Locked Door Who Should Read This Policy Target Audience All Inpatient Staff Version 1.0 October 2016
Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process for Access and Exit 4 4.1 Minimum Standards to be applied by Ward Staff 4 4.2 Legal Implications 5 5.0 Procedures connected to this Policy 9 6.0 Links to Relevant Legislation 9 6.1 Links to Relevant National Standards 10 6.2 Links to other Key Policies 12 6.3 References 12 7.0 Roles and Responsibilities for this Policy 13 8.0 Training 14 9.0 Equality Impact Assessment 14 10.0 Data Protection and Freedom of Information 14 11.0 Monitoring this Policy is Working in Practice 15 Appendices 1.0 Exiting the Ward - Notice to Patients, Visitors and Staff 16 2.0 Legal Rights for Informal Patients Leaflet 19 Version 1.0 October 2016 2
Explanation of terms used in this policy Locked Door A locked door situation is where the ward or unit door is locked by a key or other means (swipe card) and access to or from the unit is only possible by request to a nurse. Patients therefore have no means of leaving the ward independent of a request to nursing staff Mental Health Act The Mental Health Act covers the reception, care and treatment of mentally disordered persons, the management of their property and other related matters. In particular, it provides the legislation by which people diagnosed with a mental disorder can be detained in hospital or police custody and have their disorder assessed or treated against their wishes. Its use is reviewed and regulated by the Care Quality Commission Detained Patients This refers to patients who are admitted to the wards subject to the Mental Health Act Deprivation of Liberty Safeguards This is the legal and administrative safeguards which protect patients who may be deprived of their liberty whilst in our services. The DOLS are set out within the MCA Informal Patients This refers to patients who have been admitted without the use of the Mental Health Act and can only be prevented from leaving a ward if the MHA is applied or Deprivation of Liberty Safeguards Authorisation is sought Access and Exit This refers to the entry and exit of patients, staff and visitors to inpatient wards Responsible Clinician The consultant in charge of a detained patient s treatment. Although this may be other professions currently in the Trust this will be the lead consultant psychiatrist Best Interest Assessor This is a role under the Deprivation of Liberty Safeguards. This is usually a Social Worker who is able to consider the appropriateness of applying for a DOLS Authorisation Care Plan In this policy where we refer to a care plan this will be the patients nursing management plan and not their community care plan Mental Capacity Act The MCA provides a framework for acting and making decisions on behalf of people who lack capacity Care Quality Commission The CQC have a responsibility to monitor the application of both the MHA and MCA Absconding/Missing When an informal patient is not on the ward when expected to be after either not returning from leave or failing to notify staff they are leaving the ward Absent Without Leave When a detained patient is missing from the ward, either not returning from leave or managing to leave the ward undetected by staff, Section 18 of the Mental Health Act Version 1.0 October 2016 3
1.0 Introduction This policy sets out the approach to be taken by the Trust in respect of locked ward doors. The Trust operates a locked door policy across all services and expects all staff to ensure patients are aware of their rights, the reasons for the locked door and options for access and exit are made clear to both patients and visitors. Key features of this policy are the provision of information, engagement with patients and carers, escalation procedures and minimum expectancies for the above. This includes the Trust observation and application of the relevant legislation and consistently seeking to improve the patient experience through research and development in the approach to locked doors on Mental Health wards. The Trust believes the safety of patients, staff and visitors is our utmost priority, and recognises its responsibilities and duty of care to ensure provision of safe and secure environments. This decision has legal and operational implications and this policy sets out our approach for all those affected by this decision. This policy outlines the Trust s philosophy and provides a systematic and consistent approach to the management of access and exit procedures across the Trust. The Trust recognises its duty to ensure clear communication and offer appropriate routes of escalation to those patients and visitors who experience difficulties with our access and exit policy. The Trust recognises that those patients admitted to Mental Health wards have complex, specific and individual needs. The locking of ward doors is intended to protect patients. This extends to protecting our patients and staff from others gaining access to the wards. This approach is compliant with the Mental Health Act, Code of Practice (Chapter 16). 2.0 Purpose The purpose of this document is to provide guidance to all staff on their approach and management of locked doors and entry and exit protocols. The policy sets out the overarching aims of the Trust and should be supported with local guidance that considers local issues i.e. dementia patients, higher percentage of informal patients as these will require individualised approaches. 3.0 Objectives To provide a trust wide approach to managing locked doors To ensure Staff are aware of their responsibility in relation to operating a locked door service To ensure patients are aware of their rights when being treated in a locked door facility 4.0 Process for Access and Exit 4.1 Minimum Standards to be applied by Ward Staff All ward areas will ensure they have clear information displayed by the ward doors to inform patients and visitors how they can leave the ward. All staff will be clear on the reasons and purpose for employing locked doors on the ward and this will be discussed in supervision, community meetings and any issues Version 1.0 October 2016 4
will be reported using incident reporting system or feedback to Ward Manager as appropriate. Patients will be provided with verbal and written information how to access and exit the ward, on the availability of this policy, how to raise a complaint with procedures relating to locked doors, and this will be done as soon as practicable following admission and on a regular basis thereafter. This will include information on their legal status and the implications of this on accessing and exiting the ward. Information should also be provided to the patient s family and carers on admission to ensure they are clear in the ward s approach to access and exit. This will include discussion of how they may complain or comment on the procedures and reasons for the approach taken by the Trust. In the case of informal patients all staff working with the patient should ensure they are supportive of the patient s right to leave the ward, explaining their legal rights where necessary and ensuring any difficulties experienced by the patient are raised as a concern. The information provided and discussions with the patient should include details of how they can discharge themselves from the hospital and their compliance with the agreed care plan and how to request a review of this. Informal patients must not feel they are unable to agree with conditions set out in the care plan and these should not extend into unnecessary or disproportionate restrictions. All patients must be provided with a copy of their care plan (or in the case of patients who refuse a copy, they should know how this can be requested) and this should include information on their access and exit rights. This should incorporate their individual needs e.g. smokers, informal patients and those deemed to be at risk of self harm or suicide. For both informal and detained patients their ability to understand the processes relating to the access and exit to wards should be continuously reviewed. The Mental Capacity Act is the governing framework for assessments of capacity and this should be adhered to support to improve their understanding should be provided and in some areas this will extend to additional tools of communication i.e. picture signs, repeating discussions when carers are present. As with other information that the Trust produces consideration must be given to the availability of the information on access and exit in other languages and formats which meets the requirement of the Accessible Information Standard (AIS). The ward manager must ensure all staff being inducted onto the ward are provided with information on the approach, philosophy and aims of this policy. The legal implications of not adhering to this policy should be made clear to all staff members. 4.2 Legal Implications There are several relevant legal implications on the Trust decision and approach to locking doors on inpatient areas. All staff should ensure they are familiar with the frameworks and request additional advice, guidance or training through their line manager and supervisors if they have any training needs relating to the legal issues set out within this section. Version 1.0 October 2016 5
4.2.1 Mental Health Act (MHA) The MHA allows the Trust to take necessary steps to protect the patient from harm or from causing harm to others. Whilst detained under the MHA the Trust can take reasonable steps to ensure the protection of harm and there are implied powers to control and detain patients in a suitable manner. For detained patients the Trust is able to refuse exit from the ward unless the patient has a valid period of leave (authorised by the Responsible Clinician under Section 17 of the MHA). Any patient exiting the ward without authority should be recorded as AWOL Section 18 of the MHA and the missing persons policy applied. Even in circumstances where there is a Section 17 is in place the nursing staff may complete a risk assessment and refuse the patient leave from the ward. This should be documented in the patient notes and explanation and rationale offered to the patient and their carer. Although the law is clear for detained patients that the Trust can restrict their leave from the ward as appropriate this should not negate discussion and engagement with the patient. Section 132 of the MHA sets out the duty to provide information to the patient about their detention status on a regular basis and this should include discussions with the patient about the locked doors and their feelings towards this. If a detained patient has concerns regarding the locked door policy they can be directed to: Patient Engagement Team for informal discussions and potential complaint to the Trust Independent Mental Health Advocate Statutory provision of advocacy services. Independent of the Trust and can assist with complaint or appeal against detention Mental Health Tribunal and Hospital Managers If the patient wishes to appeal against the decision to keep them in hospital under section, they can appeal in writing to the hospital managers and/or to the Mental Health Tribunals service; a hearing will then be arranged to decide if the patient needs to remain on section Staff dealing with concerns should seek to resolve them directly through changes to the care plan or discussing the issues with the patient directly. The guiding principles in the Mental Health Act, Code of Practice should be observed by staff when working with patients, carers and processes relating to locked doors: Purpose Ensure the Trust is clear about the purpose of the locked doors in reducing the negative impacts of mental disorder and reducing the risks to patients, staff, carers and the public Least Restriction Observe the least restrictive principle when working with patients regarding the locked door policy. The observance of the requirements set out within this policy should promote the least restrictive approach but all steps necessary and appropriate in individual circumstances should be taken Respect The rights of patients should be respected with staff being aware of and mindful that the locked door policy has potential to increase the feeling of a loss of control and impact upon a person s liberty. Individual patient needs should be considered including access to information in other formats, respecting a person s feelings and personal opinions Participation the provision of information, facilitated discussions and openness regarding the locked door policy is fundamental to ensuring patients are involved in the Trusts approach. This should be recorded in notes and care plans and ongoing discussions should occur on a frequent basis Version 1.0 October 2016 6
Effectiveness, efficiency and equity Trust staff must seek to use the resources that are available for patients in the most effective, efficient and equitable way. This extends to the way wards are managed and issues with the locked door approach must be escalated if they have the potential to alter the effectiveness and efficiency Section 5 of the MHA provides for detention by nursing staff or doctors in the event of an informal patient requesting to leave the ward against medical advice. These powers are only available to qualified staff who should clearly document their reasons for applying Section 5 and complete the statutory paperwork. It should be remembered that Section 5 does not allow for treatment of the patient against their wishes unless this is done in compliance with the MCA and recorded as such. 4.2.1.1 Community Treatment Orders (CTOs) Patients subject to a Community Treatment Order (CTO) under the MHA constitute a special category. Whilst in the community, a patient on a CTO is subject to a legal framework of care. However, they are not detained and cannot be made to take medication or be given other treatment against their will. If a CTO patient deteriorates in the community they may be recalled to hospital for up to 72 hours. This is to allow a full assessment to be carried out. During this time they may be prevented from leaving. If a patient on a CTO is admitted to hospital informally, either directly from the community or following their recall, they are considered an informal patient and as such they cannot be prevented from leaving the hospital. But CTO patients are different from other informal patients in that they cannot be made subject to the holding powers under section 5 MHA 1983 as their detention status is suspended. If the patient wants to leave but there is some concern that the patient or any other person would be at risk of harm if the patient were to leave they should be recalled by the Responsible Clinician (RC). The patient can only be held under common law until the RC or on call consultant completes the CTO3 and recalls the patient. 4.2.2 Mental Capacity Act and Deprivation of Liberty Safeguards The MCA is the legal framework that sets out an approach for decision making in the case of patients who lack capacity. Capacity is decision specific and in the case of locked door environments the bar for capacity will be lower than in the case of some treatment decisions. A capacity assessment can be completed by the nurse who is providing information to the patient regarding the locked door policy. This should include consideration of the presence of a disturbance in the functioning of the mind or brain (section 2). As most patients in the Trust s wards will be suffering from a mental disorder this may indicate a potential disturbance and staff should consider the patient s ability to understand, retain, weigh and use the information provided regarding access and exit (Section 3). Any concerns regarding the patient s ability to do this should be clearly set out within their care plan and revisited as appropriate. The Trust expects that patients who may lack capacity are offered support in increasing their understanding and the method of communication is considered. Good practice methods should be shared between wards and can be reported to the Head of Service for this purpose. Version 1.0 October 2016 7
Where it is determined a patient does not have capacity to understand the access and exit policy on the ward all staff must ensure the restrictions as a result of the locked door policy do not extend into deprivations upon the patients liberty. There are two elements to start with when identifying what deprivation of liberty is, an objective and a subjective element. For the objective element: the person is confined to a restricted space for a not negligible length of time For the subjective element: the person has not validly consented to the conditions of accommodation in question. A person who lacks capacity to consent cannot validly consent The test for whether there is deprivation of liberty is whether the person is under continuous supervision and control AND is not free to leave. In the case of P v Cheshire West and Chester Council and another P and Q v Surrey County Council. The Supreme Court Judgment held; The acid test : 1. Is the person subject to continuous supervision and control? All 3 aspects are necessary; and 2. Is the person free to leave? The person may not be saying this or acting on it, but the issue is about how staff would react if the person did try to leave It is recommended that any concerns with the potential deprivation of patients (raised by staff or carers) is discussed with their consultant psychiatrist and advice sought from a Best Interest Assessor. The Trust expects that any determination of deprivation will include as a minimum: All the circumstances for that individual patient What measures are in place for that individual to reduce the likelihood of deprivation, what are the effects of any restrictions placed on them? Have these been discussed with carers or independent representatives? These considerations should bear in mind that just the presence of a locked door does not necessarily mean a deprivation is occurring. If it is apparent that any informal patient is being deprived of liberty on a ward an application for a DOLS authorisation is required by the Trust (unless the person is ineligible by virtue of Schedule 1A Mental Capacity Act, in which case a Mental Health Act assessment will be undertaken). 4.2.2.1 Informal Patients with Capacity Informal patients should be made aware of their legal position and rights, failure to do so could lead to a patient mistakenly believing that they are not allowed freedom of movement, which could result in an unlawful deprivation of their liberty. Staff should ensure: There are signs up informing informal patients of their rights to leave the ward in different languages a copy of the informal rights leaflet is provided to the patient Where a patients legal status changes from detained to informal they should be informed of their rights as an informal patient and this should be documented in the notes Version 1.0 October 2016 8
Informal patients (who are not legally detained in hospital) have the right to leave at any time. They cannot be required to ask permission to do so, but may be asked to inform staff when they wish to leave the ward. The trust has a duty of care towards the patient, if a patient expresses a wish to leave, the nurse must make a decision based on the latest risk assessment and the patient s current presentation whether it is safe for them to leave. If it is not felt to be safe and the patient cannot be persuaded to stay on the ward, a doctor must be contacted to carry out a section 5(2) MHA 1983 assessment urgently. If there is a delay of 15 minutes or more in the doctor coming to do the assessment, the nurse should consider the use of section 5(4) MHA 1983. The common law power to detain a patient in an emergency cannot supersede the statutory powers contained in the MHA 1983 or be used for a lengthy period of time. The use of section 5 MHA 1983 should not be used as a threat to deter a patient from trying to leave the ward. In the case of a patient who is deemed to have capacity, understands the locked door policy and agrees to remain on the ward the case of Rabone v Pennine Care NHS Foundation Trust is relevant. This case which considered the Human Rights Act and the duty of NHS Providers to protect a patient s right to life also considered the approach of the Trust and their locked door policy. The Court of Appeal recognised the patient s right to be aware of the possibility of a MHA Assessment being completed if she requested exit / discharge from the hospital. The Supreme Court found that if an adequate risk assessment had been completed the patient should have been prevented from leaving, due to concerns of self harm and patient presenting as an immediate risk to herself, by application of Section 5 of the MHA. In this case the Supreme Court also stated that suicidal psychiatric patients are unlikely to have capacity to make a decision about admission and treatment. The Trust view is that each individual would be subject to a capacity assessment by the clinicians involved and the outcomes will obviously vary. A blanket approach to incapacity would not be acceptable and the Supreme Court view is included for information only. This case demonstrated that the legal implications of access and exit are often complex and may invoke considerations of the Human Rights Act and in particular the right to life. Risk Assessments are crucial to the Trust and professional defence. Cases where patients seek discharge or leave against the advice of staff. Records should be taken by clinical staff in all areas routinely and particular consideration given to this area of treatment and management. 5.0 Procedures connected to this Policy There are no Standard Operating Procedures connected to this policy. 6.0 Links to Relevant Legislation Mental Health Act 1983 (amended 2007) The Mental Health Act (2007) amended the Mental Health Act (MHA) of 1983. The main purpose of the legislation is to ensure that people with serious mental disorders, which threaten their health or safety or the safety of other people can be treated irrespective of their consent where it is necessary to prevent them from harming themselves or others. The amended act introduced: Version 1.0 October 2016 9
A new broad definition of mental disorder to encompass any disorder or disability of the mind An appropriate treatment test, preventing patients from being compulsorily detained unless appropriate medical treatment is available Community Treatment Orders to supervise the treatment of certain patients in the community New safeguards including a provision for Independent Mental Health Advisors to provide information and help people understand and exercise their rights New roles to replace the roles of approved social worker and responsible medical officer Provision for powers to reduce the time limits for the automatic referral of some patients to the Mental Health Review Tribunal Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework to empower and protect vulnerable people who are unable to make their own decisions. It aims to ensure that people are given the opportunity to participate in decisions about their care and treatment to the best of their capacity. It covers all aspects of health and social care. The Act creates a new statutory service, the Independent Mental Capacity Advocate (IMCA) Service. Its purpose is to help vulnerable people who lack mental capacity who are facing important decisions about serious medical treatment and changes of residence. The Act also created a new criminal offence of Ill treatment or neglect of a vulnerable adult. 1 April 2009 saw the implementation of the Deprivation of Liberty Safeguards under the Mental Capacity Act. These safeguards were created to create legal protection for adults who lack capacity to consent to care or treatment in a hospital or care home and that care or treatment constitutes a deprivation of their liberty. These safeguards are not an alternative to the Mental Health Act but instead provide a legal framework for people who cannot legally be made subject to the Mental Health Act (i.e. they are not eligible for some reason). 6.1 Links to Relevant National Standards CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety and welfare. Version 1.0 October 2016 10
CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment. CQC Regulation 13: Safeguarding Service Users from Abuse and Improper Treatment The intention of this regulation is to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. Improper treatment includes discrimination or unlawful restraint, which includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005. To meet the requirements of this regulation, providers must have a zero tolerance approach to abuse, unlawful discrimination and restraint. This includes: neglect subjecting people to degrading treatment unnecessary or disproportionate restraint deprivation of liberty. Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people they may have contact with when using the service, including visitors. Abuse and improper treatment includes care or treatment that is degrading for people and care or treatment that significantly disregards their needs or that involves inappropriate recourse to restraint. For these purposes, 'restraint' includes the use or threat of force, and physical, chemical or mechanical methods of restricting liberty to overcome a person's resistance to the treatment in question. Where any form of abuse is suspected, occurs, is discovered, or reported by a third party, the provider must take appropriate action without delay. The action they must take includes investigation and/or referral to the appropriate body. This applies whether the third party reporting an occurrence is internal or external to the provider. CQC Regulation 15: Premises and Equipment The intention of this regulation is to make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located, and that the equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely and used properly. Providers retain legal responsibility under these regulations when they delegate responsibility through contracts or legal agreements to a third party, independent suppliers, professionals, supply chains or contractors. They must therefore make sure that they meet the regulation, as responsibility for any shortfall rests with the provider. Where the person using the service owns the equipment needed to deliver their care and treatment, or the provider does not provide it, the provider should make every effort to make sure that it is clean, safe and suitable for use. Information Governance Toolkit The Information Governance Toolkit is a Department of Health (DH) Policy delivery vehicle that the Health and Social Care Information Centre (HSCIC) is commissioned Version 1.0 October 2016 11
to develop and maintain. It draws together the legal rules and central guidance set out by DH policy and presents them in in a single standard as a set of information governance requirements. The organisations in scope of this are required to carry out self-assessments of their compliance against the IG requirements. 6.2 Links to other Key Policies Deprivation of Liberty Safeguards Policy Mental Capacity Act Policy The purpose of this policy is to underpin the implementation of the MCA within the Trust by outlining the procedures to assess mental capacity, make decisions in the best interests of patients including patients who appear to have no family or friends to consult, use restraint, and follow valid and applicable advanced decisions. The Trust takes its responsibility for the care and treatment of patients seriously and aims to ensure compliance with legislation, statutory instruments and guidance. Clinical Risk Management Policy This policy is intended to guide practitioners who work with service users to manage the risk of harm. It sets out the principles and standards required that should underpin best practice across all health settings. Incident Reporting Policy The purpose of this policy is to make clear the system used for reporting incidents involving patients, staff and others undertaking activities on behalf of the Trust. 6.3 References National Patient Safety Agency West Midlands Quality Review Essence of Care Aims Standards IG Toolkit Version 1.0 October 2016 12
7.0 Roles and Responsibilities for this Policy Title Role Responsibilities All Clinical Staff Adherence - Familiarise themselves with this policy and adhere to its principles in order to be able to respond to the immediate needs of patients and service users - Attend training applicable to their role - Promote the well-being and dignity of the patient at all times - Ensure compliance with all Trust policies this is a condition of employment and a breach of this policy may result in disciplinary action - Ensure any errors or incidents relating to this policy and area of practice are reported on DATIX, the Trust s electronic incident reporting system - Raise any concerns about the way this policy is being implemented or about this area of practice in general with your line manager or lead clinician/service manager. If you feel unable to raise the matter with them, you may write to an Executive Director. If you feel unable to raise the matter with an Executive Director, you may write to the Chairman or a Non-Executive Director. If you are unsure about raising a concern or require independent advice or support, you may contact:- - your Trade Union representative - the relevant professional body Ward Managers/ Team Leaders/ Senior Nurses - the NHS Whistleblowing Helpline - 08000 724 725 Operational - Ensure that all staff are aware of their role under the policy - Ensure staff have received sufficient training and/or are competent to implement the policy - Ensure records are kept as specified - Ensure that all incidents/issues relating to this policy and area of practice are reported Service Managers Implementation - Ensure they are familiar with this policy and be responsible for staff adhering to the procedures referred to - Ensure staff attend training applicable to their role and for implementing the guidance across their areas of responsibility - Ensure staff work to the standards set out in this policy Clinical Directors/ Group Directors Trust Leads - Lead discussions around this topic area and policy at Group Quality and Safety Group meetings - Oversee the completion of audits in respect of this topic area and policy - Provide updates on this area of practice and policy within their Group to the Quality and Safety Steering Group Group Managers Strategic - Provide support and guidance regarding resources to enable this policy to be implemented - Ensure systems are put in place to enable this policy to be implemented within their service areas - Ensure all managers are aware of the policy and promote good practice Group Quality and Safety Groups Quality & Safety Steering Group Executive Director of Nursing, AHPs and Governance Monitor - Monitor and review all incidents, complaints and claims relating to this area of practice and policy within their Group - Receive the results and recommendations of all related completed audits and be responsible for monitoring action plans to implement changes to current practice until completion Scrutiny and - Scrutinise the implementation of a systematic and consistent approach to this policy in all service areas Performance - Provide exception and progress reports to the Quality and Safety Committee - Lead responsibility for the implementation of this policy Executive Lead - Lead on strategies and innovations to improve current practice - Ensure any serious concerns regarding the implementation of this policy are brought to the attention of the Board of Directors Version 1.0 October 2016 13
8.0 Training What aspect(s) of this policy will require staff training? Mental Health Act Training Mental Capacity Act Training Which staff groups require this training? - Medical Practitioners - Registered Nurses - Hospital Managers All inpatient Registered Nurses and Health Care Support Workers Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? No, staff will receive specific training in relation to this policy where it is identified in their individual training needs analysis as part of their development for their particular role and responsibilities No, staff will receive specific training in relation to this policy where it is identified in their individual training needs analysis as part of their development for their particular role and responsibilities If no, how will the training be delivered? Refresher training will be arranged by the Trust s Learning and Development Department Face to face Who will deliver the training? This may be either provided in house or by an external provider MCA and DOLs Practitioner How often will staff require training Annually Every 3 years Who will ensure and monitor that staff have this training? Service Managers in conjunction with the Trust s Learning and Development Department Workforce Development Group 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email EqualityImpact.assessment@bcpft.nhs.uk 10.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. Version 1.0 October 2016 14
11.0 Monitoring this Policy is Working in Practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Implementation of the policy 7.0 Roles and Responsibilities for this Policy Audit that posters are displayed and patients have information leaflets as required Unit Managers Matrons Monthly Group Quality and Safety Groups Group Quality and Safety Groups Minutes of meetings/ action plans signed off Compliance with the policy 4.0 Process Audit as above. Feedback from CQC MHA review teams. Unit Managers Matrons 6 monthly Group Quality and Safety Groups Group Quality and Safety Groups Minutes of meetings/ action plans signed off Trends relating to incidents 4.0 Process Monitoring incidents Complaints and Concerns relating to the policy Local governance leads ongoing Group Quality and Safety Groups Group Quality and Safety Groups Minutes of meetings/ action plans signed off Version 1.0 October 2016 15
Appendix 1 Exiting the Ward Notice to Patients, Visitors and Staff Please be aware that we operate a locked door policy across all inpatient wards. This is for the protection of our patients, visitors and staff and is not intended to restrict you unnecessarily. To leave the ward please let a member of staff know you wish to leave. If you are a patient, staff are expected to consider your observation levels and legal status. If you do not understand the reasons for any refusal to allow you to leave you MUST raise this with staff and request a fuller explanation. If you are entering or exiting the ward please make sure you lock the doors behind you and raise any concerns with the doors to staff immediately We keep all our approaches under review and welcome your feedback on the locked door policy and your experiences. Please ask a member of staff how you can give us feedback positive and negative for us to consider. Version 1.0 October 2016 16
Locked Door Policy Leaving this Unit We have locked doors in our units. This is to keep patients, visitors and staff safe. They are not locked to stop patients from doing activities outside the unit. Sometimes there are legal or care reasons why patients cannot leave. Staff have to check each person, their rights and if they are able to leave. Version 1.0 October 2016 17
If you want to leave the ward please talk to your named Nurse. Your named Nurse should explain if there is any reason you may not leave. Version 1.0 October 2016 18
Appendix 2 Patient Advice and Liaison Service (PALS) 0121-612-8030 or freephone 0800-587-7720 pals.officer@bcpft.nhs.uk Useful Contacts One Voice We provide a voice advocacy service for service users in Wolverhampton. Regent House Bath Avenue Wolverhampton WV1 4EG Tel: 01902 810016 Email: mail@1voice.org.uk POhWER We provide a voice advocacy service for service users in Dudley, Walsall and Sandwell. PO Box 14043 Birmingham B6 9BL Tel: 0300 456 2370 Legal Rights for Informal Patients Your rights and responsibilities as an informal patient Kaleidoscope plus 1st Floor Hawthorns House Halfords Lane West Bromwich West Midlands B66 1BB Tel: 0121 565 5605 Leaflet Control Ref: P004a Carers Team - Sandwell Version: 4 Bristnall Hall Road Oldbury Issue Date: June 2016 B68 9TY Tel: 0121-612-6000 Review Date: June 2017 Fax: 0121-612-6007 Version 1.0 October 2016 19
Who is an informal patient? An informal patient is someone who has agreed to come into hospital for assessment and treatment of a mental health condition or someone who was detained under the MHA but the section has ended and they have remained on the ward. You have the same rights as those admitted to hospital with a physical condition. This leaflet explains your rights whilst in hospital. Some patients are detained under the Mental Health Act 1983 and are known as formal patients; there is a separate leaflet describing their rights. Soon after admission, you will receive information about the roles and responsibilities of the staff who will be caring for you, ward facilities and relevant hospital policies. What are my rights regarding care and treatment? You have agreed to come into hospital to receive care, treatment or therapy and we will involve you at all stages in this. During your stay you will be allocated a named nurse who will co-ordinate your care. You should be given all the information you need in order to make a decision about treatment. This should include what the treatment is, what it will achieve, any likely side effects and what alternatives there are. You will not be given any treatment without your agreement. If you do agree to treatment you can change your mind at any time. You may wish to discuss your treatment with friends or relatives. However, they cannot consent to treatment on your behalf. What observations will be used? We usually observe patients hourly to ensure their well-being and safety. We may do this more often if we feel that it is appropriate. If you have any concerns regarding our observation processes, you can discuss these with your named nurse. Can I leave the hospital? Where ward exit doors are locked, there may be a number of reasons for this usually for security reasons. However, it is not to prevent you from leaving and you have a right to request them to be opened to allow you to leave. As an informal patient, you are not held against your will: you have the right to leave the ward or hospital at any time. The only exception is if you are subject to the Mental Health Act. We are responsible for the safety and care of all patients, so you should always tell a member of staff when you are leaving the ward or hospital. If we are concerned that you may harm yourself or others, we will discuss our concerns with you. If you still want to leave, we may consider requesting a further assessment under the Mental Health Act which may result in you not being allowed to leave the ward. If you are discharging yourself, then - following any further discussion with you on the merits of self discharge - you will be asked to sign a Discharge Against Medical Advice Form, but you are not obliged to sign this form. How do I access my health records? You have the right to see or be given a copy of your mental health record whether it is held on paper or electronically. If you want to see your records, contact the manager where you are receiving your care. If you are unsure who this is, your named nurse will help you. Version 1.0 October 2016 20
Policy Details Title of Policy Unique Identifier for this policy State if policy is New or Revised Locked Door Policy BCPFT-CLIN-POL-14 New Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * n/a Clinical Executive Director of Nursing, AHPs and Governance Head of Nursing LD and CYPF Health and Safety Committee September 2016 Month/year policy approved October 2016 Month/year policy ratified and issued October 2016 Next review date October 2019 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Yes Yes n/a B can be disclosed to patients and the public * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date Details of Change 1.0 Oct 2016 New policy for BCPFT Version 1.0 October 2016 21