Accreditation for Inpatient Mental Health Services Learning Disabilities (AIMS-LD)

Transcription

1 Accreditation for Inpatient Mental Health Services Learning Disabilities (AIMS-LD) Standards for Adult Inpatient Learning Disability Units Assessment and Treatment Units Editors: Joanne Cresswell, Sarah Bleksley and Suzie Lemmey Second Edition November 2010 Pub. No. CRTU077

2 A manual of standards written primarily for: Non-forensic Assessment and Treatment Units for adults of working age with learning disabilities where the person is admitted for a short to medium term and is then discharged Also of interest to: People with learning disabilities Cares of people with learning disabilities Commissioners Policy makers Researchers Second Edition November 2010 First edition published October 2009 Correspondence: AIMS-LD Team The Royal College of Psychiatrists Centre for Quality Improvement 4th Floor, Standon House 21 Mansell Street London E1 8AA Tel: Fax: AIMS@cru.rcpsych.ac.uk A full copy of this document is available on our website at: Standards have been classified as follows: Type 1: failure to meet these standards would result in a significant threat to patient safety, rights or dignity and/or would breach the law; Type 2: standards that an accredited ward would be expected to meet; Type 3: standards that an excellent ward should meet or standards that are not the direct responsibility of the ward The Royal College of Psychiatrists

3 Foreword We are really delighted to be able to release the second edition of the AIMS Standards for Adult Inpatient Learning Disability Units Assessment and Treatment Units. This second edition is based on revisions suggested by the discussion group and reviewers. These were discussed and ratified by the AIMS-LD Steering Group. The AIMS process is increasingly becoming recognised as one of the very best tools currently available to produce some badly needed improvements. Such improvements could make a meaningful difference to all those that either provide or receive care in today's psychiatric wards. It is always worth remembering that none of this would have been possible without the unbelievable hard work of all of those that are associated with this process. This includes the staff at the Royal College of Psychiatrists, the healthcare professionals, the service user and carer reviewers, and the staff who work on our member wards. This edition is completely the result of your invaluable input: thank you so much for your continuing support. You should be justly proud of this laudable work and please remember to promote AIMS whenever and wherever you can. Jo Cresswell AIMS Senior Programme Manager November 2010

4 Contents Introduction Acknowledgements v vi STANDARDS: Section 1: General Standards 1 Section 2: Timely and Purposeful Admission 9 Section 3: Safety 19 Section 4: Environment and Facilities 23 Section 5: Therapies and Activities 29 Glossary of Terms and Abbreviations 33 Bibliography 37 AIMS-LD Standards Feedback Form 41

5 Introduction The standards for accreditation are drawn from key documents and will help wards demonstrate compliance with the Healthcare Commission s Standards for Better Health as well as supporting implementation of NICE guidelines and the National Service Framework. They have been subject to extensive consultation with all professional groups involved in the provision of acute inpatient mental health services and with service users and their representative organisations. This second edition has been completely revised to meet the needs of Assessment and Treatment Units. They have been reordered, renumbered and divided into sections relating to the care pathway of the patient. The standards are reviewed on an annual basis and are applied each year during the self- and peer-review processes by AIMS member wards. The standards cover the following topics: General Standards Timely and Purposeful Admission Safety Environment and Facilities Therapies and Activities The full set of standards are aspirational and it is unlikely that any ward would meet all of them. To support their use in the accreditation process, each standard has been categorised as follows: Type 1: failure to meet these standards would result in a significant threat to patient safety, rights or dignity and/or would breach the law; Type 2: standards that an accredited ward would be expected to meet; Type 3: standards that an excellent ward should meet or standards that are not the direct responsibility of the ward. A copy of these standards will be sent to every ward that becomes a member of AIMS-LD. The standards are also available on our website at: v

6 Acknowledgements The following people gave us continued advice and support in compiling and editing the First Edition of these standards: Ms Deborah Agulnik Dr Sabyasachi Bhaumik Dr Harm Boer Ms Sarah Burgess Ms Becca Cooper Ms Vivien Cooper Mr Dominic Corry Ms Beverley Dawkins Mr Matthew Dodwell Ms Roisin Fallon-Williams Ms Sue Freeman Ms Jackie Freer Ms Alison Giraud -Saunders Dr Shaun Gravestock Mr Gavin Harding Mr Graham Hinchcliffe Mrs Rosemary Jenkinson Dr Susan Johnston Dr Theresa Joyce Dr Adam Kirby Ms Shirley Lavender Royal College of Psychiatrists' Centre for Quality Improvement Royal College of Psychiatrists Coventry and Warwickshire Partnership NHS Trust Dorset Healthcare Foundation Trust Service User Representative, York People First Carer Representative, The Challenging Behaviour Foundation National Patient Safety Agency Mencap Surrey and Borders Partnership NHS Foundation Trust Coventry and Warwickshire NHS Partnership Trust Northamptonshire Healthcare NHS Trust Coventry and Warwickshire Partnership NHS Trust Foundation for People with Learning Disabilities South London and Maudsley NHS Foundation Trust Service User Representative, York People First Royal College of Psychiatrists' Centre for Quality Improvement North Yorkshire and York Primary Care Trust Nottinghamshire Health Care Trust South London and Maudsley NHS Foundation Trust Dudley Primary Care Trust Nottinghamshire Healthcare Trust vi

7 Ms Maureen McGeorge Ms Debra Moore Ms Ann Norman Ms Julie Nutbrown Dr Peter Oakes Ms Lucy Palmer Ms Margaret Pine Ms Vicki Raphael Ms Fiona Ritchie Dr Alison Robertson Mr Keith Smith Ms Hannah Thorpe Ms Christine Warburton Royal College of Psychiatrists' Centre for Quality Improvement Debra Moore Associates Royal College of Nursing North Yorkshire and York Primary Care Trust University of Hull Royal College of Psychiatrists' Centre for Quality Improvement NHS Fife (Dunfermline & West Fife CHP) Carer Representative Care Quality Commission NHS Fife (Dunfermline & West Fife CHP) British Institute of Learning Disabilities (BILD) Royal College of Psychiatrists' Centre for Quality Improvement Coventry and Warwickshire Partnership Trust Special thanks to: AIMS Standards Reference Group for providing the existing inpatient service standards. York People First for developing the easy read version of these standards and the Patient Interview Tool. The staff, patients and carers at the pilot units for invaluable feedback on the programme: Oval 4, Coventry and Warwickshire NHS Partnership Trust Oakrise, North Yorkshire and York Primary Care Trust Atlas House, Oxleas NHS Foundation Trust vii

8 2 nd edition revision: Dr Sabyasachi Bhaumik Dr Harm Boer Ms Sarah Burgess Ms Vivien Cooper Dr Shaun Gravestock Mr Graham Hinchcliffe Mr Dermot Hurley Mr Jonathan Hurley Mrs Rosemary Jenkinson Dr Susan Johnston Ms Maureen McGeorge Ms Ann Norman Dr Peter Oakes Mr Keith Smith Royal College of Psychiatrists Coventry and Warwickshire Partnership NHS Trust Dorset Healthcare Foundation Trust Carer Representative, The Challenging Behaviour Foundation South London and Maudsley NHS Foundation Trust Royal College of Psychiatrists' Centre for Quality Improvement Carer Representative Service User Representative North Yorkshire and York Primary Care Trust Nottinghamshire Health Care Trust Royal College of Psychiatrists' Centre for Quality Improvement Royal College of Nursing University of Hull British Institute of Learning Disabilities (BILD) viii

9 Section 1 General Standards

10 Policies and Protocols NUMBER TYPE STANDARD All staff are informed how to access policies, procedures and guidelines, and are able to do so when required. MDT staff are consulted in the development of policies, procedures and guidelines that relate to their practice. Managers audit the implementation of policies and procedures and provide feedback to MDT staff. All policies and protocols are reviewed at a minimum of every three years with the support of the policy development/clinical governance teams. Staffing The unit has an agreed minimum staffing level across all shifts, which is met All staff have an up-to-date CRB check There are systems in place to ensure that all factors affecting staffing numbers and skill mix are taken into consideration, and staffing levels are reviewed on a daily basis. These factors are: levels of observation; sickness and absence; training; supervision; escorts; consultation, outreach and liaison functions; the need to promote patients independence; therapeutic engagement; acuity levels; conformance with local human resources guidance; staff capabilities; clinical meetings The nurse in charge of the shift is the point of contact for consultation, negotiation, and decision-making for all unit operational matters The agreed minimum staffing level includes one or more registered nurse(s) per shift. The unit has its own dedicated lead consultant who will provide expert input into key matters of service delivery, staff support and supervision, and overall service co-ordination. Specific sessions are set aside in the consultant s job plan to ensure sufficient time is available for their consistent and regular input to the team and related forums The unit manager has control over the unit budget. 2

11 The unit has access to the following referral services: Dental assessment and dental hygiene services; Visual reviews; Hearing reviews; Podiatry; Wound care services; Phlebotomy services; Specialist infection control services; A tissue viability nurse; Specialist continence services. There is access to relevant faith-specific support, preferably through someone with an understanding of mental health and learning disability issues. There is access to dedicated sessional or part-sessional administrative support which meets the needs of the ward. Recruitment and Retention of Staff In the event of vacancies, long term sickness or maternity leave, immediate arrangements are made for staff cover. There is a clear and written policy on the recruitment and use of bank and agency staff, including: a system to ensure staff have the basic skills, attitudes and competencies required; proper arrangements for the induction and management of bank and agency staff; a system to routinely monitor and report on the use of bank and agency staff MDT staff exit interviews are fed back to the Unit Manager Arrangements are in place so that Service User representatives can be involved in interviewing potential members of the MDT during the recruitment process Arrangements are in place so that Carers/carer representatives can be involved in interviewing potential members of the MDT during the recruitment process. 3

12 Appraisal, Supervision and Staff Support The unit has clear clinical supervision guidelines, which incorporate supervision contracts between supervisor and supervisee to cover: learning/training objectives; resolution of conflict (arbitrator identified); roles and responsibilities; practicalities, e.g. location; boundaries, e.g. time and agreed agenda; documentation to be used; confidentiality (adherence to professional code of conduct and Trust policy); actions in event of non-attendance or cancellation; frequency and duration. Clinical supervision occurs at a minimum of every eight weeks, or more frequently, as per professional body guidance. All staff receive an annual appraisal and personal development planning. Staff receive regular managerial supervision from a person with appropriate experience and qualifications. Supervisors receive appropriate training as agreed in local policy, taking into consideration profession-specific guidelines. Staff are able to contact a senior colleague as necessary, 24 hours a day. Staff have access to a ward-based reflective practice/staff support group to discuss clinical work at least monthly with a suitable facilitator. All staff are able to take regular allocated breaks away from patients during their shift. Staff Education and Training Training budgets enable all staff to meet requirements for their continuing professional development and the Knowledge and Skills Framework. Access to training is facilitated, and there are arrangements for staff cover to allow staff to attend training All new staff are allocated a mentor/preceptor who oversees their induction Unqualified staff are encouraged and enabled to develop additional skills There is clinical leadership training for registered mental health nurses (band 6 and above), psychiatrists and other members of the MDT. 4

13 All staff have up-to-date training in basic life support, fire and manual handling. Staff who undertake assessment and care planning have received training in assessing capacity and gaining consent from people with learning disabilities. Staff who undertake assessment and care planning have received training in how to involve patients and carers All staff have been trained in the principles of patient-centred care All staff have received awareness training in how to communicate effectively with people, including: understanding the person s preferred means of communicating; the use of different communication methods and visual aids; the importance of tone of voice; non-verbal communication; the use of appropriate language; active listening techniques; recognising when people might be suggestible/acquiescing; recognising when people are communicating distress, and responding to it; the link between communication and challenging behaviour; the appropriate use of interpreters. Staff who undertake assessment and care planning receive training in locally agreed outcome measures. Staff who undertake assessment and care planning have received training in risk management and risk assessment. Staff who undertake assessment and care planning have received training in self-harm and suicide awareness and prevention techniques. Staff who undertake assessment and care planning have a basic understanding of medical conditions associated with learning disability. Staff who undertake assessment and care planning have received training in recognising and managing swallowing difficulties. Teams working together have undertaken the same accredited prevention and management of challenging/violent behaviour training All practitioners who administer medications have been assessed as competent to do so. This is repeated on a yearly basis using a competency-based tool All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to whom parenteral rapid tranquillisation has been administered, have received training in immediate life support. 5

14 Clinical staff receive training and support from staff with appropriate clinical skills to provide basic psychological and psychosocial interventions (including, but not limited to, conflict resolution/deescalation, engagement activity scheduling, group facilitation) The unit can demonstrate that qualified staff from nursing, OT, psychiatry and clinical psychology receive ongoing training and supervision to provide a repertoire of problem-specific, low intensity psychological interventions in line with NICE guidance The unit can demonstrate that qualified staff from nursing, OT, psychiatry and clinical psychology receive ongoing training and supervision to provide a repertoire of problem-specific, high intensity psychological interventions in line with NICE guidance. Advocacy The unit has a formal link with a range of advocacy services that includes the Independent Mental Capacity Advocate (IMCA) service. The patient (and their carer) has access to independent advocacy services, and staff explain the benefits of using these services. Compliments and Complaints There are clear policies and procedures for managing complaints The patient (and their carer) is actively encouraged to give feedback on the service throughout their admission, and on leaving the service, via consultation groups, a compliments and suggestions box, discharge questionnaires, satisfaction surveys, follow-up letters etc. Information is available in a user-friendly format for patients/carers about: how to make a verbal complaint; how to make a written complaint; how to suggest service improvements and enhancements; how to make a written compliment; how to make a donation. This is publicised and easily available There is evidence of audit, action and feedback from complaints. Reporting inappropriate/ abusive care Interagency protocols are in place for the safeguarding of adults There are protocols/procedures/strategies in place for the confidential reporting or whistleblowing on abuse or inappropriate care. 6

15 8.3 2 The patient (and their carer) is informed of the procedures that would be followed if a disclosure of abuse were made, and they are reassured that they would be taken seriously Staff receive up-to-date training and development consistent with their role in recognising the signs or symptoms associated with: physical abuse; sexual abuse; emotional abuse; financial abuse; institutional abuse; self-neglect; neglect by others. Staff receive up-to-date awareness training in helping people with learning disability recognise potentially or actually abusive behaviour in any of their relationships. Smoking There is a smoke-free policy for staff and patients, which follows HDA guidance and best practice There is support for staff and patients to assist with the smoking policy, including: consideration of the use of NRT while on the premises to help with withdrawal or as a coping strategy; a comprehensive support programme, with information about the support on offer; strategies to make sure staff know and understand the smoking policy, and to monitor levels of comprehension. Where smoking is permitted, there is a safe allocated area for this purpose. 7

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17 Section 2 Timely and Purposeful Admission

18 TIMELY AND PURPOSEFUL ADMISSION NUMBER TYPE STANDARD There is an information sharing protocol confirmed at Trust board level of which all staff are aware, and this is publicised to visitors and patients Staff are aware of the limits of information-sharing, according to: data protection; freedom of information. Control of Bed Occupancy Bed occupancy is managed at a service level, and there is a clear process for exceeding this level. Written referral criteria clearly specify the function of the inpatient service, and the age groups and problems that the unit does and does not cater for. Before Admission There is an identified and documented contact or link person for each agency involved with each patient. Pre-admission assessments are attended by a member of the inpatient unit team. Before a routine admission, the patient (and their carer) is given the name and contact details of a link person for admission queries. Inpatient staff are involved in pre-admission discussions to determine whether or not the unit is suitable for the individual s needs, taking into account the remit of the unit and the needs of the resident population. Admission Systems There is a documented, up-to-date referral procedure for routine referrals, which is agreed with other agencies and services and made available to referrers. There is a documented, up-to-date referral procedure for emergency referrals (i.e. people being admitted within 24 hours), which is agreed with other agencies and services and made available to referrers. For routine admissions, the unit accesses all of the recent community paperwork that is available on the patient. This might include: mental health and risk assessments; details of current medication; physical health assessments, and a copy of Health Action Plans; existing care plans/person-centred plans/cpas; details of daily living routines and preferences; the role of family and carers; communication needs and use of communication methods. 10

19 For emergency admissions, where the patient arrives out-of-hours, there is evidence that community assessment paperwork was actively sought the next working day. This might include: mental health and risk assessments; details of current medication; physical health assessments, and a copy of Health Action Plans; existing care plans/person-centred plans/cpas; details of daily living routines and preferences; the role of family, carers and significant others; communication needs and use of communication methods. There are protocols for transfer or shared care between LD and generic mental health services, which clearly specify: consultant responsibility; the roles and responsibilities of inpatient and community teams in both mental health and learning disability services; the requirement for joint care planning at an individual level; the requirement for a written care plan to specify what support each service can expect from the other; roles and responsibilities in relation to CPA; information sharing. There are protocols for transfer or shared care between LD and social care services. Admission Process The patient and accompanying person (where appropriate) are met on arrival, shown to an appropriate area, and offered refreshments etc The patient is introduced to a member of staff who will be their point of contact for the first few hours of admission Before admission, or as soon as they arrive, a member of staff checks that the patient has any aids or equipment that they need. The admitting nurse checks that the referring agency gives clear information as to the security of the patient s home, whereabouts of children/animals, etc. On the day of their admission, or as soon as they are well enough, the patient is shown around the unit at a steady pace. 11

20 On the day of their admission, or as soon as they are well enough, the patient is given an accessible information/welcome pack that describes life on the unit. This might include: the purpose of the unit; methods of treatment; unit facilities, daily life and programme of activities; choice of food; personal safety on the unit; visiting arrangements; what practical items people need to bring in; the rights of people who are staying there and what is expected of them, including levels of freedom and restriction; sleeping arrangements (e.g. shared or single bedrooms). The patient is made aware of their rights to access records held by the service. If the patient is detained under the Mental Health Act, on the day of their admission or as soon as they are well enough, they are given written information on their rights, in accordance with section 132 of the Act. If the patient is admitted informally, on the day of their admission or as soon as they are well enough, they are given accessible written information on their rights, rights to advocacy and second opinion, right of access to interpreting services, professional roles and responsibilities and the complaints procedure On the day of their admission or as soon as they are well enough, the patient (and carer, where permitted) is told the name(s) of their Primary Nurse/care team and how to arrange to meet with them Each patient has a named member of staff who co-ordinates their care and this is recorded. Clinical protocols/procedures/strategies are in place to review whether the patient and their named worker are getting on. The patient s individual preferences are taken into account in the initial selection of their named worker e.g. gender. If the patient is having difficulty settling in and would benefit from extra contact with their carer, staff make efforts to facilitate this. This might include: showing flexibility around visiting times and telephone contact; allowing carers to stay overnight. Assessments All assessments are documented, signed/validated (electronic records) and dated by the assessing practitioner. 12

21 The patient has a choice of who comes to any meetings where their care is being assessed, planned or reviewed, including whether their carer attends, except in cases where the person s care is subject to the Care Programme Approach, Offender Management and Ministry of Justice requirements. A full physical examination is carried out as part of the admission process During intimate or physical examinations a chaperone is always considered, depending on the risks and needs of the patient or staff and the ward has a protocol relating to this Physical investigations are carried out and recorded in accordance with the request of the assessing clinician. The symptoms, progress and treatment of the patient s long-term physical disorder(s) are reviewed and documented not less than monthly by medical staff. If the patient has epilepsy, initial information is gathered and recorded on: seizure type, frequency and stability; managing prolonged or serial seizures; arrangements for use of rescue medication. If the patient has epilepsy, descriptions of their seizures and frequency are recorded on standardised charts Unit staff facilitate the patient s access to health services Interagency protocols are in place for liaison with general practitioners to investigate non-urgent physical health issues. A comprehensive physical health review takes place as part of the initial assessment, within 72 hours of admission. The review might include: details of past medical history (or request made for information from relevant agencies); a comprehensive review of symptoms; current medication, including side effects; lifestyle factors e.g. sleeping, diet, smoking, exercise, sexual activity, alcohol and drugs. The patient s initial needs are assessed in relation to mobility e.g. aids and adaptations, exercises etc., and these are recorded. 13

22 The patient s assessment takes into account existing information and covers risk and safety issues. This must include any of the following that were relevant to the person: risk of absconding; risk of harm to self or others; risk of vulnerability, exploitation or abuse; examples of situations under which any challenging behaviour is most likely to occur/historical factors that have contributed to behaviour and any relevant environmental/social/health factors; forensic history. The patient s assessment takes into account existing information and covers mental and physical health/well-being. This must include any of the following that were relevant to the patient: past and present mental health problems; mental capacity; consent or refusal of consent to treatment; developmental history. The patient s assessment takes into account existing information and covers social and personal well-being. This would include any of the following that were relevant to the person: their wishes and expectations regarding their admission; communication needs; family/social network/social needs; the role of carers, supporters and advocates; individual needs relating to gender, ethnicity, culture or spirituality; pattern of daily life and activities/ability to carry out activities; food preferences, including special dietary requirements; any concerns over living situation/financial worries/employment status. The patient s assessment takes into account existing information and covers their sensory processing profile and the environments they typically function within. This might include: sensory based assessment of any challenging or self-injurious behaviours; sensory based assessment of the events leading to or maintaining the hospital admission; the use of sensory approaches and environments to help manage challenging and self-injurious behaviours, and promote development of positive regulation and self-management strategies. Care Planning The patient s care plan builds on strengths and is focused on clear and attainable goals, which are recorded. The patient (and their carer) is encouraged to be an active partner in developing all aspects of the care plan, including agreeing aims and interventions, and their views and wishes are recorded by the assessing practitioner. A copy of the care plan is offered to the patient (and their carer) in an accessible format, and this is recorded. 14

23 The patient (and their carer) plays a key role in monitoring, evaluating and reporting the effects of interventions. The patient is given the opportunity to develop a Health Action Plan or equivalent (or review their existing one), and this is recorded. The patient is given the opportunity to have access to a health facilitator and this is recorded. Details of the Health Action Plan are incorporated in the patient s care plan. The patient s behavioural support plan is individualised and consists of ways of avoiding the need for the behaviour(s) to occur. These might include prevention and secondary prevention strategies and clear interventions for all to follow. If a detained patient - who is a risk to themselves or others - is identified to be at risk of absconding, then a crisis plan is completed which includes instructions for alerting carers and any other person who may be at risk There are systems for recording unmet needs, e.g. CPA documentation. Consent to Interventions Staff make efforts to establish the patient s capacity before each intervention, including seeking advice from the person s carer if required, and this is recorded. There is evidence that interventions are only conducted without the patient s consent if: it has been established that the patient lacks the current capacity to consent to the treatment; all other options have been exhausted; the treatment is deemed to be in their best interests. Where necessary, documented best interest meetings are held about a patient for carers, professionals, advocates and relevant others to discuss the situation and support healthcare professionals to reach a decision about how to proceed. When the patient is assessed as lacking capacity and is treated against their will, this is conducted within the appropriate legal framework, and this is recorded. If the patient lacks capacity and is treated against their will, staff still provide the patient (and their carer) with as much information about the intervention as possible, and this is recorded. Reviews The patient has a minimum of weekly documented sessions with their named worker to review their progress. 15

24 There is ongoing recorded monitoring in relation to: help with taking medication; health promotion; dental care arrangements; advice on sexual health and contraception Patients are weighed on admission and in accordance with their care plan thereafter, but no less than monthly Physical health review examinations and investigations are repeated at least annually, and this is recorded. Staff monitor and record clinical outcomes and risk at regular intervals, using validated tools. Risk management plans are reviewed at a minimum frequency of once a month and are updated accordingly. Action from reviews is fed back to the patient (and their carer), and this is documented. The patient s care is reviewed weekly and recorded by the multidisciplinary team. Review notes record any progress made against the aims of the care plan. Review notes demonstrate that the care plan is adapted where necessary, in response to the patient s individual needs. A documented CPA review/admission meeting is held within one week of the patient s admission. Patients are made aware of the standards for reviews/ward rounds. Each shift handover contains a discussion of risk factors and individual needs resulting in an action plan for the shift, with individual and group responsibilities. Discharge Planning The patient s discharge plan is initiated and documented on or before admission. The patient s place of discharge is known before admission, and this is recorded. The patient s initial discharge plan includes expected length of stay and a provisional/anticipated discharge date. The patient (and their carer) is fully involved in decisions about the stage at which they will move on from the service, and this is recorded. The patient (and their carer) is given timely notification of transfer or discharge, and this is documented in their notes. 16

25 In addition to the needs identified through the care planning processes, discharge/aftercare plans record: the patient s preferences for their future living arrangements including social, educational and employment factors; the care and rehabilitation to be provided; the name of the care co-ordinator (if further care is required); the action to be taken if relapse or crises occur. The patient (and their carer) is offered a copy of the written discharge/aftercare plan, and this is recorded. A documented discharge meeting/review (e.g. CPA/Mental Health Act Section 117) is held prior to discharge. Inpatient staff provide other community services (including out of area services) three weeks notice of discharge planning meetings. Prior to discharge, the date of the follow-up review is recorded in the notes and communicated to the patient (and their carer) and relevant services. Within seven days of discharge, a copy of the care plan is sent to all relevant service providers, including the referring agent. There is a procedure in place for informal patients who discharge themselves against medical advice. Inpatient staff make every effort to ensure a smooth transition. This might include: helping to arrange for patients, carers or staff to visit the new setting, to check its suitability; finding out about statutory and voluntary services that might be helpful to the person (and their carer) once they leave the unit. Interagency protocols are in place for access to support after patients have been discharged. The patient s allocated community-based care co-ordinator visits them on the unit during the two weeks prior to discharge, and this is recorded. Local information systems are capable of producing accurate and reliable data about delayed transfers/ discharges and action is taken to address any identified problems. Carers The patient s main carers are identified and contact details are recorded The principal carer is advised how to obtain an assessment of their own needs. 17

26 The principal carer meets with a named professional, within three working days of admission, during which: the carer s views about ongoing and future involvement are recorded; the carer is given an explanation and information sheet about ward procedures, etc; the carer is offered information on carer advocacy; staff explain how carers can contact the unit for extra information, advice or support as needed, including outside of planned meetings. With the consent of the patient, staff and carers meet to update each other on any significant information about the patient s care, before and after any leave of absence. During any leave of absence, carers are given information on how to contact the unit staff for support. Prior to any leave of absence, staff offer the patient and their carer advice on coping techniques and behaviour management techniques. Staff support the psychological and emotional needs of family carers by signposting them to local carers support groups or counselling services, as required. 18

27 Section 3 Safety

28 SAFETY NUMBER TYPE STANDARD There is an annual and comprehensive general risk assessment to ensure the safety of the clinical environment. There is a management plan to address any shortfalls in the safety of the clinical environment All staff adhere to Department of Health Guidance on confidentiality (HSC 2000/009: Data Protection Act 1998: protection and use of patient information. Department of Health, 2000) Protocols/procedures/strategies are in place for the reporting, investigation and resulting actions of complaints, adverse incidents and near-misses. Observation Clinical protocols/procedures/strategies are in place on the use of observation in the context of the prevention and management of challenging/violent behaviour. There is a policy on patient safety, the use of therapeutic interventions and observation that includes: how activities, therapies and staff skill mix are used specifically to improve patient safety; how patients are informed about maintaining their personal safety, including the use of alarms; who can instigate observation above the general level and who can change the level of observation; who should review the level of observation and when reviews should take place (at least every shift); how the patients perspective will be taken into account; the process through which a review by a full clinical team will take place if observation above the general level continues for more than one week. Subject to MDT review, the patient is informed of the level of observation that they are under. Management of Violence There is an operational policy on searching, based on legal advice, which complies with NICE Guidance and the Human Rights Act There are agreed protocols in place with the local police that ensure effective and sensitive liaison regarding incidents of criminal activity/ harassment and violence. Clinical protocols/procedures/strategies are in place for the use of physical restraint. 20

29 Any incident requiring rapid tranquillisation, physical intervention or seclusion is recorded contemporaneously, using a local template, which records the use of these interventions and the procedures taken during these interventions, and any adverse outcomes. The unit has mechanisms to document all incidents of violence and aggression. Clinical protocols/procedures/strategies are in place relating to the administration of PRN medication. Clinical protocols/procedures/strategies are in place for reviewing incidents of challenging/violent behaviour. This might include: a clear description of the behavioural sequence(s); a measure of the frequency, intensity and duration of the behaviour; a conclusion about why the behaviour occurred. There are systems in place to assure that post-incident support and review are available and take place. The following groups are considered: staff involved with the incident; patients; carers and family, where appropriate; other patients who witnessed the incident; visitors who witnessed the incident. A collective response to alarm calls is agreed before incidents occur, and is consistently rehearsed and applied Where risk assessment indicates, there is an established, reliable and effective means of communication during escorted leave etc., such as two-way radios or mobile phones Management of Alcohol and Illegal Drugs The unit has a strategy for the comprehensive care of patients with alcohol and/or drug problems. Liaison between mental health and substance misuse services; Regular drug/ alcohol screening to suppot decisions about care/ treatment options; Liaison between mental health and statutory and voluntary agencies; Staff training (which includes input from the police); The appointment of key staff who will lead clinical developments; Clear protocols, agreed with the police; Consideration as to the impact on other patients of adverse behaviours due to alcohol/ drug abuse. There are clear and comprehensive policies and procedures regarding positive risk taking. 21

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31 Section 4 Environment and Facilities

32 ENVIRONMENT AND FACILITIES NUMBER TYPE STANDARD Whilst ensuring appropriate levels of security, the environment is open and does not unnecessarily restrict people. For patients who meet the criteria within the Mental Capacity Act a DoLS assessment has been completed. Choice is only restricted for significant clinical or safety reasons, which are explained to the person and recorded in their care plan. The unit environment complies with current legislation on disabled access The external sign-posting to the unit is clear The internal sign-posting is clear and appropriate to the needs of the people who reside there. There is secure, lockable access to patient bedrooms, with external staff override. Alarm Systems An effective system is in place to ensure that patients, visitors and staff are able to summon help in an emergency. Alarm systems/call buttons/personal alarms are checked and serviced regularly. Medical Equipment In any area where rapid tranquillisation, physical intervention and/or seclusion are used, a fully-equipped crash bag is available within three minutes A replenished First Aid kit is available on each unit All staff are aware of the contents of the crash bag and what each item is used for within an emergency procedure The crash bag is maintained and checked weekly and after use The unit has access to a specific room for physical examination and minor medical procedures. This may be the patient s own bedroom, where appropriate. Confidentiality Confidential case material is kept in locked cabinets, locked offices or securely password-protected on IT systems. 24

33 In spaces where personal and confidential discussions are held, such as interview rooms and consulting/examination/treatment spaces, conversations cannot be heard outside of the room. Seclusion There is a clear written policy on the use of seclusion, which complies with the MHA and NICE Guidance 25. In services where seclusion is practiced, there is a designated room fit for the purpose. The seclusion room: allows clear observation; is well insulated and ventilated; has access to toilet/washing facilities; is able to withstand attack/damage; has a two-way communication system; has a clock that patients can see. Use of Rooms and Space Areas which need to be quiet are located as far away as possible from any sources of unavoidable noise There is at least one room for interviewing and meeting with individual patients and relatives, which is furnished with comfortable seating The unit is arranged in a way that allows optimum use of available space and rooms. There are private, designated spaces for patients to receive visitors, including children Visits from friends, family and others are encouraged and facilitated A separate area can be made available to receive patients with police escorts. There is a dedicated area or room (de-escalation space) that staff may consider using, with the patients agreement, specifically for the purpose of reducing arousal and/or agitation. (Note: this area is in addition to the seclusion room, and may be the patient s own room if they are the sole occupier.) The unit is able to meet the individual sensory needs of patients Male and female patients have separate sleeping accommodation in separate areas of the ward. The unit offers a range of semi-private and public spaces outside the private bedroom, which allow people a different level of participation with the life of the unit There are lounge areas that may become single-sex areas as required. 25

34 There is a quiet room with comfortable seating. Catering There is a dining area big enough to allow patients to eat in comfort and to enjoy social interaction. Staff should be able to move freely to enable observation Water and soft drinks are available 24 hours a day Hot drinks are available to patients 24 hours a day upon request Staff make efforts to find out individual preferences for types of food and style of preparation, including food allergies. There is a choice of well-prepared food that meets nutritional, personal, cultural and clinical dietary needs, e.g. vegetarian, low sugar, kosher, etc. Assistance with eating food is given individually and discreetly and with care and sensitivity The unit is able to access dietetic advice for patients Healthy meals or snacks are available outside of mealtimes. Dignity All patients have access to lockable storage, which may include their own individual rooms or access to a safe on the unit. There is access to the day room at night if the patient is unable to sleep. The unit has access to aids and equipment to allow the patient to do as much for themselves as they wish. The patient is supported and encouraged to manage their own affairs (e.g. their personal finances) as far as is possible. The patient can be involved in the day-to-day running of the unit if they wish to. This might include: planning social events; menu planning, shopping and food preparation; laying tables, clearing away and washing up; laundry and housework; gardening. There are formal, documented arrangements that provide the patient with as much choice and control over their life as possible, including bedtimes and bathtimes, eating and drinking, and how they spend their time. The patient is able to wash and use the toilet safely, in privacy and separate from the opposite sex. 26

35 Protocols/procedures/strategies are in place promoting positive sexuality and relationships. The patient s privacy and dignity is ensured when receiving intimate care. There is a policy on the use of devices with the capacity to communicate and/or record, which is communicated to staff, patients and visitors, e.g. by means of a poster/unit leaflet. This would include devices such as mobile phones. The patient is supported to practise/follow their own cultural or religious beliefs. This might include having access to associated items, such as a copy of the Qu ran, Bible or similar, support to attend services, respecting festivals and religious holidays. Where necessary, staff provide sensitive advice on clothing, hygiene and personal presentation. Staff respect the patient s personal space, e.g. by knocking and waiting before entering their bedroom. Patient Comfort The unit has adequate light The unit is a comfortable temperature The unit is well ventilated There is an alternative (such as night lights) to bright fluorescent lighting in bedrooms, providing different levels of lighting which both patients and staff can control. Provision of Information Information is available about a range of mental health conditions. This might include medications and their side effects, treatment alternatives and their relative effectiveness. Staff receive up-to-date training on culturally sensitive practice, disability awareness and other diversity and equality issues. Information is available about local mental health and learning disability services. The patient has access to health promotion advice in an accessible format, including advice on diet and exercise, oral health, smoking cessation, and sexual health Information is clear, up-to-date and available in sufficient quantity There is a board on display showing the photographs, names and roles of staff. 27

36 Activity Equipment Entertainment facilities suit a range of personal and culturally specific tastes. This might include: daily newspapers; good quality magazines; board games; cards; TV and VCR/DVD with videos/dvds; computers and internet access; games console. Outside Space There is direct access to a safe outside space The outside space is pleasant. This might include there being a garden area with seating available for relaxation, stimulating features such as a herb garden, flowerbeds, greenhouse and scented flowers. Staff Ward-based staff have access to a dedicated staff room, either on or off the ward All staff have access to a locker or locked area to store personal belongings. 28

37 Section 5 Therapies and Activities

38 Medication NUMBER TYPE STANDARD During the administration or supply of medicines, the patient s privacy, dignity and confidentiality are respected. The patient (and their carer) is provided with enough information to make informed choices about care and treatment. This might include information about the evidence base, risks, benefits and side effects of intervention options and of non-intervention. Upon commencement of any new medication, the patient s allocated nurse monitors the tolerability and side effects of this on a daily basis. If the patient takes medication, the medical team monitors and records the therapeutic response of medication on a weekly basis. If the patient is on antipsychotic medication, they are offered screening for side effects after one month and three months of treatment, and thereafter every six months, and this is recorded. If the patient takes certain groups of medication (clozapine, anticonvulsant agents, lithium etc), they are offered regular blood tests in accordance with therapeutic guidelines, and this is recorded. Patients have access to a pharmacist and/or pharmacy technician to discuss medications. Carers have access to a pharmacist and/or pharmacy technician to discuss medications. In preparation for discharge, the unit helps all patients to understand the functions, limitations and side effects of their medications, and to self-manage as far as possible. The unit enables the patient to manage their own medication, including self-administration and self-monitoring of the desired effects and side effects. Engagement During all communication, staff make sure that they are understood. For example, by: using communication methods that are consistent with the patient s usual and preferred means of communication; avoiding the use of clinical language/jargon and abbreviations; avoiding having too much new information in one sentence; checking that the patient has understood the information by asking them to explain it back, in their own words. 30