all new staff receive observation training and a competency assessment within the first two weeks in post For all staff, a copy of the competency assessment must be retained in personal files for quality monitoring purposes. SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 11

Agency staff will have the observation policy explained to them as part of the induction process and will be expected to be competent in undertaking observations including having completed training and observation practice. All students who participate in therapeutic observation practice must complete the Trust approved training and have been deemed competent to undertake therapeutic observations in accordance with the observation competency assessment prior to carrying out observations without supervision. A copy of the competency assessment must be retained in the clinical area for quality monitoring purposes. 7. Monitoring Compliance The policy will be audited once a year on a sample of patients from each inpatient area against the observation standards highlighted in Section 5.2 Audit will also include a service experience measure Incidents arising from observation will be shared including lesson learned. Observation practice will be continually improved as we learn from practice and incidents Training compliance will be monitored as part of the overall performance management and ensuring quality and safety is maintained 8. Reporting Incidents 8.1 Staff would record incidents arising from observation in line with the Trust s Incident Reporting System (Ulysses) 9. Policy Review 9.1 The policy will be reviewed periodically in line with learning and at least every 3 years 10. Associated Documents SH CP 49 Admission, Discharge and Transfer policy SH CP 38 Management of Service user/patient who goes missing SH CP 27 Risk assessment and management for patients and service users SH CP 28 Managing Clinical Risk practical guidance SH CP 52 Policy for the use of leave under Sec 17 of the Mental Health Act 1983 SH HS 07 Search of Patients (detained or informal), Visitors and their property SH NCP 23 Management of Violence and Aggression Procedure SH CP 144 Privacy, Dignity and Respect SH IG 1 Clinical Information Assurance (Record Keeping) policy SH IG 5 Record Keeping Standards and Audit policy 11. Supporting References NICE Clinical Guidelines No 25 (2005). The short term management of disturbed/violence behaviour in psychiatric in-patient settings and emergency departments. Safe and Supportive Observation of Patients at Risk, (June 1999) Standing Nursing and Midwifery Advisory Committee. Mental Health Act 1983 - Code of Practice chapter 15 SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 12

Department of Health (2006) Mental health observation, including constant observation: Good practice guidelines for staff working in prisons Patient Safety First How to Reducing Harm from Deterioration Patient Safety First website page Standard Nursing and Midwifery Advisory Committee (1999) Practice Guidance. Safe and Supportive Observation of Patients at Risk The City 128 Study. Correlation Between levels of Conflict and Containment on Acute Psychiatric wards: NPSA data from 1 st Jan 2009 to 31 st Dec 2009 https://pathways.nice.org.uk/pathways/violence-andaggression#path=view%3a/pathways/violence-and-aggression/restrictive-interventions-formanaging-violence-and-aggression-in-adults.xml&content=view-node%3anodes-observation SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 13

APPENDIX 1 LEAD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Deputy Head of LEAD or LEAD Strategic Education Lead) before the policy goes through Policy Group Training Programme Observation Training Once Frequency Course Length Delivery Method Trainer(s) Recording Attendance This is individual to each member of staff but the training and assessing of competency will take up to 4 hours Face to face training in the clinical area and competency assessment Modern Matron/Ward Manager Modern Matron/Ward Manager will report competency through LEaD training data base Strategic & Operational Responsibility Strategically Head of Nursing, AHP and Quality for MH. Operationally Modern Matrons/Ward Managers Directorate Division Target Audience All Qualified Nurses, OT's, OT technicians, Assistant Associate Practitioners, Specialist Practitioners/Advanced Practitioners/Practitioners, Health care Support Workers/Support Workers and Trainee Practitioners working in the following services; MH/LD Mental Health & Specialised Services Learning Disabilities Older Persons Mental Health Elmleigh (Elmleigh inpatient & PICU); Hollybank; Melbury Lodge (Kinglsey Ward, Mother & Baby Unit & Melbury OT); Parklands Hospital (Hawthorns inpatient, PICU and MOD unit); Antelope House (Saxon, Hamtun, Trinity & Abbey wards and South OT); South Fast Stream Rehab (Forest Lodge); Leigh House; Ravenswood House (Ashurst, Lyndhurst, Malcolm Faulk, Mary Graham, Meon Valley wards, RSU Therapies and RSU Management); Southfield & Southfield OT; Bluebird House (Bluebird Nursing & Security, Bluebird House OT, Hill, Moss & Stewart wards) Woodhaven Hospital (Ashford Ward). All Qualified Nurses, OT's, OT technicians, Assistant Associate Practitioners, Specialist Practitioners/Advanced Practitioners/Practitioners, Health care Support Workers/Support Workers and Trainee Practitioners working in the following services; Willow ward All Qualified Nurses, OT's, OT technicians, Assistant Associate Practitioners, Specialist Practitioners/Advanced Practitioners/Practitioners, Health care Support Workers/Support Workers and Trainee Practitioners working in the following services; Gosport War Memorial Hospital (Dryad & Daedalus wards); Melbury Lodge (Stefano Oliveri ward); Parklands Hospital (Beechwood, Elmwood wards & North Inpatient Therapies ); Western Community Hospital (Beaulieu, Berrywood & Minstead wards & Western Inpatient Therapies) SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 14

APPENDIX 2 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on different groups within the community For guidance and support in completing this form please contact a member of the Equality and Diversity team on 01256 376358 Name of policy/service/project/plan: Therapeutic Observation and positive engagement Policy Policy Number: SH CP 37 Department: Lead officer for assessment: Mental Health Division/ Learning Disability/ OPMH services Carole Adcock Associate Director of nursing AMH Date Assessment Carried Out: July 2017 1. Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Provide brief details of the scope of the policy being reviewed, for example: Is it a new service/policy or review of an existing one? Is it a national requirement? Answers / Notes The purpose of the Therapeutic Observation and Positive Engagement Policy is to ensure patient safety following an appropriate risk assessment. It is a therapeutic intervention used in the prevention and management of suicide, self- harm. It will monitor the persons mental health and evaluate progress against planned care. Review of existing policy 2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 15

APPENDIX 2 Southern Health NHS Foundation Trust Equality Impact Assessment / Equality Analysis Screening Tool Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions 2.1 What is the equalities profile of the team delivering the service/policy? Data, research and information that you can refer to The policy is relevant to ALL clinical staff working within Mental Health wards 2.2 What equalities training have staff received? All clinical staff undertake Equality and Diversity training as part of corporate induction and e-learning 2.3 What is the equalities profile of service users? The Equality and Diversity team will report on patient data on an annual basis 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? 2.5 What engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? 2.6 If you are planning to undertake any consultation in the future regarding this service or policy, how will you include equalities considerations within this? The Trust has implemented the Equality and Diversity Delivery System which has 4 key objectives: 1. Better health outcomes for all 2. Improve patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership Full consultation opportunity within Mental Health division Consultation would be open to all staff and Service User representation SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 16

In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this. Age Positive impact (including examples of what the policy/service has done to promote equality) The policy is applicable to all Mental Health division in-patient units inclusive of CAMH s Negative Impact Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Disability The Trust ensures that all its facilities are accessible and safe through disability access audits and the design of in-patient services. This policy is only applicable to inpatient units Gender Reassignment The policy is applicable to all genders Marriage and Civil Not applicable SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 17

Partnership Pregnancy and Maternity Race Religion or Belief The policy would have no impact on pregnant patients. The policy is designed to protect service users from risk to self or to others following a multi-disciplinary risk assessment. The policy works in line with this initial risk assessment which incorporates individual need. The policy covers service users across all races. The policy would have no impact on service user religion or belief. The policy is designed to protect service users from risk to self or to others following a multi-disciplinary risk assessment. The policy works in line SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 18

with this initial risk assessment which incorporates individual need. Sex Sexual Orientation The policy applies to mixed sex in-patient wards which comply with the Eliminating Mixed Sex Wards legislation. The Trust monitors compliance and reports to commissioners on a monthly basis The policy is implemented in line with the Privacy and Dignity compliance monitored through the audit process. Potential breach of EMSA on the Psychiatric Intensive Care wards PLACE inspections identify potential breaches with immediate action undertaken by the unit manager. All units are checked on a monthly basis against EMSA compliance regulations SH CP 37 Therapeutic Observation and Positive Engagement Policy Version: 4 September 2017 19

Rm No: 1 Low level intermittent Observation RECORD (day and night) WARD: DATE: W = Ward Areas B = In Bedroom S = Sleeping O/L = On Leave G = Garden/Courtyard C = Corridor Rooms L = Lounge Name 00: 00 01: 00 02: 00 03: 00 04: 00 05: 00 06: 00 07: 00 08: 00 09: 00 10: 00 11: 00 12: 00 13: 00 14: 00 15: 00 M = Meal D = Dining Room A =AWOL 17: 18: 19: 20: 21: 22: 00 00 00 00 00 00 16: 00 23: 00 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Signature: There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting.

Recording Sheet for 5 Minute Observations DATE:.. WARD: Reason for observation : Reasons and Special Instructions Risks : Instructions for bathroom/toilet : Instructions for when asleep : Specific staff gender required male/female or any : Number of staff to carry out the observation : Mental state, behaviour, interaction with staff and patients Signature 00:00-00:05 00:05-00:10 00:10-00:15 00:15-00:20 1 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

00:20-00:25 00:25-00:30 00:30-00:35 00:35-00:40 00:40-00:45 00:45-00:50 00:50-00:55 00:55-01:00 01:00-01:05 01:05-01:10 01:10-01:15 01:15-01:20 01:20-01:25 01:25-01:30 01:30-01:35 01:35-01:40 01:40-01:45 01:45-01:50 01:50-01:55 01:55-02:00 02:00-02:05 02:05-02:10 02:10-02:15 02:15-02:20 2 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

02:20-02:25 02:25-02:30 02:30-02:35 02:35-02:40 02:40-02:45 02:45-02:50 02:50-02:55 02:55-03:00 03:00-03:05 03:05-03:10 03:10-03:15 03:15-03:20 03:20-03:25 03:25-03:30 03:30-03:35 03:35-03:40 03:40-03:45 03:45-03:50 03:50-03:55 03:55-04:00 04:00-04:05 04:05-04:10 04:10-04:15 04:15-04:20 3 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

04:20-04:25 04:25-04:30 04:30-04:35 04:35-04:40 04:40-04:45 04:45-04:50 04:50-04:55 04:55-05:00 05:00-05:05 05:05-05:10 05:10-05:15 05:15-05:20 05:20-05:25 05:25-05:30 05:30-05:35 05:35-05:40 05:40-05:45 05:45-05:50 05:50-05:55 05:55-06:00 06:00-06:05 06:05-06:10 06:10-06:15 06:15-06:20 4 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

06:20-06:25 06:25-06:30 06:30-06:35 06:35-06:40 06:40-06:45 06:45-06:50 06:50-06:55 06:55-07:00 07:00-07:05 07:05-07:10 07:10-07:15 07:15-07:20 07:20-07:25 07:25-07:30 07:30-07:35 07:35-07:40 07:40-07:45 07:45-07:50 07:50-07:55 07:55-08:00 08:00-08:05 08:05-08:10 08:10-08:15 08:15-08:20 5 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

08:20-08:25 08:25-08:30 08:30-08:35 08:35-08:40 08:40-08:45 08:45-08:50 08:50-08:55 08:55-09:00 09:00-09:05 09:05-09:10 09:10-09:15 09:15-09:20 09:20-09:25 09:25-09:30 09:30-09:35 09:35-09:40 09:40-09:45 09:45-09:50 09:50-09:55 09:55-10:00 10:00-10:05 10:05-10:10 10:10-10:15 10:15-10:20 6 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

10:20-10:25 10:25-10:30 10:30-10:35 10:35-10:40 10:40-10:45 10:45-10:50 10:50-10:55 10:55-11:00 11:00-11:05 11:05-11:10 11:10-11:15 11:15-11:20 11:20-11:25 11:25-11:30 11:30-11:35 11:35-11:40 11:40-11:45 11:45-11:50 11:50-11:55 11:55-12:00 12:00-12:05 12:05-12:10 12:10-12:15 12:15-12:20 7 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

12:20-12:25 12:25-12:30 12:30-12:35 12:35-12:40 12:40-12:45 12:45-12:50 12:50-12:55 12:55-13:00 13:00-13:05 13:05-13:10 13:10-13:15 13:15-13:20 13:20-13:25 13:25-13:30 13:30-13:35 13:35-13:40 13:40-13:45 13:45-13:50 13:50-13:55 13:55-14:00 14:00-14:05 14:05-14:10 14:10-14:15 14:15-14:20 8 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

14:20-14:25 14:25-14:30 14:30-14:35 14:35-14:40 14:40-14:45 14:45-14:50 14:50-14:55 14:55-15:00 15:00-15:05 15:05-15:10 15:10-15:15 15:15-15:20 15:20-15:25 15:25-15:30 15:30-15:35 15:35-15:40 15:40-15:45 15:45-15:50 15:50-15:55 15:55-16:00 16:00-16:05 16:05-16:10 16:10-16:15 16:15-16:20 9 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

16:20-16:25 16:25-16:30 16:30-16:35 16:35-16:40 16:40-16:45 16:45-16:50 16:50-16:55 16:55-17:00 17:00-17:05 17:05-17:10 17:10-17:15 17:15-17:20 17:20-17:25 17:25-17:30 17:30-17:35 17:35-17:40 17:40-17:45 17:45-17:50 17:50-17:55 17:55-18:00 18:00-18:05 18:05-18:10 18:10-18:15 18:15-18:20 10 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

18:20-18:25 18:25-18:30 18:30-18:35 18:35-18:40 18:40-18:45 18:45-18:50 18:50-18:55 18:55-19:00 19:00-19:05 19:05-19:10 19:10-19:15 19:15-19:20 19:20-19:25 19:25-19:30 19:30-19:35 19:35-19:40 19:40-19:45 19:45-19:50 19:50-19:55 19:55-20:00 20:00-20:05 20:05-20:10 20:10-20:15 20:15-20:20 11 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

20:20-20:25 20:25-20:30 20:30-20:35 20:35-20:40 20:40-20:45 20:45-20:50 20:50-20:55 20:55-21:00 21:00-21:05 21:05-21:10 21:10-21:15 21:15-21:20 21:20-21:25 21:25-21:30 21:30-21:35 21:35-21:40 21:40-21:45 21:45-21:50 21:50-21:55 21:55-22:00 22:00-22:05 22:05-22:10 22:10-22:15 22:15-22:20 12 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

22:20-22:25 22:25-22:30 22:30-22:35 22:35-22:40 22:40-22:45 22:45-22:50 22:50-22:55 22:55-23:00 23:00-23:05 23:05-23:10 23:10-23:15 23:15-23:20 23:20-23:25 23:25-23:30 23:30-23:35 23:35-23:40 23:40-23:45 23:45-23:50 23:50-23:55 23:55-24:00 Service users view of being on observation 13 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Recording Sheet for High Level intermittent observations - 10 Minute frequency Patient Label DATE:.. WARD: Reason for observation : Reasons and Special Instructions Risks : Instructions for bathroom/toilet : Instructions for when asleep : Specific staff gender required male/female or any : Number of staff to carry out the observation : Mental state, behaviour, interaction with staff and patients Signature Signature of new allocated staff, agreeing they have taken over and know the risks 1 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

00:00-00:10 Appendix 3 00:10-00:20 00:20-00:30 00:30-00:40 00:40-00:50 00:50-01:00 01:00-01:10 01:10-01:20 01:20-01:30 01:30-01:40 01:40-01:50 01:50-02:00 02:00-02:10 02:10-02:20 02:20-02:30 02:30-02:40 02:40-02:50 02:50-03:00 03:00-03:10 03:10-03:20 03:20-03:30 03:30-03:40 03:40-03:50 03:50-04:00 2 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

04:00-04:10 Appendix 3 04:10-04:20 04:20-04:30 04:30-04:40 04:40-04:50 04:50-05:00 05:00-05:10 05:10-05:20 05:20-05:30 05:30-05:40 05:40-05:50 05:50-06:00 06:00-06:10 06:10-06:20 06:20-06:30 06:30-06:40 06:40-06:50 06:50-07:00 07:00-07:10 07:10-07:20 07:20-07:30 07:30-07:40 07:40-07:50 07:50-08:00 3 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

08:00-08:10 Appendix 3 08:10-08:20 08:20-08:30 08:30-08:40 08:40-08:50 08:50-09:00 09:00-09:10 09:10-09:20 09:20-09:30 09:30-09:40 09:40-09:50 09:50-10:00 10:00-10:10 10:10-10:20 10:20-10:30 10:30-10:40 10:40-10:50 10:50-11:00 11:00-11:10 11:10-11:20 11:20-11:30 11:30-11:40 11:40-11:50 11:50-12:00 4 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

12:00-12:10 Appendix 3 12:10-12:20 12:20-12:30 12:30-12:40 12:40-12:50 12:50-13:00 13:00-13:10 13:10-13:20 13:20-13:30 13:30-13:40 13:40-13:50 13:50-14:00 14:00-14:10 14:10-14:20 14:20-14:30 14:30-14:40 14:40-14:50 14:50-15:00 15:00-15:10 15:10-15:20 15:20-15:30 15:30-15:40 15:40-15:50 15:50-16:00 5 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

16:00-16:10 Appendix 3 16:10-16:20 16:20-16:30 16:30-16:40 16:40-16:50 16:50-17:00 17:00-17:10 17:10-17:20 17:20-17:30 17:30-17:40 17:40-17:50 17:50-18:00 18:00-18:10 18:10-18:20 18:20-18:30 18:30-18:40 18:40-18:50 18:50-19:00 19:00-19:10 19:10-19:20 19:20-19:30 19:30-19:40 19:40-19:50 19:50-20:00 6 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

20:00-20:10 Appendix 3 20:10-20:20 20:20-20:30 20:30-20:40 20:40-20:50 20:50-21:00 21:00-21:10 21:10-21:20 21:20-21:30 21:30-21:40 21:40-21:50 21:50-22:00 22:00-22:10 22:10-22:20 22:20-22:30 22:30-22:40 22:40-22:50 22:50-23:00 23:00-23:10 23:10-23:20 23:20-23:30 23:30-23:40 23:40-23:50 23:50-24:00 7 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Service users view of being on observation 8 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Recording Sheet for High Level intermittent observations - 15 Minute Observations frequency Patient Label DATE:.. WARD: Reason for observation : Reasons and Special Instructions Risks : Instructions for bathroom/toilet : Instructions for when asleep : Specific staff gender required male/female or any : Number of staff to carry out the observation : Mental state, behaviour, interaction with staff and patients Signature Signature of new allocated staff, agreeing they have taken over and know the risks 1 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

00:00-00:15 00:15-00:30 00:30-00:45 00:45-01:00 01:00-01:15 01:15-01:30 01:30-01:45 01:45-02:00 02:00-02:15 02:15-02:30 02:30-02:45 02:45-03:00 03:00-03:15 03:15-03:30 03:30-03:45 03:45-04:00 04:00-04:15 04:15-04:30 04:30-04:45 04:45-05:00 05:00-05:15 05:15-05:30 05:30-05:45 2 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

05:45-06:00 06:00-06:15 06:15-06:30 06:30-06:45 06:45-07:00 07:00-07:15 07:15-07:30 07:30-07:45 07:45-08:00 08:00-08:15 08:15-08:30 08:30-08:45 08:45-09:00 09:00-09:15 09:15-09:30 09:30-09:45 09:45-10:00 10:00-10:15 10:15-10:30 10:30-10:45 10:45-11:00 11:00-11:15 11:15-11:30 3 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

11:30-11:45 11:45-12:00 12:00-12:15 12:15-12:30 12:30-12:45 12:45-13:00 13:00-13:15 13:15-13:30 13:30-13:45 13:45-14:00 14:00-14:15 14:15-14:30 14:30-14:45 14:45-15:00 15:00-15:15 15:15-15:30 15:30-15:45 15:45-16:00 16:00-16:15 16:15-16:30 16:30-16:45 16:45-17:00 17:00-17:15 4 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

17:15-17:30 17:30-17:45 17:45-18:00 18:00-18:15 18:15-18:30 18:30-18:45 18:45-19:00 19:00-19:15 19:15-19:30 19:30-19:45 19:45-20:00 20:00-20:15 20:15-20:30 20:30-20:45 20:45-21:00 21:00-21:15 21:15-21:30 21:30-21:45 21:45-22:00 22:00-22:15 22:15-22:30 22:30-22:45 22:45-23:00 5 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

23:00-23:15 23:15-23:30 23:30-23:45 23:45-24:00 Service users view of being on observation 6 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Recording Sheet for High Level intermittent observations - 30 Minute Observations frequency Patient Label DATE:.. WARD: Reasons and Special Instructions Reason for observation : Risks : Instructions for bathroom/toilet : Instructions for when asleep : Specific staff gender required male/female or any : Number of staff to carry out the observation : Mental state, behaviour, interaction with staff and patients Signature Signature of new allocated staff, agreeing they have taken over and know the risks 1 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

00:00-00:30 Appendix 3 00:30-01:00 01:00-01:30 01:30-02:00 02:00-02:30 02:30-03:00 03:00-03:30 03:30-04:00 04:00-04:30 04:30-05:00 05:00-05:30 05:30-06:00 06:00-06:30 06:30-07:00 07:00-07:30 07:30-08:00 08:00-08:30 08:30-09:00 09:00-09:30 09:30-10:00 10:00-10:30 10:30-11:00 11:00-11:30 11:30-12:00 2 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

12:00-12:30 Appendix 3 12:30-13:00 13:00-13:30 13:30-14:00 14:00-14:30 14:30-15:00 15:00-15:30 15:30-16:00 16:00-16:30 16:30-17:00 17:00-17:30 17:30-18:00 18:00-18:30 18:30-19:00 19:00-19:30 19:30-20:00 20:00-20:30 20:30-21:00 21:00-21:30 21:30-22:00 22:00-22:30 22:30-23:00 23:00-23:30 23:30-24.00 3 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Service users view of being on observation 4 There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting

Continuous Observation recording chart - Patient Label DATE:.. WARD: Reasons and Special Instructions Reason for observation : Risks : Instructions for bathroom/toilet : Instructions for when asleep : Specific staff gender required male/female or any : Number of staff to carry out the observation : Nurse in charge prescribed nature of continuous observation: Specify within eyesight or within arms lengh Mental state, behaviour, interaction with staff and patients Signature Signature of new allocated staff, agreeing they have taken over and know the risks There are to be no changes made to this form. Any request will be required to go through the Divisional Quality and Safety Meeting.