Operational Policy Panel. Acute Adult Inpatient Wards

Transcription

1 Operational Policy Acute Adult Inpatient Wards Authorising Officer Keith Moullin, Head of Service Delivery Version: 3 Ratified By: Operational Policy Panel Date Ratified: August 2011 Name Of Originator/Author James Spence Practice Governance Lead Name Of Responsible Practice Governance Lead Committee/Individual Date Issued: January 2012 Review Date: August 2013 Summary: The admission, treatment and care of all people admitted to an acute inpatient ward. Target Audience: All staff involved with the admission, treatment and care of service users admitted to an Acute Inpatient Ward Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity.the Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities. Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership NHS Foundation Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all. Page 1 of 38 Acute Inpatient Operational Policy July 2011

2 Acute Ward Operational Policy Section Contents Page The National Service Framework 3 1 Introduction 4 2 Purpose and Aims 5 3 Criteria for Admission to In-patient Care 5 4 Service User Profile 6 5 Admission Process 7 6 Care Programme Approach 9 7 Formulating the CPA Care Plan 10 8 Discharge from the Mental Health Unit 11 9 Working Procedures Services for In-patients Medical Cover and Medication Ward Lead Consultant Role Managing Risk Induction, Appraisal, Supervision and Training Bed Management and Out of Hours On-call System Comments, Complaints and Compliments Confidentiality Access to Records Care Notes Health and Safety Communication Capacity to Consent Records Management Freedom of Information Quality, Audit and Practice Governance Equality and Diversity References Review 23 Appendices Section Content Page A Standards for the Admission of Service Users to 24 Mental Health Units within Hertfordshire Partnership NHS Foundation Trust B Guidelines for the Transfer of Service Users between 30 Wards and Departments C Legal Responsibilities delegated to HPFT by 33 Hertfordshire County Council D Equalities Impact Assessment 36 Page 2 of 38 Acute Inpatient Operational Policy July 2011

3 Acute Ward Operational Policy Adult Mental Health The National Service Framework The National Service Framework sets out the framework for the delivery of mental health services. Acute In-patient Wards are committed to delivering the standards set out in the framework. In particular: Standard 1.Mental Health Promotion To ensure health and social services promote mental health and reduce the discrimination and social exclusion associated with mental health problems Standard 4. To provide effective services for people with mental illness To ensure that each person with severe mental illness receives the range of mental health services they need; that crises are anticipated or prevented where possible; to ensure prompt and effective help if crisis does occur; timely access to an appropriate and safe mental health place or hospital bed, including a secure bed, as close to home as possible Standard 5 Each service user who is assessed as requiring a period of care away from their home should have timely access to an appropriate hospital bed, or, an alternative bed or place, which is in the least restrictive environment consistent with the need to protect them and the public as close to home as possible Standard 6. Caring about Carers To ensure health and social services assess the needs of carers who provide regular and substantial care for those with severe mental illness, and provide care to meet their needs. Standard 7. Preventing Suicide To ensure health and social services play a full part in the achievement of the target in Saving Lives: Our Healthier Nation to reduce the rate of suicide by at least one fifth by 2010 Page 3 of 38 Acute Inpatient Operational Policy July 2011

4 1. Introduction 1.1. In-patient acute beds within Mental Health Units in Hertfordshire are part of Hertfordshire Partnership NHS Foundation Trust (HPFT) service provision for individuals requiring assessment and treatment for acute mental illness. The services forms part of a planned and integrated whole system approach to care which is delivered in conjunction with community mental health services The service is based on recovery model principles and good practice guidelines outlined in the National Service Framework (NSF), the Hertfordshire Partnership NHS Foundation Trust policy Integrated Care Programme Approach (CPA) and Care Management, and in the Department of Health Mental Health Policy Implementation Guide Within Hertfordshire responsibilities for the delivery of social care services has been delegated to HPFT by the Hertfordshire County Council under section 75 of the partnership agreement. These delegated legal responsibilities are shown in appendix C. Under Department of Health Guidelines eligibility for social care services is based on the severity of risks to a person s independence if social care is not provided Any person admitted for in-patient care requires treatment which is therapeutic and promotes recovery. Within the acute ward all aspects of health, including physical health, social care needs and risk, is jointly assessed by the multi-disciplinary team. Treatment and care is then planned with the service user within the Care Programme Approach. Risk assessment and management plans are an integral part of these plans A written CPA Care Plan is agreed with the multi-disciplinary team, the service user and appropriate carers. The views of service users and appropriate carers form part of the care plan which is regularly reviewed This County Operational Policy addresses the management of service users admitted to acute wards. Local protocols should be developed on issues specific to a locality and not covered within this policy. 2. Purpose and Aims Mental Health In-patient Units are committed to: Page 4 of 38 Acute Inpatient Operational Policy July 2011

5 Offering care and treatment within an in-patient setting that respects individual rights and allows treatment to occur in the least restrictive manner possible Provides a standard of treatment and care that respects peoples rights for privacy and dignity, in a safe and therapeutic environment in the most acute and vulnerable stage of illness, which is line with standards and principles to Eliminate Mixed Sex Accommodation (EMSA) Ensure staff actively promote recovery through the use of recovery principles Ensure all health, social care needs and risk are assessed by the multi-disciplinary team and that an appropriate treatment/care plan and risk management plan is agreed. The plan will include the views of the service user and relevant carers and discharge planning arrangements Respect confidentiality within the context of professional and legal constraints. This will be in accordance with the HPFT Policy and Guidance on the Management of Care Records and the Interagency Protocol on Sharing Information 3. Criteria for Admission for In-patient Care 3.1. HPFT is committed to ensuring that whenever an in-patient admission for mental health problems is being considered, other options for treatment, in a less restrictive environment, will have been ruled out 3.2. Crisis, Assessment and Treatment Teams (CATT) offer a 24 hour 7 days a week consultation and assessment service and operate in all areas of Hertfordshire. CATT offers home treatment as an alternative to hospital admission when clinically appropriate CATT should be consulted prior to any admission, to consider with the referrer, whether treatment home may be a viable alternative to in-patient care. A same day assessment will be arranged whenever this is required 3.4. Referrals to CATT, during office hours, are made via the local CMHT, Assertive Outreach, and A&E Liaison or by the medical teams. Outside office hours referrals are accepted from on call Consultants, GPs, A&E Liaison teams, Emergency Duty Team, Hertsdoc, CATT clients and the Police Surgeon 3.5. It is acknowledged that particularly high risk situations may arise during a Mental Health Assessment, making consultation with CATT difficult prior to admission. When the clinical presentation Page 5 of 38 Acute Inpatient Operational Policy July 2011

6 indicates any delay would be of significantly high risk, the service user will be admitted and CATT informed of the action taken. A CATT assessment will take place the following day to determine if the service user can be managed in the community with a home treatment package 3.6. Ward Managers or their delegated representatives will ensure the above standards are met prior to admission. They must not accept a service user for admission unless CATT has been involved in the decision to admit 3.7. Staff or their close relatives who require admission to a mental health facility would not usually be admitted to their local unit but would be admitted to another close by HPFT. Exceptionally there may be a need to access Mental Health Services of another Trust via a reciprocal arrangement Service users requiring admission for detoxification for substance or alcohol misuse will not be eligible for admission to an acute mental health assessment and treatment ward for the sole intervention of a detox. 4. Service User Profile 4.1 The acute ward accepts admissions for adults with acute mental illness that requires assessment and treatment, when there is no viable alternative to in-patient admission 4.2 Adults over the age of 65 years with a functional mental illness can be admitted to the acute ward. If a ward for older people is available this may be more appropriate. The most appropriate ward will be assessed during the admission procedures and agreed with the Ward Manager (or delegated representative). Out of office hours this would be agreed by the bleep-holder 4.3 Young People under 18 years of age should not be admitted to an adult psychiatric ward. CAMHS provide age appropriate accommodation and expertise at Forest House. In the event of no available beds in Forest House or where the risks are deemed too high, a bed should be sought in the child and adolescent independent sector in the first instance. If there are no available beds there, the decision to use an adult bed as an emergency measure must be agreed by the 2 nd on-call Manager and the Duty Psychiatrist after determining the level of risk/need of the young person. Forest House will support this. In this case, transfer to Forest House should be expedited as soon as possible after the admission. If an adolescent does have to be admitted to an adult acute ward it is the expectation that CAMHS would offer advice during the period of in-patient care. Page 6 of 38 Acute Inpatient Operational Policy July 2011

7 These exceptional circumstances will need to be recorded as a level 3 incident as it is in breach of the National Mandate in relation to 16/ 17 year olds being admitted to adult psychiatrist inpatient wards and commissioners will be informed. 4.4 Services users with mild/moderate learning disability may be admitted when there is a diagnosed mental illness that requires treatment. When such an admission occurs staff will work with the relevant consultant and staff from community Learning Disability services. Refer to section 26.4 for the Trust s commitment to access to healthcare for people with a learning disability. 4.5 The acute ward is an open ward. It is not possible to manage service users who are particularly violent, aggressive or a serious suicide risk. In such cases, and following a clinical discussion, a transfer will be arranged to the nearest Psychiatric Intensive Care Unit (PICU) until the period of high risk is controlled. During this time the acute ward Named Nurse and the Care Co-ordinator will maintain contact with the service user and the PICU. The service user will be transferred back to an acute ward as soon as clinically appropriate and in line with the Guidelines on Transfers of Service Users between Wards and Departments 5. Admission Process 5.1 The professional arranging the admission should notify the ward and ensure a bed is available. The admitting team must hand-over the care of the service user to the admitting nurse at the Mental Health Unit that is accepting the admission. Information about whether the service user has children and who they remain in the care of must also be handed over to the admitting nurse. Where a service user has a child under the age of 5 years, in consultation with the service user, the referring team should give consideration to informing the health visitor. 5.2 The first 72 hours of an admission are particularly important as the service user orientates themselves to the new situation. The Admitting Nurse on the ward will ensure the service user is appropriately received and the admission assessment of mental state and risk completed with the on-call doctor. A 72 hour plan will be agreed by the Admitting Nurse, the on-call doctor, relevant carers if present and whenever possible the service user. The care plan should be completed immediately following the completion of the risk assessments by the admitting nurse, ideally on the day of admission. 5.3 The risk assessments, care plan and HoNOS score should be completed at the same time by the same people. The HoNOS rating should be based on the service user s history in the last two weeks. Page 7 of 38 Acute Inpatient Operational Policy July 2011

8 5.4 It is important that service users are not subjected to having the same information requested time and time again nevertheless on admission it is necessary to assess the current mental state and risks and the reasons underlying the admission. During the course of the admission this understanding will be increased as further information becomes available. All information should be recorded on Care Notes the electronic patient record. 5.5 On the first working day following the admission the Named Nurse (or nurse in charge) will notify the CMHT/Older Peoples Services/AO/CATT/Learning Disability Services the admission has occurred. If the admission occurs out of hours a message will be left on the relevant answer phone. If the service user is not known to the service a care co-ordinator should be identified within 7 working days 5.6 Service users admitted under a compulsory order of the Mental Health Act will be given information leaflets regarding their detention and legal rights and this will be clearly documented in Care Notes. All relevant Mental Health Act forms should be completed. Staff will be mindful that some service users may require support and assistance in reading and understanding the information on their rights. Should the service user have a learning disability the local learning disability services should be involved to assist with this process. The explanation of the service user s rights will be repeated throughout the period of detention to ensure understanding. All actions taken by ward staff will be in accordance with the policy on People Detained under the Mental Health Act 5.7 General Practitioners will be notified by the ward staff of the admission on the first working day after the admission has taken place. 5.8 During the admission process the needs of carers will be considered and they will be given information regarding assessments and any other local help that can be accessed through carers groups and/or Carers in Hertfordshire 5.9 On admission service users will be given the following information: Patients Information Book Leaflets on any drugs prescribed (if appropriate) Legal Rights Leaflets for detained service users (if appropriate) Advice on the managed door system within the ward environment 5.10 The use of illegal drugs and alcohol is prohibited on the ward. If a service user is found to have them on admission they will be removed and illegal drugs will not be returned on discharge. Please see Admission Standards in Appendix A. Should carers, relatives or friends bring alcohol or drugs onto the ward or be under the influence of any substance they will be asked to leave. Page 8 of 38 Acute Inpatient Operational Policy July 2011

9 5.11 In-patients may be transferred from another Mental Health Unit or from one ward to another. Transfer of any in-patient would be following the agreement of the sector consultant (or delegated representative). Ward Managers would facilitate the transfer. Transfers must always follow the guidelines shown in appendix B and admission must be in accordance with all sections above 5.12 Male and female service users will not share sleeping accommodation, share toilet or washing facilities. They will not have to pass through sleeping, toilet or washing areas of the opposite sex to access their own Ascertaining whether a ward has any vacant beds for new admissions, will be done in the terms of male or female beds. This will ensure that wards are not obliged to accept an admission when they cannot guarantee delivering same sex facilities If a breach of these standards should take place, the ward manager and Modern Matron will be informed and the event will be reported as an incident under the Learning from Adverse Events policy. 6 Care Programme Approach 6.1 In-patient services will comply with all the requirements of the HPFT Policy on Care Programme Approach, incorporating Care Management 6.2 All in-patients with mental illness admitted for an in-patient episode are managed within the Care Programme Approach (CPA) on Enhanced Level in relation to the planning of care and discharge 6.3 The first ward round/review following a new admission to the ward will be designated a CPA review and a CPA Care Plan and Risk Assessment agreed and recorded 6.4 A Named Nurse under CPA is identified from within the ward team. The named nurse (or their delegated representative) has specific responsibilities in relation to the co-ordination of care, having regular contact with the service user and with the community Care Co-ordinator. Further information is to be found in the Nursing Care Plan Policy 6.5 All in-patients must have an allocated Care Co-ordinator and the ward will ensure the community services are notified of new admissions. If a care co-ordinator is not currently allocated the community team must ensure allocation is given priority 6.6 During the course of the admission, Service Users and relevant carers will be encouraged to be involved in the formulation of the CPA Care Plan, (see section 7), this will include relevant care and Page 9 of 38 Acute Inpatient Operational Policy July 2011

10 treatment whilst in hospital and identify the services required upon discharge. 6.7 CPA reviews will occur on the ward at regular intervals during the period of in-patient care. Planned discharges from in-patient care must be preceded by a pre-discharge CPA and risk assessment review. When an unplanned discharge occurs the CPA review will be arranged in the community by the Care Co-ordinator at the earliest possible date 6.8 The service user, and appropriate carers if agreed, will be given a copy of the CPA Care Plan and have an opportunity to express their views on its content 6.9 Staff will be mindful of the needs of carers in relation to the treatment and care of their relative. Service users will be encouraged to share information with the carer. Carers will be advised of the support they can receive from Carers in Hertfordshire and local information regarding support for carers will be on the ward notice board 7. Formulating the CPA Care Plan 7.1 In-patient services are committed to a whole system approach and to maximise their connections with all community services and other agencies. In particular strong working relationships with the CMHT, Older Peoples Services, Learning Disability services, Assertive Outreach Team, Community Support Team (CST), and CATT are seen as crucial in order to connect the service user with the community during the period of in-patient care 7.2 Weekly ward rounds/reviews are the venue where all disciplines, from both in-patient and community teams, meet together with the service user, relevant carers, community Care Co-ordinator and any other involved services or agencies to formulate and review plans. These plans are formally agreed at the CPA review 7.3 Following admission and the initial assessment, a comprehensive multi-disciplinary health, psychological, social care and risk assessment will be completed during the first week of the admission. Family difficulties, including child protection issues, will be identified. The assessment of physical health needs is seen as an integral part of this comprehensive assessment. The Named Nurse will co-ordinate this in conjunction with the Care Coordinator. (See also 5 regarding recording of the assessment). The needs identified form the basis of the CPA Care Plan which will include medical and psychological aspects of treatment together with details of how any community social care and physical health needs will be met Page 10 of 38 Acute Inpatient Operational Policy July 2011

11 7.4 A Nursing Care Plan, written by ward nurses, records the daily therapeutic activities the service user will attend during the inpatient episode which will assist the service user s stabilisation and return to health during the course of the admission. The Nursing Care Plan is monitored daily, up-dated according to the Nursing Care Plan Policy and shared at ward round reviews 7.5 Carers needs will be identified and a Carers Assessment arranged by the Named Nurse or Care Co-ordinator if this is required and desired 7.6 The CPA Care Plan will address issues that emerge during the admission or can be anticipated upon discharge from in-patient care. This will include ensuring the service user is registered with a local GP; identify housing issues that may effect discharge, consider the suitability of intensive home treatment from CATT or on-going intensive care from the Assertive Outreach Team and will address any social care issues 7.7 The CPA Care Plan may also identify the need for on-going involvement in home or community activities during the in-patient episode. This may be arranged with the help of the CST, AO or the CMHT during the period of the in-patient episode providing it is clinically appropriate and agreed by the clinical team 7.8 Whilst an in-patient it is seen as high priority that any issues to do with Welfare Benefits are addressed in the Nursing Care Plan and the CPA Care Plan and immediate assistance is offered 8. Discharge from the Mental Health Unit 8.1 Discharge planning commences at the beginning of any in-patient episode and is addressed within the Care Plan, formulated at weekly ward reviews, and, confirmed and agreed within CPA meetings. 8.2 A pre-discharge CPA is held. The GP, together with the service user, relevant carers, the multi-disciplinary team and any other involved agencies are invited 8.3 Attention will be given to the home situation to ensure identified social care needs have been addressed and return home is practicable and safe prior to discharge 8.4 CATT will attend ward reviews, or have regular contact with the Ward Manager (or delegated representative) to consider whether early discharge with intensive home support and day treatment could be considered by the Named Consultant and multidisciplinary team 8.5 A CMHT representative will be present at all ward rounds/reviews and ensure that community services are commenced following the Page 11 of 38 Acute Inpatient Operational Policy July 2011

12 patients discharge from hospital. A representative from Older Peoples Services and Learning Disability services will be present when a service user requiring their services is to be discharged 8.6 Discharge against medical advice or following inappropriate behaviour (such as the use of alcohol or illegal drugs on the ward), will sometimes occur. When this happens during normal working hours ward staff will ensure the carers, the CMHT and any other relevant community services are notified immediately. 8.7 When an unplanned discharge occurs outside normal working hours or over a weekend or bank holiday the Ward Manager (or delegated representative) will contact the relevant carers to inform them of the unplanned discharge. Possible risks will be assessed and the Ward Manager (or their delegated representative) will consider the most appropriate short term follow-up. This may be by way of CATT or the GP. The bleep-holder and first on call manager will be advised of the situation and the actions taken 8.8 The use of drugs or alcohol whilst an in-patient may lead to immediate discharge if this action is clinically appropriate. The use of illegal drugs is a criminal offence and if this occurs on the ward the police will be notified according to the agreed procedures 8.9 When any unplanned discharge occurs the Care Co-ordinator is responsible for arranging an urgent home visit/contact within 7 working days in accordance with the HPFT Policy Follow-up After Discharge from Mental Health In-patient Units and an early CPA review 8.10 In the period immediately prior to the discharge a physical examination should be carried out if felt necessary by the relevant consultant 8.11 The final Enhanced CPA review, prior to discharge, should identify the date of the first community review, the level of CPA on discharge and the name of the Care Co-ordinator. The date for the 7 day follow-up contact will be agreed in accordance with the HPFT Policy Follow-up After Discharge from Mental Health In-patient Units 8.12 All service users will be encouraged to complete an Advanced Directive indicating their views on treatment should in-patient admission be required at any future date. Further information on Advanced Directives is to be found in the HPFT Policy 8.13 The GP is notified of the discharge by ward staff within 48 hours and the discharge summary is sent within 14 days together with the final CPA Care Plan and risk assessment. 9. Working Procedures Page 12 of 38 Acute Inpatient Operational Policy July 2011

13 9.1. The acute ward uses a holistic approach working closely with individual service users to achieve a therapeutic intervention whilst maintaining maximum independence. Staff believe in empowering service users to take an active part in their treatment and be involved in planning their discharge from in-patient care Ward staff are committed to a recovery model of work that builds on the personal strengths and resilience of the service user. Encouraging hope and respecting diversity. The service user, their family and support networks are central to the process of any work undertaken by ward staff 9.3. The progress of the service user is regularly reviewed by the completion of the HONOS ratings on admission and at CPA Review Meetings (this would include the pre-discharge CPA) 9.4. In order to effectively provide the service ward managers (or delegated representative) ensure: Every service user on the ward has an identified named nurse who will see the service user for regular one to one sessions to discuss on-going needs The named nurse will ensure the service user is aware of ward routines including ward rounds and CPA Reviews Nursing staff participate in ward rounds/reviews and feedback on the service user s progress and concerns The Nursing Care Plan and the agreed CPA Care Plan is facilitated by ward staff Activities within the community are facilitated if this is part of an agreed care plan Nursing staff participate in risk assessments and reviews The named nurse and the Care Co-ordinator will maintain regular contact during the course of the admission The Named Nurse or Ward Manager notifies the Community Care Co-ordinator of any planned leave from the ward or of any service user absent without official leave (AWOL) Nursing staff facilitate escorted leave when an up-dated risk assessment indicates this is appropriate and medical agreement has been given. (Guidelines for good practice are given in the Section 17 Leave Policy) When in-patients are held under an order of the Mental Health Act the Section 17 Leave of Absence Policy and Procedure is followed Nursing staff ensure service users are aware of how to access the Advocacy Service and the Patient Advisory Liaison Services (PALS) Nursing staff facilitate different ward based activities and service user groups including a weekly group addressing any issues about life on the ward Page 13 of 38 Acute Inpatient Operational Policy July 2011

14 As the need arises nursing staff offer day to day guidance and support to carers The nurse in charge will ensure an appropriate induction at the commencement of shift and a full handover at the end of the shift. The handover should highlight the relevant risks for each service user, the reason for admission, the risk profile and any changes in risk. There is a Ward Round Code of Conduct that staff will follow at all times. When any in-patient requires closer monitoring (observation) this will be in accordance with the HPFT Observation Policy. The responsibilities for general and intermittent observations will be conducted by different members of staff. The nurse in-charge is accountable for the review of supportive observations and should ensure they have in place systems to oversee and report significant changes that support robust handover and ongoing continuity of care in a timely manner. On Election Days service users who are entitled to vote will be assisted to exercise their rights There is a regular staff meeting held at no less than monthly intervals, to support and inform staff, reflect on clinical issues and identify any group training needs. 10. Services for In-Patients Advice is offered by nursing and community staff on a range of issues including: Rights under the Mental Health Act Patient Advocacy Service (POhWER) Patients Advisory Liaison Services (PALS) Housing Issues Welfare Benefits Local Carers Groups 10.1 Specific services will be arranged for service users from different ethnic backgrounds and an interpreter will be identified if this is required 10.2 Facilities for service users include a ward telephone and newspapers. Such items as toiletries, confectionary and soft drinks are also available on most sites. When a shop is unavailable staff hold a small supply of emergency toiletries 10.3 Spiritual and religious guidance/chaplaincy for all denominations is available on request 10.4 A Patients Forum/Community Meeting is held weekly when any general issues regarding life on the ward may be discussed 10.5 An advocacy service is available to service users Page 14 of 38 Acute Inpatient Operational Policy July 2011

15 10.6 Ward activities are organised daily for service users and are programmed on the ward notice board. These may include games, discussions and organised activities 10.7 Occupational Therapy (OT) is part of a service user s treatment throughout an admission with sessions on the ward, in the OT department and in the community. There is opportunity for the service user to continue planned treatment after discharge 10.8 The Arts Therapies Service, which may include Art Therapy, Drama Therapy and Music Therapy (as available) provides psychological treatment for service users. Sessions may be in the form of open groups or for individual sessions as agreed within a care plan 10.9 A female lounge is available in most mental health units. When a female lounge is unavailable a quiet area for sitting is set aside for this purpose On the ward there is a picture board showing photographs of staff to aid identification 11. Medical Cover and Medication 11.1 Whilst an in-patient every service user has an allocated named consultant psychiatrist 11.2 The Consultant, together with his/her medical team are responsible for the medical treatment of the service user whilst they remain an in-patient 11.3 Appropriate medication is prescribed and the service user given information on the treatment, likely positive outcomes and possible side effects. When available and it is appropriate, taking into account the clinical picture, they will be given a leaflet on the medication prescribed 11.4 Every in-patient is medically reviewed at least weekly by the Named Consultant and medical team. If concern arises at any time this is reported by nursing staff to the medical team who arrange an early review 11.5 During the course of the admission in the weekly ward round/review meeting the Named Consultant and the medical team work together with nursing and community staff to ensure the service user receives care that addresses all assessed needs 11.6 When a medical diagnosis has been agreed the service user will be informed and information offered regarding the condition, treatment and prognosis. Page 15 of 38 Acute Inpatient Operational Policy July 2011

16 12. Lead Ward Consultant Role A lead Consultant will be identified for the ward their role will be to: Offer support to the ward Manager and discuss management issues such as patient numbers, serious incidents, complaints and compliments To be involved in any review of ward services To offer appropriate support to nursing staff on the ward when possible by attending a regular staff meeting To assist the manager identify training issues To listen and feedback to the Ward Manager (or vice versa) any general concerns or issues raised by medical staff To support teamwork on the ward and line management with the objective of providing a culture of openness 13. Managing Risk Risk is defined as The likelihood of an event happening with potentially harmful or beneficial outcomes for self or others 13.1 The creation and maintenance of a safe environment for service users, visitors and staff is of high importance. Personal privacy and dignity will be respected, distressed service users and carers will be offered individual support and guidance 13.2 Regular health and safety inspections occur to ensure the physical safety of the ward. This is according to HPFT Policies 13.3 The acute ward will have sufficient staff with appropriate qualifications and experience on duty at all times to manage the number of service users on the ward. The number of staff required will reflect the levels of risk and will be reviewed daily, or more frequently, by the Ward Manager/bleep-holder (or delegated representative) 13.4 The wards operate a managed door policy to manage the risk of absconding whilst managing the requirements of those who have liberty to gain exit and entry to the wards All ward staff are required to undergo specific training in relation to the assessment and management of risk. This is as follows: Knowledge and understanding of the HPFT Policy Care Programme Approach Incorporating Care Management Page 16 of 38 Acute Inpatient Operational Policy July 2011

17 Recurrent (minimum 2 yearly) risk assessment and management training. Service Manager to ensure that this is adhered to and records maintained by Modern Matron. SCIP training (Bank staff must also complete SCIP training) Fire training Staff are required to have relevant and mandatory training, knowledge and understanding of Health and Safety procedures and ensure these are followed in accordance with HPFT policies Staff are required to have relevant training and have knowledge, understanding and be competent in performing Basic Life Support procedures Relevant training and knowledge of Child Protection Procedures Learning for Adverse Events Policy including Reporting and Managing Adverse Incidents/Accident Procedure To have understanding and knowledge of the Adult Protection Procedure Staff must attend basic training on Moving and Handling and attend refresher courses Staff are required to be certificated in Basic Food Hygiene Basic understanding of the risk factors associated with substance misuse and detoxification Ligature training 14. Induction, Staff Support, Supervision, Appraisal and Training 14.1 Staff development and training is a high priority for HPFT and each member of staff has an annual appraisal and a Personal Development Plan identifying training needs 14.2 Regular staff support is offered via Staff Support Groups and also by access to external HPFT counselling for members of staff 14.3 Clinical/Management supervision is provided for all staff by a more senior member of the nursing staff. Sessions are at least monthly and offer an opportunity to focus upon their professional role and clinical practice 14.4 All newly appointed staff undergo a comprehensive induction programme in line with HPFT policy. The programme commences with an intensive five day induction to their own in-patient unit during their first week of work. Further induction is planned over the following three months of employment. There is also a corporate induction organised by the Human Resources Department which all new staff must attend. It is the responsibility of the line manager to insure the induction is signed off on the Induction Check List 14.5 During the first week of employment it is the Ward Managers responsibility to ensure the new member of staff is registered for the use of Care Notes and undertakes the mandatory training in order to be competent in its use Page 17 of 38 Acute Inpatient Operational Policy July 2011

18 14.6 All staff, including bank and agency staff are required to have an induction period however this may be locally agreed according to the length of time they are expected to be employed 14.7 Training courses form an integral part of every nurses Personal Development Plan. Training Bulletins are issued regularly by the Trusts Training and Development Department. Mandatory courses must be attended and regular bank staff will be expected to attend 15. Bed Management and Out of Hours On-call System 15.1 The ward manager (or delegated representative) will inform the Bed Management and Placement Service daily of the numbers of inpatients on the ward, the level of care they require and any specific clinical issues that cause concern 15.2 On a daily basis bed occupancy is reviewed by the Modern Matron/Bed Manager with a view to consider early discharge with intensive home treatment and/or attendance at the Acute Day Services Treatment Unit 15.3 If the ward is reaching capacity the Consultants and CATT will be informed by the Ward Manager/Modern Matron and requested to review in-patients to identify whether any in-patient could be considered for early discharge with intensive home treatment 15.4 If the ward is full and no further admission is possible new admissions will need to be admitted to another HPFT bed out of the local area or to a bed in a private hospital. If this occurs the Ward Manager will endeavour to transfer the service user back to the home unit within 5 working days or at the earliest clinically appropriate time in accordance with the Bed Management Policy When it is necessary, during normal working hours, to admit or transfer a service user to another Mental Health Unit the Ward Manager (or delegated representative) will identify a suitable bed and inform the appropriate Consultant Psychiatrist. The Consultant Psychiatrist will then communicate with the receiving consultant and ensure appropriate documentation including an up- dated risk assessment is forwarded. If there is any dispute over admission when a bed is available this should be referred immediately to the Service Manager (or his delegated representative) 15.7 Out of hours the senior nurse in charge of the Acute Ward has access to the Duty on-site Bleep-holder and the Manager on-call to discuss any issue, including admissions and/or disputes that cause concern. Disputes that arise out of hours will be discussed with the bleep-holder and reported to the on-call Manager. Any out of area admission will be reported to the Acute Services Manager at 9.00am on the first working day following Page 18 of 38 Acute Inpatient Operational Policy July 2011

19 Further details regarding bed management are to be found in the HPFT Bed Management Policy which should be followed at all times 16. Comments, Complaints and Compliments All comments, complaints and compliments will be dealt with in accordance with the jointly agreed Hertfordshire Partnership NHS Foundation Trust and Adult Care Services Policy. Any comment, complaint or compliment should be made directly to the Complaints Manager. A leaflet outlining the procedures is available on the ward 17. Confidentiality Ward staff will aim to preserve the confidentiality of information acquired from service users and protect the privacy of individuals about whom such information is collected or held Carers and relatives frequently request information. This will be given to them when appropriate and with the agreement of the service user. If there is a significant danger to the service users or others then information will be shared with carers on a need to know basis and the service user will be informed of this necessity Subject to the requirements of the law, ward staff will take care to prevent the identity of service users being revealed without the expressed permission of the individual. Ward staff operate a system of shared confidentiality this means information about users will be shared by members of the multi-disciplinary team for the purposes of allocation, advice and supervision. Further guidance is to be found in the HPFT Policy on the Management of Care Records and the protocol Inter-Agency Exchange of Information. 18. Access to Records (Including Legal Access to Records) Members of staff have a statutory duty (Data Protection Act 1998) to inform services users that information is being held by the Trust which records details of their health and social care assessment, treatment and progress, and that these records are identifiable. Service users must also be informed of the right to request access to their records. This information should be given verbally and by offering the service user the relevant information leaflet. The mental health professional should inform the service user that all information is confidential but may be shared on a need to know basis If a legal representative needs to see records for a Managers' or Tribunal hearing, s/he must present written authority to disclose. If the RMO has agreed that there is nothing that needs to be kept from the service user, the solicitor will then have free access (subject to making an appointment to view with the staff). All records MUST be printed off Care Notes for the solicitor to view. Page 19 of 38 Acute Inpatient Operational Policy July 2011

20 They will then make any notes they wish and leave the print-out on the premises; they may not put them in their briefcase and take them away This is to prevent loss or theft of sensitive material. In the future it is anticipated that there will be a special code to allow solicitors to view the record directly on Care Notes. When this comes into force it will be necessary to have an audit trail to guarantee that confidentiality is not breached. Staff should follow, at all times, the Protocol on Non-HPT Authorised Visitor Access to Care Notes Request for information by Independent Mental Capacity Advocate (IMCA) Where someone lacks capacity and the criteria to instruct an IMCA are fulfilled then the IMCA should be allowed access to the relevant records. A form must be completed by the IMCA to say that they are requesting access If the RMO assesses some information should not be disclosed to the service user the solicitor must be told. He/she will have free access to the record but is not allowed to reveal the information to the service user, unless the Managers or Tribunal Panel rule that fairness requires disclosure If a solicitor requests access to records for ANY other reason, for example a court case, he/she should be reminded that this is handled under the Trust's formal access to records procedure and a written request must be made to medical records, enclosing client's authority On no account should information be disclosed to a solicitor unless the procedures detailed in section above have been followed. Handing over records without the procedures being followed is a breach of HPT Policy and could lead to breaching the confidentiality of the service user Applications for access to records have to be made in writing and can be sent direct to the Modern Matron. 19. Care Notes Care Notes is the HPFT Electronic Patient Record. Staff are required to have training on the use of the system Staff must record all contacts with the service user on Care Notes 20. Health and Safety On the ward the health and safety of staff, service users and visitors is of high importance. Any kind of violence verbal or physical to Page 20 of 38 Acute Inpatient Operational Policy July 2011

21 staff, service users and visitors will not be tolerated and may well be reported to the police and a criminal prosecution may follow. It is the general duty of every member of staff to take reasonable care of their own health and safety, and that of others. This includes the use of necessary safety devices and protective clothing, and to co-operate with managers in meeting responsibilities under Health and Safety legislation. Staff should report all concerns of a health and safety nature to the ward manager (or delegated representative) for appropriate action. 21. Communication Good communication between health care professionals and service users, their partners, relatives and carers is essential. The information provided should meet the individual s communication needs, e.g. people with physical, sensory or learning disabilities or people who do not speak or read English. The Trust Policy on Communicating with Service Users from Diverse Communities provides guidance on communication needs and the procedure on accessing the interpreting service. 22. Capacity to Consent The Mental Capacity Act 2005 and associated Code of Practice provide the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves. Everyone working with and/or caring for an adult who may lack capacity to make specific decisions must comply with this Act when making decisions or acting for that person, when the person lacks the capacity to make a particular decision for themselves. The same rules apply whether the decisions are life changing events or everyday matters. (Please refer to the MCA Code of Practice and the Hertfordshire policy on mental capacity for further information) 23. Records Management All NHS employees (including seconded staff) are responsible for all records that they create or use in the course of their duties. This responsibility is defined both in law and in other professional guidelines covering the handling of records. For example, the Public Records Act 1958, the Data Protection Act 1998 and the Freedom of Information Act The Trust's Records Management Policies give full details of those responsibilities and the standards we need to meet. 24. Freedom of Information The purpose of the Freedom of Information Act (FOI) is to allow greater access to non-clinical information held by public authorities Page 21 of 38 Acute Inpatient Operational Policy July 2011

22 and potentially every document (that is not about an individual e.g. service user) can be scrutinized by the Public. The Act gives the Public the right to be told whether a piece of information exists and the right to receive it if requested. The FOI Act DOES NOT supersede the Data Protection Act 1998 and information about an individual (and described as personal data) would not be disclosed under the FOI Act. 25. Quality, Audit and Practice Governance Every effort will be made to provide services of high quality. Local Practice Governance Groups, involving all stake holders, meet bimonthly to review, reflect, prioritise and learn the lessons identified from practice issues such as serious incidents, near misses, complaints and compliments. Staff will be provided with space and opportunity to explore their practice and service delivery. De-briefing is arranged after any untoward incident and there are regular opportunities offered for discussion on practice at staff away days and through in-house training. 26. Equality and Diversity All staff must be aware of issues relating to equality and diversity for service users and carers including: Understanding how to ask questions about culture, religion and ethnic background Arranging interpreters where necessary Offering adaptations for people with disabilities e.g. Hearing Loop, Downstairs meeting rooms etc. Opportunity to discuss relationships and issues relating to sexuality Ensuring that older people to not suffer disadvantage and are dealt with appropriately within services The needs of both men and women are represented equally including the needs of trans [1] service users Staff have a responsibility to challenge discrimination they may witness and report back in accordance with risk management and complaints and incidents processes All staff have the right to be treated with dignity and respect. Any situations of harassment, bullying or other abuse must be dealt with in accordance with the Trust harassment & bullying policy and other associated guidelines. All staff are also entitled to access the Trust counselling service if need Page 22 of 38 Acute Inpatient Operational Policy July 2011