Corporate Locked Door: Standard Operating Procedure Document Control Summary Status: Replacement. Replaces: Locked Door Policy (C/YEL/ip/02) Version: v1.0 Date: March 2016 Author/Owner/Title: Kenny Laing - Deputy Director of Nursing Approved by: Policy and Procedures Committee Date: 17 th March 2016 Ratified: Policy and Procedures Committee Date: 17 th March 2016 Related Trust Strategy and/or Strategic Aims Implementation Date: March 2016 Review Date: March 2019 Key Words: Associated Policy or Standard Operating Procedures Contents Provide high quality recovery focused services Mental Health Act; DOLS; Locked door Mental Health Act Policy Mental Capacity Act Policy DOLS SOP 1. Introduction... 2 2. Purpose... 2 3. Scope... 2 4. Legal Framework... 3 5. Wards where the doors are locked... 3 6. Procedure to be followed in the event of ward doors having to be locked.... 4 7. Process For Monitoring Compliance And Effectiveness... 5 8. References... 5
Locked Door SOP Feb 2016 Change Control Amendment History Version Dates Amendments 1.0 February 2016 Amended to ensure MHA compliance. Revised internal and external notices added. 1. Introduction The Trust is committed to ensuring that wards providing services for people with mental health problems should strive to deliver care in the least restrictive way possible. This is in keeping with the principles set out in the Mental Health Act Code of Practice and in research undertaken by Professor Len Bowers. This SOP has been developed to ensure that all service users have their privacy, safety and dignity respected and provides guidance in keeping with the Mental Health Act (1983) Code of Practice Chapter 8. This SOP describes that steps that staff must take to protect the rights of service users when, under certain circumstances, practice areas have to lock their doors in order to maintain a safe environment. In open ward environments where for the safety of informal patients, who would be at risk of harm if they wandered out of a clinical environment, the primary interventions to maintain safety should be adequate staffing levels, positive therapeutic engagement and good observation, not simply by locking the doors of the unit or ward. 2. Purpose This SOP is designed to provide guidance on the locking of open wards and includes all entrances and exits to that ward, including the garden. The nurse in charge of any shift is responsible for the care and protection of service users, staff and the maintenance of a safe environment, taking into consideration the rights of service users under the Mental Health Act and legislation supported by Deprivation of Liberty Safeguards (DOLS) within the Mental Capacity Act. This responsibility includes the care of service users who may be vulnerable because they are considered a risk to other people, to themselves or may lack capacity. The nurse in charge of a shift has discretion to lock the door of the ward to protect service users or others because of either the behaviour of a service user or to prevent access to the ward from specific issues occurring outside the ward. This may be for short episodes or for a full shift. 3. Scope The scope of this SOP is all in-patient units within South Staffordshire and Shropshire Healthcare Foundation NHS Trust and should be read in conjunction with the Trust s SOP and guidance on Deprivation of Liberty Safeguards and Informal admission. Page 2 of 8
Locked Door SOP Feb 2016 4. Legal Framework There are several legal considerations to be considered in relation to patients who may be resident on wards where doors are locked either permanently or temporarily, specifically in relation to the use of the Mental Health Act and Mental Capacity Act. Generally a patient detained under a Section of the Mental Health Act 1983 is legally required to remain on the ward unless he or she has been granted leave of absence under Section 17 of the Act by their Responsible Clinician. As a patient s mental state improves and any risk they may present to themselves or others diminishes the Responsible Clinician will decide whether that patient can leave the ward to go outside the hospital or its grounds. However a substantial proportion of detained patients who, because of their mental state, still pose a risk to themselves or others make attempts to leave the ward without the agreement of their clinical team. To minimize such risks exit from the ward may need to be managed by means of locking the ward doors. An informal patient who persistently and/or purposefully attempts to leave the ward, whether or not he or she has the capacity to understand the risks involved, should be assessed to determine whether the criteria for detention under the Mental Health Act 1983 are met and if so, whether an application for detention under this Act should be made. In the event of ward doors being locked, it is unlikely that there will be a deprivation of liberty if an informal patient, who has capacity to consent to being admitted and has done so, is informed of the locked door policy and consents to being informally admitted and remaining on the ward under these conditions. The patient should be told who they can speak to if they wish to leave and must be able to leave at any time they wish to, unless they are being detained using the holding powers under section 5 of the Mental Health Act or an application for detention. A ward should never lock the doors in response to having low staffing levels, however if this decision has to be taken in response to a major incident or unforeseen emergency then this must be immediately reported to the Head of Service and Director of Nursing and an incident form completed to reflect rationale as to the decision for locking the doors. 5. Wards where the doors are locked The following wards are locked all the time: Ward All Hatherton Centre Wards (Ashley, Norton, Newport, Radford) Ellesmere Ward Clee Building Wards (Yew & Willow) Rationale for locked door The ward has to comply with the security and safety standards for Medium Secure Forensic Services, which require a locked door amongst other physical security infrastructure. The ward has to comply with the security and safety standards for Low Secure Forensic Services, which require a locked door amongst other physical security infrastructure. The ward has to comply with the security and safety standards for Low Secure Forensic Services, which require a locked door Page 3 of 8
Locked Door SOP Feb 2016 Ward Baswich Ward Norbury Brockington Peri-natal Unit Oak Ward Rationale for locked door amongst other physical security infrastructure. The service users on this ward have organic mental illness, usually of a dementia. Their level of cognitive impairment necessitates the locking of the ward door to reduce the risk of wandering and potential harm to them as a result. This is a Psychiatric Intensive Care Unit (PICU). It complies with the national guidance for PICU which states that the doors should be locked to manage the risks which service users in need of this level of care require. The locked door on this ward is to control access onto the ward to maximise the safety of the baby within the unit. The service users on this ward have organic mental illness, usually of a dementia. Their level of cognitive impairment necessitates the locking of the ward door to reduce the risk of wandering and potential harm to them as a result. For those informal patients who are resident on the wards listed above, or on an open ward where the doors have been locked, consideration must be given as to their capacity to consent to remaining on the ward whilst the doors are locked (even if they are not attempting to leave). Following the Supreme Court judgment of 19 March 2014 in the case of Cheshire West clarified an acid test for what constitutes a deprivation of liberty (P v Cheshire West and Chester Council and another and P and Q v Surrey County Council). The acid test states that an individual is deprived of their liberty for the purposes of Article 5 of the European Convention on Human Rights if they: Lack the capacity to consent to their care/ treatment arrangements Are under continuous supervision and control Are not free to leave. If the informal patient meets the following meet the above criteria, then an application for detention in accordance with either the Deprivation of Liberty Safeguards (DoLS part of the MCA) or by the Court of Protection must be made. 6. Procedure to be followed in the event of ward doors having to be locked. (with the exception of the wards identified in section 5 above) In the event of the nurse in charge making the decision to lock the ward doors to protect the health and safety of patients, the following steps must be taken: The nurse in charge should consider how to reduce the negative psychological and behavioural effects of having locked doors, whether or not patients are formally detained. The implementation of the locked door SOP must be communicated to all staff on the ward. There must be a notice posted internally and externally at all access and egress points on the ward, including main entrance and garden doors. The wording to be used can be found in the appendices to this SOP. Page 4 of 8
Locked Door SOP Feb 2016 Whilst the locked door policy is in operation, staff will need to be vigilant to ensure that other service users are not restricted in gaining access onto the ward, or leaving as appropriate, in line with their individual care plans. The in-patient manager or matron on duty should be informed of the reasons of the need to implement the locked door procedure. An adverse incident form must be completed on each shift the door is locked. Information contained within the incident should always include reasons for the implementation of the locked door process and identify the individual service users in the persons involved section of the incident form, who have necessitated the implementation of the policy as well as the rationale for implementation. The nurse in charge must ensure a review of the locked door is conducted at least hourly. If the duration of the locked door Exceeds 24 Hours, a review must be undertaken by the senior manager and ward manager. This review will include other clinical management strategies including transferring the service user to a more suitable environment.. Any decision will be taken as a result of a risk review and assessment under the Mental Health Act, if the service use is not already detained, and not for the purpose of containment. 7. Process For Monitoring Compliance And Effectiveness Monitoring of compliance and effectiveness of this SOP will be undertaken by the Mental Health Legislation Committee by annual review. 8. References Mental Health Act (1983) Code of Practice. The Stationary Office. London. Page 5 of 8
Internal Notice: Notification of Locked Door Unfortunately, it is necessary to lock this door for a period of time to ensure the safety of our service users and visitors. The door will be locked for a minimum amount of time possible and will be reviewed frequently. If you wish to leave the Ward please speak to a member of staff who will be happy to help. Page 6 of 8
If you are an informal patient who wishes to leave the ward, please see a member of staff who will open the door for you. Thank you for your assistance and cooperation, we apologise for any inconvenience. Page 7 of 8
External Notice: Notification of Locked Door It is necessary to lock this door to ensure the safety of service users and visitors. If you wish to come into the ward, please press the bell for attention. Thank you for your assistance and cooperation. Page 8 of 8