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

Policy: A4 Alcohol and Illicit Drugs Procedure (Broadmoor Hospital only) Policy relates to: D2 Dual Diagnosis policy Version: A4/08 Ratified by: Policy Review Group Date ratified: 24 th September 2015 Title of Author: Title of responsible Director Governance Committee Clinical Director High Secure and Forensic Services Director of High Secure Services Broadmoor SMT Date issued: 26 th October 2015 Review date: August 2018 Target audience: Disclosure Status All staff at Broadmoor Hospital B Can be disclosed to patients and the public EIA / Sustainability N/A Implementation Plan N/A Other Related Procedure or Documents: West London Mental Health NHS Trust Page 1 of 13

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 13

A4: Alcohol and Illicit Drugs (Broadmoor Hospital) Version Control Sheet Version Date Title of Author Status Comment A4/01 Sept 1999 A4/02 Sept 2000 The Substance Misuse Strategy Group The Substance Misuse Strategy Group A4/03 Aug 2004 Director of Forensic Services A4/04 1 st Feb 2006 Director of Forensic Services A4/05 01.09.09 Director of Nursing and High Secure Services. A4/06 08.03.11 Clinical Director - HSS New Policy Issued Policy reviewed No changes Policy revised On 13 th Aug 2004 Updates made to para 4.4,4.5 and 4.6 and Appendix 4 Policy revised On 16 th Jan 2006 Updates made to para 4.4,4.5 and 4.6 Reviewed by Deputy Director of Nursing and consulted with Security Department. Revised procedure issued as working document under consultation period ending 12 th April 2011. Title change to Alcohol and Illicit Drugs Agreed at Broadmoor SMT on 17.09.09 Reviewed with Security Directorate Draft revised procedure presented to HSS SMT on 17.03.11 for approval to go to consultation as working document. Ratified at HSS SMT on 16.6.11 to be published as a procedure. A4/07 Aug 11 Clinical Director - HSS A4/08 Sept 2015 Issued as a Working Document until Procedure Template available. Noted at 25 th August 2011 Policy Review Group as Procedure related to Trust Parent policy D2 Dual Diagnosis. Clinical Director Policy review Under Trustwide consultation ending 03.09.2015. Approved at September HSS SMT West London Mental Health NHS Trust Page 3 of 13

Section Page 1. Flowchart... 5 2. Introduction... 6 3. Scope... 6 4. Definitions... 6 5. Duties... 6 5.1 Chief Executive... 6 5.2 Accountable Director... 6 5.3 Clinical Director (High Secure Services) and Director of Security... 6 5.4 Managers... 7 5.5 Clinical Teams... 7 5.6 All Staff... 7 6. Prevention of substance misuse... 7 7. Testing for illicit substance misuse... 9 8 Responding to illicit drugs misuse... 11 9 Training... 12 10 Monitoring and review... 12 11 Fraud statement... 13 12 References... 13 13 Supporting documents... 13 14 Glossary of terms / acronyms... 13 West London Mental Health NHS Trust Page 4 of 13

1. Flowchart Screening for history of substance misuse on/prior to admission Clinical team to formulate case material and care plans in light of history and develop risk management plans Clinical team reformulation in line with updated knowledge Evidence via security intelligence/formal testing of on-going misuse Provide information about testing procedures including random and requested tests Refer to psychological services for comprehensive assessment Potentially refer for intervention e.g. group work Repeat and include updates in CPA review/ Intervention teams to feedback to clinical teams West London Mental Health NHS Trust Page 5 of 13

2. Introduction 2.1 The definition of illicit substances, for the purposes of this procedure is alcohol, tobacco, illegal drugs, legal highs or controlled medication other than that prescribed to the individual patient. 2.2 Patients admitted to Broadmoor Hospital may have problems related to substance misuse and, although detained in conditions of high security, may gain access to illicit substances. For many patients detained in conditions of high security substance misuse may exacerbate their mental disorder and thereby also increase their risk of interpersonal violence. Any such deterioration will have an impact not just on the patient but also on other patients and staff. 3. Scope 3.1 This procedure describes the steps taken within High Secure Services to prevent and detect the use of illicit substances. The procedure also details how clinical teams might appropriately respond to a patient s previous or current substance misuse. 4. Definitions N/A (provided within the policy where appropriate) 5. Duties 5.1 Chief Executive The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations. 5.2 Accountable Director The Director of High Secure and Forensic Services is the responsible Director for this policy and has overall responsibility for ensuring that policy and practice within the High Secure Service adheres to the relevant legislative requirements. 5.3 Clinical Director (High Secure Services) and Director of Security The Clinical Director is the policy author and, in conjunction with the Director of Security is accountable to the Director of High Secure and Forensic Services and responsible for ensuring the implementation, monitoring and review of policy and practice in relation to alcohol, illicit drugs and legal highs within the High Secure Service. West London Mental Health NHS Trust Page 6 of 13

5.4 Managers Managers are responsible for ensuring policies are communicated to their teams / staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented. 5.5 Clinical Teams Clinical teams are responsible for ensuring the appropriate assessment and management of patients substance misuse issues. 5.6 All Staff All staff should be aware of the contents of this policy, in particular staff working directly with patients and relevant staff within the security directorate. All staff are responsible for ensuring that their practice is in accordance with the detail of this policy. This includes taking appropriate action in response to anything untoward or any concerns, and seeking advice where necessary. The results of both random/routine and targeted urine drug screens / alcohol tests are recorded in the drug reports application on the Trust intranet (the Exchange). A hard copy of the results should also be printed and filed in the patient s record. The screening results are recorded by the Nursing staff conducting the test. The results should be recorded as soon as practicable after the testing is complete. 6. Prevention of substance misuse 6.1 Demand Reduction 6.1.1 There may be many reasons for a person wanting to misuse drugs or alcohol. These include inability to cope with previous and current adverse experiences including symptoms of mental illness, current personal psychological factors. Other factors include the availability and use of substances within a particular peer group. It follows that the demand by an individual for substances is rarely constant, but varies with all of the foregoing and may be reduced by specific interventions. Procedure 6.1.2 From the point of admission, clinical teams will screen for any history of illicit substances and be alert to any potential immediate psychophysiological problems (e.g. withdrawal). Through assessment, clinical teams will form and document a clear understanding of their patients history of substance misuse and its relationship with their mental disorder and previous offending. Those patients identified as having particular problems with previous or present substance misuse West London Mental Health NHS Trust Page 7 of 13

will receive more intensive and targeted interventions. Clinical teams will ensure patients are fully informed of the harmful effects of illicit substance misuse on mental disorder and will develop a treatment plan aimed at reducing the patients misuse of illicit substances. 6.1.3 The Social Work Department will be asked to ensure that any pattern of substance misuse in the patient's family is highlighted, this being a key risk factor for future abstinence/relapse prevention. The findings from this process will be discussed by the clinical team and contribute to the patient's risk assessment and management. 6.1.4 Patients who are identified as having (a) a significant history of substance misuse, (b) previous offending linked to substance misuse and/or (c) misused illicit substances in hospital, will receive a more detailed assessment that will inform a treatment plan addressing their substance misuse. Clinical Teams may refer any patients requiring specialist assessments or treatments to Psychological Services including the Centralised Group-work Service (CGS). 6.1.5 During the patient s Care Programme Approach (CPA) meeting (particularly prior to transfer or discharge), the clinical team will specifically consider the contribution of substance misuse to risk management. 6.2 Supply Reduction 6.2.1 The hospital is committed to preventing the supply of illicit substances to patients. Procedure 6.2.2 All patients' social visitors will receive specific information about the harmful effects of illicit substances on the health, welfare and recovery of patients and they will be advised what to do if a patient is placing them under pressure to bring illicit substances into the hospital. 6.2.3 Visitors will be made aware of action that the hospital may take if they are found to be in possession of illicit drugs or alcohol. This may include police involvement and the introduction of supervised or curtailed visits. 6.2.4 A small number of visitors may be regarded as posing a high risk of smuggling illicit substances into the hospital. Such concerns may arise through known/suspected involvement with illicit drugs, or by other intelligence gathered. This intelligence will be coordinated and disseminated by the Security Directorate and such visitors will be subject to proportionately increased monitoring. 6.2.5 If a visit is anticipated to carry a high risk of illicit substance transfer, the Clinical Team and Security Liaison Nurse will discuss the necessity of imposing "supervised visits which will be observed throughout and in which no physical contact between patient and visitor will be allowed. West London Mental Health NHS Trust Page 8 of 13

These visits will need to be pre-booked in order to make the necessary staffing arrangements and ensure any additional appropriate arrangements are in place. The Site Manager must be informed of the pre-booking arrangements. 6.2.6 Careful monitoring and examination of mail and parcels by the Postal Monitors and ward staff is essential. The contents of parcels and gifts received on wards must be examined with the utmost vigilance (refer to policy M6 - Patients Mail & Postal Packets). 6.2.7 Staff who are approached by a patient or patient s visitor to smuggle such items must report the matter without delay to their line manager and the Security Department. 6.2.8 The hospital will use the services of trained drug-detection dogs to conduct random searches within hospital premises. The Security Directorate will arrange these services. 6.2.9 If following a visit, staff suspect that a patient may have gained access to illicit substances, the Site Manager must be contacted immediately for advice and support and to obtain a drug screen. 6.2.10 The Site Manager, where appropriate, will consult with the Senior Clinical Manager (or on call Senior Manager if out of hours) with regard to the possible need for a level 2 search. The patient must be asked to submit a sample for screening as soon as practicable, following any such suspicion, and in any case, no later than 24 hours following the initial concern. 7. Testing for illicit substance misuse 7.1 The Hospital has a systematic screening programme to aid detection of, and therefore discourage, illicit substance misuse. The process of testing and rationale for its use will be fully explained to any person who receives screening. Procedure 7.2 The hospital uses the Drug Screen system and alco screen oral fluid swabs. This equipment is available centrally in the Security Liaison Office and Site Management with instructions for use. 7.3 On initial admission (or re-admission e.g. following trial leave), every patient will be asked to provide a urine sample for drugs screening. This sample must be provided within 24 hours of admission. In exceptional circumstances where the patient s mental state prevents a sample being taken, a note to this effect must be made in the patient s multidisciplinary (MDT) notes and will be recorded as an inability to provide a sample. West London Mental Health NHS Trust Page 9 of 13

7.4 On admission, each patient is given a unique identification number. Each month all the unique numbers are put into a random number generator within the security department. A minimum of 5% of the hospital patient population is then chosen at random for drug screens. 7.5 On the first working day of every calendar month the Security Intelligence Office contacts the relevant Security Liaison Nurses informing them of the patients selected for drug screens. 7.6 The Security Liaison Nurse is then responsible for managing the collection of the sample from the nominated patients. As soon as testing is complete, results will be forwarded by the Security Liaison Nurse to the Security Intelligence Office for collation and information. 7.7 In addition to the random screening programme, Clinical Teams may test a patient if there is some reasonable suspicion of substance misuse e.g. from intelligence, observation of the patient etc. In this situation clinical teams should discuss and decide whether, or not, to give a reason to the patient, bearing in mind that the decision to screen may be based on intelligence, the source of which should be protected. In such cases, the Drug Screening equipment will be collected from Site Management. Reasonable suspicion might also include intelligence relating to the misuse of prescribed substances (e.g. storing, ingesting and/or sharing medication that has been prescribed for another patient). 7.8 The provision of urine samples will be directly observed by a nurse of the same sex as the patient. A second nurse, also of the same sex, should be in attendance. 7.8.1 With regard to routine/random testing, where practicable, one of these staff will be a Security Liaison Nurse. 7.8.2 The procedure must be carried out in a private area and preferably one designated for the purpose. 7.8.3 The patient must be subject to a level one search immediately prior to being asked to provide the sample. 7.8.4 The patient should be asked to provide the sample into a suitable receptacle (i.e. cardboard urinal bottle). The results of the analysis should be recorded as described above and reported to the Clinical Team. 7.9 A patient who is unable (rather than unwilling) to provide a sample should be given a maximum of 4 hours to provide the sample. If after 4 hours a sample has not been produced this should be taken as a refusal and dealt with accordingly (unless, see 7.3, in exceptional cases where the patient s mental state prevents a sample from being provided in which case this will be recorded as an inability to provide a sample). West London Mental Health NHS Trust Page 10 of 13

7.10 The results of all urine/breath samples tested will be entered on the electronic Substance Screen Form which will be submitted to the Security Directorate, a copy should then be printed and filed in the MDT notes. 7.11 The results need not immediately be notified to the patients, but may first be considered by the Clinical Team. Further samples of urine may be requested for confirmatory analysis. 7.12 No patient can be required to provide a urine/breath sample without his express consent. In the event of a patient refusing to consent, the clinical implications of this must be considered by the Clinical Team. Such a refusal may be regarded as tantamount to having used drugs or alcohol and, therefore, in the interim, restrictions on the patient(s) movement or activities may have to be considered. 7.13 Any information concerning the misuse of illicit substances and the seizure of any suspected illicit substances must immediately be reported to the Security Directorate. The seized substance will be collected from the ward by Security Directorate staff for testing and retention or disposal. 8 Responding to illicit drugs misuse 8.1 In responding to detected illicit substance misuse, the Clinical Team must ensure that their interventions contribute to the mental health and welfare of the patient, and are not a punitive or disciplinary response. This is not to ignore security implications but to emphasise that security responses should contribute to mental health and welfare of individual patients and to all patients. All such responses should be clearly documented in the patient s MDT notes and/or addressed in a revised treatment plan. Procedure 8.2 Detection of any illicit substance misuse should be discussed by members of the Clinical Team at their next meeting. Their discussion should consider the need for repeated testing, the possible impact of substance misuse on the mental health and/or behaviour of the patient, and on their current and future risk management. The patient s treatment plan may need revision. 8.3 The patient should be interviewed and counselled by the most appropriate member of the Clinical Team. Where the Clinical Team conclude that the substance misuse problem is severe or complicated, referral may be made to substance misuse groups within the Centralised Group-work Service (CGS). West London Mental Health NHS Trust Page 11 of 13

8.4 As part of the clinical evaluation, the Clinical Team must also consider the security implications of detected illicit substance misuse. The Security Liaison Nurse will be able to offer advice and assistance to the Clinical Team. 8.5 Consideration must be given to increased supervision of visits, a review of patient activities (e.g. off-ward social activities) and ground access status, and the patient may require more frequent searching on return from work areas. Any such intervention must be justified on the grounds of reducing the risk of relapse of the patient or of spread of illicit substance misuse to others. These measures should be clearly documented in the patient s MDT notes. 8.6 Patients and their visitors must be provided with information about the potential impact of persistent misuse of illicit substances, and its association with exacerbation of mental disorder and/or increased risk of violence, and therefore the potential for misuse to have an adverse influence on their rate of progress through Broadmoor Hospital and any subsequent move to conditions of lesser security. 9 Training 9.1 All Clinical Teams will have access to training on substance misuse as requested. Training and advice can be sought from Psychological Services including Centralised Group-work Service. 10 Monitoring and review 10.1 The Director of Security will produce a quarterly report for the Executive Team, summarising details of all illicit substances found and the results of urine/breath testing. This information will help the hospital managers to determine any variation in the rates of random drugs screening in any particular area. 10.2 Adherence to this procedure is subject to external review by the National Offender Management Service (NOMS) Audit Team on an annual basis. 10.3 This procedure will be reviewed every three years, or sooner where a need is identified. The Clinical Director of High Secure Services is responsible for carrying out the review. West London Mental Health NHS Trust Page 12 of 13

11 Fraud statement N/A 12 References N/A 13 Supporting documents N/A 14 Glossary of terms / acronyms N/A - all abbreviations have been clarified at their first point of use in the document. West London Mental Health NHS Trust Page 13 of 13