Standards for Low Secure Services

s for Low Secure Services CCQI publication number: CCQI 130 Editors: Sarah Tucker, Maddy Iqbal and Sam Holder Date: June 2012

The Quality Network ran a competition to fd a piece of service user artwork to use on annual reports, standards and leaflets. This design was pated by a service user from Edenfield Centre. The team would like to thank all of the service users who submitted entries.

Contents Page Preface 4 Method 5 A: Model of 7 1: Admission 7 2: Recovery 8 3: Physical Health 10 4: Discharge 11 B: A Safe Therapeutic Environment 12 1: Physical Security 12 2: Relational Security 13 3: Procedural Security 14 C: Service Environment 17 1: Environmental Design 17 2: Risk assessment and management 17 3: De-escalation and seclusion 18 4: Access to external spaces 19 5: Facilities for Visitors 19 D: Workforce 20 1: Capacity and capability 20 2: Trag and contug professional development 20 E: Governance 23 1: Reportg and management of adverse cidents 23 2: Busess Contuity 23 F: Equalities 25 Appendix 1: Delegates, s Workg Group 26 Appendix 2: Delegates, s Consultation Event 26 Appendix 3: Advisory Group 26 Appendix 4: Project Team 26 3

Preface It is a pleasure to welcome these s for Low Secure Services developed by the Quality Network. The Quality Network has worked closely with the Department of Health followg the consultation on The Good Practice Commissiong Guide for Low Secure Services which will provide guidance. These standards will form the basis of the self-and peer-reviews the recently launched Quality Network s dedicated low secure network. They are an accessible way for services to engage comprehensive on-gog service development and improvement for the benefit of patients le with Department of Health policy. This new network will build on the Quality Network s successful work with medium secure services over the past six years. This work has been valued by the specialised service commissioners and has provided demonstrable benefits terms of quality improvement. The dedicated quality network for low secure services has the potential to further develop standards for these services and through the peer-review process further improve quality. Over the next year commissioners will be workg closely with the Quality Network for Forensic Mental Health Services to use these standards to provide an on-gog national structure for quality assurance and improvement low secure services. Ged McCann Associate Director of Commissiong, Yorkshire and Humber Office, North of England Specialised Commissiong Group, Forensic and Secure Clical Reference Group Phil Brian Assistant Director (Specialised Mental Health), West Midlands Office Midlands and East Specialised Commissiong Group, Advisory Group Quality Network for Forensic Mental Health Services 4

Method Context This third consultation draft of s for Low Secure Services has been developed by the Quality Network for Forensic Mental Health Services directly from the Low Secure Services: Good practice commissiong guide consultation draft Department of Health, February 2012. In addition some standards from the Secure Units (second edition CCQI 105) have been cluded. These standards have been developed with the purpose of formg the basis of the self- and peer-review questionnaires for the Quality Network for Forensic Mental Health Services low secure services self- and peer-reviews. Formg the foundation of the iterative annual review cycle the standards provide an accessible way for services to actively engage on-gog service development towards implementg the Department of Health recommendations. The Development of the s The standards have been developed the followg ways and stages: 1) The tense and where appropriate, the sentence structure of the Department of Health Low Secure Services: Good practice commissiong guide consultation draft has been edited. This provides user-friendly and easily accessible questions for use self- and peer-review questionnaires. 2) Where these standards capture more than one criterion, the standard has been divided to separate criteria. This prevents ambiguous answers. 3) Where these standards make an ideal statement (e.g. There should be. ) this has been edited to a statement of fact (e.g. There is. ). This provides more user-friendly standards for the peer-review questionnaires. 4) The s for Low Secure Services have been mapped on to the Quality Network s Secure Units. This enables comparison and avoids potential duplication. 5) The s for Low Secure Services have been mapped onto the Quality Commissions Quality and Safety (March 1. This enables services to streamle the data collection process. The references denote the Outcome, Regulation and Prompt number onto which the implementation criteria have been mapped, followg the format: Outcome Number, Regulation Number. Prompt Number, e.g. 1.17.1a denotes Outcome 1, Regulation 17, Prompt 1a. 6) On 27 March 2012 the Quality Network consulted an expert standards workg group on a first consultation draft of these standards (see Appendix 1). Members of the workg group were asked to identify omissions and to comment on clarity, measurability and importance. On the basis of feedback from this workg group the Quality Network edited a second draft of the standards. 7) On 31 May 2012 the Quality Network consulted more widely at a standards consultation event on the second draft of these standards (see Appendix 2). Members of the event (which cluded patients) were asked to identify omissions, particular, those the Secure Units which did not appear the Low Service s). Members were also asked to comment on clarity, measurability and importance. On the basis of feedback from this event the Quality Network edited this third edition of the standards. 1 http://www.cqc.org.uk/_db/_documents/_standards_of_quality_and_safety_final_081209.pdf 5

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A: Model of A1.1 A1.2 A1.3 1: Admission There are clear admission procedures which centre on a multi-disciplary assessment process takg account of a patients care, treatment (cludg physical health treatments) and security needs. There are clear clusion criteria for the admission of patients to the unit which clude all of the followg: i. A defable clical risk to others or a legal requirement to be custody ii. Men and women aged 18 years and over and detaed under the Mental Health Act. iii. Prisoners or Immigration Act detaees meetg the criteria for detention under the Mental Health Act. iv. People who will benefit from a period of rehabilitation. v. People who may require a long period of rehabilitation. vi. People who may have a history of offendg behaviour with low levels of violence for example assault. vii. People who do not require the degree of security provided by medium or high secure care. viii. People with challengg behaviour. ix. People with co-morbid substance misuse issues (past or current). There are clear exclusion criteria for the admission of patients to the unit which clude all of the followg: i. People under 18 years who do not meet criteria for detention under the Mental Health Act or require treatment a specialist service for ii. iii. iv. children and adolescents. People with a primary diagnosis of substance misuse without a secondary diagnosis of mental illness, who are not engagg with substance misuse terventions. People requirg detention medium or high security. People with complex needs who can be managed and treated adult services cludg psychiatric tensive care or rehabilitation services. 27 26 28 29 4.9.4l 5.14.5a A97 A96 A85 G3 B7 7

A1.4 Patients who receive low secure services also receive an assessment for additional specialist treatment if they have a primary diagnosis of dementia, a learng disability of sufficient severity to preclude them from actively engagg, personality disorder, acquired bra jury or other neuro-cognitive deficits, Asperger s and autistic spectrum disorder. 30 4.9.4b 4.9.4d 4.9.4n 6.24.6c A1.5 Where low secure care is not considered the most suitable option for an dividual, service staff offer advice and guidance on the management of the patient where applicable. 31 A1.6 The provider identifies the responsible local commissioner for every dividual planned admission, even where the service user is known to the service. 4.9.4p B9 A1.7 All patients will have an itial care plan place with 24 hours of admission. A95* A1.8 All patients have a lk person/care co-ordator from their home area services whose responsibilities clude the facilitation of ongog lks and the patient s care pathway. 6.24.6a 6.24.6b 7.11.7b B10* A1.9 There are clear criteria for admission to and transfer /discharge from services which will be agreed with commissioners and will be communicated to all referrers. The service ensures that the discharge procedures are operated le with the pathway (appendix 4). 4.9.4c 4.9.4o 6.24.6a 6.24.6e 6.24.6g 7.11.7e E2* 2: Recovery A2.1 A2.2 A2.3 Usg the Programme Approach (CPA), the multi-disciplary team takes a comprehensive, recovery-focussed approach aimed at buildg resilience and preventg relapse. The recovery-focussed approach cludes addressg accommodation, employment and learng needs, meangful social contact and combatg stigma. The service makes provision for men and women aged over 18 years and complies with national guidance about and expectations governg the provision of sgle sex accommodation. 32 32 16 1.17.1a 1.17.1b 1.17.1c 2.18.2a 4.9.4a 4.9.4e 4.9.4g 4.9.4n 4.9.4r 6.24.6a 16.10.16d 21.20.21a 1.17.1m 4.9.4a 1.17.1a 4.9.4f 10.15.10a 10.15.10l B13 A80 B2 A94.5 A107 E6 E7 F2w F3w F4w F9w 8

A2.4 A2.5 A2.6 A2.7 A2.8 A2.9 A2.10 A2.11 A2.12 A2.13 A2.14 A2.15 There is evidence that the model of care and treatment focuses on risk management, engagement and rehabilitation with a safe and secure environment. There are facilities for detaed patients cludg those who require short periods of tensive care with a low secure environment. There is provision for patients requirg a period of engagement and treatment away from the ma patient group. This may clude the provision of 1.17.1h (, CQC, for de-escalation and seclusion. There are a variety of recreational activities and occupational facilities available. There is a dedicated secure external garden/court yard which can be used for recreational activities. There are effective lks with community organisations (e.g. housg, leisure, employment, education) and activities to support rehabilitation and sustaable discharge. There is evidence that the service places the patient at the centre of their care, supportg patient recovery and choice with the unit where this is clically appropriate. Patients engage and participate the formulatg of, and ongog review of, a multidisciplary therapeutic evidence-based programme appropriate to their dividual needs. Patients are given a copy of the management or care plan. There is a core day described each patient's dividualised care plan (a description of the core day may also be found elsewhere e.g. the ward programme or dividual timetables). Patients receive formation about medication and its side effects. Treatments take to account the relevant NICE guidance. 17 1.17.1a 1.17.1b 1.17.1c 1.17.1f 1.17.1j 4.9.4a 4.9.4c 4.9.4e 7.11.7g 16.10.16b 16.10.16d 19 1.17.1h 20 1.17.1h 21 21 21 23 24 25 1.17.1h 4.9.4a 10.15.10a 10.15.10a 10.15.10m 1.17.1m 6.24.6a 6.24.6c 7.11.7b 1.17.1a 1.17.1b 1.17.1c 1.17.1f 1.17.1j 4.9.4a 4.9.4c 4.9.4e 7.11.7d 16.10.16d 1.17.1a 1.17.1b 4.9.4a 16.10.16c 16.10.16d 1.17.1c 2.18.2a 2.18.2b 4.9.4c 21.20.21a 1.17.1a 1.17.1e 4.9.4e 9.13.9d 16.10.16b 25 2.18.2d A93 C3 C32 D9 A94.1 A94 C22 D20 D2 D9 D19 A113 A100 A101 A10w 9

A2.16 A2.17 A2.18 A2.19 A2.20 A2.21 A2.22 A2.23 A2.24 The programme of treatment cludes psychological sessions. The programme of treatment cludes substance misuse therapy. The programme of treatment cludes offence related therapy. The programme of treatment cludes structured activity programmes. The programme of treatment cludes structured leisure time. The programme of treatment cludes unstructured free time. There are facilities appropriate to the patient group, e.g. a pool table and board/console games are provided. There are facilities for patients to make their own hot and cold drks and snacks. Books and magazes are provided recreation areas for patients. 1.17.1l 4.9.4n 4.9.4o 1.17.1h 5.14.5c A94.2* A94.3* A94.4* A94.6* A94.7 A94.8* F12 F13 F14 A3.1 A3.2 A3.3 A3.4 A3.5 A3.6 A3.7 A3.8 A3.9 A3.10 A3.11 3: Physical Health Patients routely undergo a full assessment of both physical and mental health needs. and treatment plans reflect both mental health and physical healthcare needs. Patients have access to a comprehensive range of primary healthcare services. Patients undergo follow-up vestigations and treatment for physical conditions identified their assessment durg their admission. Patients have route monitorg of medication cludg those used for physical health issues. Patients are supported their personal care cludg dental hygiene. The service meets screeng targets expected of primary care services. The service provides general health promotion activities cludg screeng, diet advice and the opportunity to exercise (with appropriate supervision). The service provides targeted programmes on smokg cessation and health promotion. There is an identified duty doctor available at all times to attend the unit. Patients have access to comprehensive primary and secondary care services to meet existg or newly developed physical healthcare and treatment needs. 34 G3 A89 A1w 35 6.24.6c G3.1 35 1.17.1i 6.24.6i G1 G5 35 6.24.6c G4 35 36 36 9.13.9a 9.13.9b 9.13.9d 6.24.6j D1* 1.17.1e 4.9.4a 5.14.5a 5.14.5c G5 G4w G5 G11 G15 G12 G13 F10 G4w 36 G6 22 1.17.1e 1.17.1i 4.9.4a 4.9.4p 6.24.6i 6.24.6j B31 G1 G5 G4 10

A4.1 A4.2 A4.3 A4.4 A4.5 A4.6 A4.7 4: Discharge Social workers, care coordators and offender managers are actively volved care planng processes for treatment on the unit and postdischarge follow-up under Section 117 arrangements. Discharge targets are agreed as part of the discharge planng process. There is a multi-disciplary assessment to determe readess for discharge/transfer. The multi-disciplary team supports the patient to develop and mata lks with community-based organisations that can provide socially clusive, mastream activities. The provider facilitates lks to the home area services of each patient terms of local statutory (health and social care) and voluntary services and matas these to ensure timely and appropriate discharge/transfer arrangements are put place. When a patient needs to transfer to services for older people, a jot review is undertaken to ensure effective hand-over takes place. The service ensures there are regular reviews for patients transferred from prison (a) on remand (b) on sentence to assess suitability for return to prison. 33 6.24.6c A123 33 A121 4.9.4c B15* 1.17.1m 4.9.4a 6.24.6c 6.24.6i 7.11.7b 4.9.4a 4.9.4c 6.24.6i 4.9.4c 4.9.4c 16.10.16c C22 B11* A122 B21* 11

B: A Safe Therapeutic Environment B1 B2 B3 There is evidence that the three domas of security (physical, relational and procedural) are developed and managed unison. There is evidence that the three domas of security (physical, relational and procedural) are used to form decisions about dividual/population care. The balance emphasis between each doma of security (physical, relational and procedural) changes given the operational needs of the unit as a whole, or the needs of a particular patient and/or group of patients, and the settg which the service is provided. 40 10.15.10c 40 10.15.10c 41 10.15.10c 1: Physical Security B1.1 There is a clearly deleated external perimeter. 42 10.15.10c A1 B1.2 B1.3 B1.4 B1.5 B1.6 B1.7 B1.8 B1.9 B1.10 B1.11 The external perimeter is designed to mata service tegrity, privacy, elimate climb pots and manage risk. (The exact nature of the external perimeter, for example fence height, claddg, angled weld mesh toppg, and anti-climb cappg, is determed by the size, layout and location of the low secure service). Gates with the perimeter do not have bolts or openg mechanisms that can be used as footholds to assist climbg. Where fencg forms all or part of the secure external perimeter, it conforms to BS358 and is a mimum height of 3 metres. Access to the low secure unit for visitors, staff and patients is via an airlock. There is evidence that the secure external perimeter is regularly checked. There is a clearly defed ternal perimeter (normally bounded by the secure doors leadg to outside areas), which facilitates patients freedom of movement with the ternal perimeter area. There are systems place to ensure that buildgs, equipment and technology are well mataed. Lockers are provided for staff away from the patient area for the storage of any items not allowed on the unit. All keys, cludg those held at reception, are controlled, issued and accounted for. 47 10.15.10a 10.15.10d 48 10.15.10a 49 10.15.10a A10 A18 A19.2 A15 A15.1 A15.3 53 A31 43 A4 46 42 10.15.10d 50 51 7.11.7m 10.15.10c 10.15.10f A7 A7.1 A20.1 F5 All keys held by reception are accounted for at least twice a 24-hour period. 51 A28.1 A13 A28 12

B1.12 Access to spaces where sharp implements e.g. kitchen knives, utensils, equipment or tools are 52 11.16.11c A71 available are to be controlled. B1.13 The use of sharp implements is monitored. 52 11.16.11c A71 B1.14 B1.15 B1.16 B1.17 B1.18 B1.19 There is evidence that the staff team have current knowledge and understandg of the units physical security measures and mechanisms. There is evidence that the staff team have current knowledge and understandg of the procedures that support the units physical security measures and mechanisms for effective operation. There is evidence that the staff team have current knowledge and understandg of their own security responsibilities and those of the wider team. There is evidence that the staff team have current knowledge and understandg of how relational and procedural measures impact on physical security. There is evidence that the staff team have current knowledge and understandg of what constitutes the ternal perimeter. There is evidence that the staff team have current knowledge and understandg of alarm systems cludg those used for staff/patient safety and fire. 45 10.15.10c 45 10.15.10c A92 C6 A92 C6 45 10.15.10c C4 45 10.15.10c 45 10.15.10c 45 4.9.4d 5.14.5a 7.11.7a 7.11.7d 7.11.7k 9.13.9g 10.15.10a 10.15.10b 10.15.10e 10.15.10g 10.15.10h 14.23.14a B1.20 There is a system place for staff to report any ligature pots identified with prompt follow up action. 10.15.10p F9.1* B1.21 There is a full-time security lead. A41* C7 B2.1 B2.2 2: Relational Security There is evidence that staff have a knowledge and understandg of their patients and of the environment, and of the translation of that formation to appropriate responses and care. There is evidence that the entire staff team works cohesively. This cludes staff who do not have direct patient contact. B2.3 All staff have an up to date enhanced CRB check. B2.4 B2.5 There are clear and effective systems for communication and handover with staff teams. There are regular multi-disciplary team meetgs for clical matters and admistration, and the team is consulted on relevant management decisions such as developg and reviewg operational policy. 55 50 6.24.6b 22.4.22b 12.21.12a 12.21.12d 16.10.16c 16.10.16d 23.5.23a 24.6.24a A88* A102 A103 13

B2.6 B2.7 B2.8 B2.9 B2.10 B2.11 B2.12 B2.13 B2.14 There are regular meetgs where staff discuss and reflect on relational security issues. This cludes as a mimum: discussion of boundaries, therapy, patient mix, patient dynamic, patient s personal world, physical environment, visitors and other external communication and may be facilitated by the See, Thk, Act Relational Security Explorer. All staff can demonstrate an understandg of their role relation to meetg the complex needs of patients. The duction trag programme covers relational security. This cludes as a mimum material on: boundaries, therapy, patient mix, patient dynamic, patient s personal world, physical environment, visitors and other external communication. This may be facilitated by the See, Thk, Act trag slides. There is annually updated staff trag on relational security. This cludes as a mimum material on: boundaries, therapy, patient mix, patient dynamic, patient s personal world, physical environment, visitors and other external communication. This may be facilitated by the See, Thk, Act trag slides. Contact with visitors and other external communication is regularly risk assessed. There is a mechanism for measurg and monitorg relational security agast established outcomes such as those See Thk Act: Your guide to Relational Security (DH. Please refer to We know we are gettg it right when: sections See, Thk Act Staff have an understandg of their role relation to Relational Security respect of the alcohol and controlled or illegal substances policies. The unit has access to a range of education professionals which clude teachers, a special educational needs co-ordator, an educational psychologist, and career guidance. The programme of treatment cludes access to real opportunities to work. 7.11.7g 12.21.12a 14.23.14a 7.11.7h 16.10.16b 2.18.2d 22.4.22c 101 7.11.7h 1.17.1m 1.17.1m B30 A108 C5 A92 A51, A72, A93, C3 C17 RS. 1 RS. 2 RS. 3 RS. 4 RS. 5 A107 A94.5* B3.1 B3.2 B3.3 3: Procedural Security There is an up to date dex of procedural security policies used the low secure service, cludg contgency and busess contuity plans. Policies and procedures acknowledge the need for proportionality and discretion and are accordance with the Mental Health Act Code of Practice and guidance issued by NICE and professional associations. Policies, procedures and contgency plans are reviewed at least annually and updated where required. 64 10.15.10h A50 65 2.18.2d 22.4.22b 22.4.22c 66 10.15.10h A50.1 14

B3.4 B3.5 Staff have ready access to and demonstrate up to date knowledge of policies and procedures governg the service and guidg their practice. There are operational policies and procedures governg, but not limited to, the safety of patients, visitors and staff, risk, adverse cidents and operational management. B3.6 In addition to organisation-wide policies, there are specific policies and procedures tailored to meet the needs of the low secure service. These policies are authorised by the wider organisation s senior management structure or board. 59 B3.7 Staff, patients and visitors feel safe on the unit. 60 Staff, patients and visitors are clear about rules and B3.8 policies governg any prohibited items cludg cameras and electronic devices and other items that may be restricted such as mobile phones. B3.9 There are policies governg access to and appropriate use of the ternet by staff and patients. 61 Policies governg access to and appropriate use of the B3.10 ternet by staff and patients conta particular advice around the appropriate use of social networkg sites, confidentiality and risk. There is a readily available policy for the authorisation and governance of practice of, searchg patients, B3.11 patient rooms, communal areas and visitors. This policy is accordance with the requirements of the Mental Health Act Code of Practice. 66 C4 58 4.9.4b 6.24.6d 7.11.7a 9.13.9b 10.15.10b 10.15.10e 23.5.23a 24.6.24a F2 A93 A124 A125 60 10.15.10c A72 61 2.18.2a A73 F15 A73 F15 62, 63 22.4.22c A51 B3.12 There is a policy on observation. A55* There is an anti bullyg policy (for those who are 7.11.7a B3.13 A56* bullyg and those who are bullied). 14.23.14d There is a policy on prevention of suicide and B3.14 4.9.4l A57* management of self harm. There is a policy on transportation of patients (e.g. to B3.15 A58* court or acute hospital). 9.13.9a 9.13.9b There is a policy on the control of prescribed 9.13.9d B3.16 A64* medication and drugs. 9.13.9e 9.13.9f 9.13.9g B3.17 B3.18 B3.19 B3.20 The unit has a robust policy on the use of and access to alcohol and controlled or illegal substances by patients and their visitors. Policies regardg alcohol and controlled or illegal substances cover the role of Relational Security. Policies regardg alcohol and controlled or illegal substances cover the management of cidents where drugs and alcohol are brought by patients and their visitors. There is a policy on the prosecution of offences with the unit which is agreed with the police and CPS. 101 1.17.1l 101 101 9.13.9b A62 A63 A65* 15

B3.21 There is a smokg policy. A67* B3.22 There is a policy on the management of patient s monies. 7.11.7m A68* B3.23 There is a policy on the censorship of material cludg pornography. A69* B3.24 There is a policy on the control of mail and use of telephones. 10.15.10k A70* B3.25 There is a policy on visitg procedures cludg child protection issues. 7.11.7e A74* B3.26 There is a policy on patient confidentiality. 2.18.2a 6.24.6b A75* 6.24.6e 4.9.4b 6.24.6d B3.27 There is a policy for managg critical cident reviews. 16.10.16b A76* 16.10.16c B3.28 There is a policy for response to staff alarms. A83 B3.29 There is a policy on child visitg/child contact which is annually reviewed. A128* B3.30 There is a policy on safeguardg children which 7.11.7a complies with National Quality Prciples which is 22.4.22b reviewed annually. A129* B3.31 B3.32 There is a clear written policy for referrals, admissions, transfers and discharges. There are clear policies on disciplary and grievance procedure; whistle blowg policy, discrimation, harassment, bullyg and violence. B3.33 There is a clear complats procedure. B3.34 B3.35 B3.36 There is a procedure regardg obtag consent from patients. The procedure for resuscitation of patients is clearly documented, resuscitation equipment is available and its location is clearly identified. Staff demonstrate a workg knowledge of mental health legislation and its application cludg their authority relation to escortg patients outside the secure perimeter. 67 4.9.4c 7.11.7e 7.11.7a 14.13.14d 16.10.16b 1.17.1h 6.24.6f 7.11.7a 16.10.16a 17.19.17a 17.19.17e 2.18.2a 2.18.2b 2.18.2c 2.18.2h 6.24.6e 11.16.11a 11.16.11c 11.16.11d 11.16.11h 22.4.22c B8* C11* C1* A81 A82 C38 16

C: Service Environment C1.1 C1.2 C1.3 1: Environmental Design There is evidence of active planng for and consideration of the impact on the therapeutic environment and safety of ward size and layout, patient numbers and population. The patient and staff environment is homely, light and bright. All accommodation is provided sgle rooms, with all new builds and upgradg programmes providg ensuite accommodation. 68 7.11.7g 10.15.10f 10.15.10i 10.15.10a 69 10.15.10a 4.9.4f 10.15.10f 10.15.10l C1.4 There is a designated dg area. 5.14.5f F11 C1.5 There is a multi-faith room available for use by all patients. 1.17.1i D7* C1.6 There are unrestricted les of sight and no concealed unsecured areas. 69 10.15.10p A46 C1.7 Furnishgs mimise the potential for fixtures and fittgs beg used as weapons, barriers or ligature 70 10.15.10p pots. C1.8 Doors rooms used by patients have observation panels with tegrated blds/obscurg mechanisms. These can be operated by patients with an external 71 override feature for staff. C1.9 Staff can override any locks that are lockable from the side e.g. patient bedrooms and bathrooms. 73 C1.10 Patient bedroom and bathroom doors are designed to prevent holdg, barrg or blockg. 73 C1.11 There are lockable facilities (with staff override 7.11.7m feature) for patient s personal possessions with 74 10.15.10c mataed records of access. A66 C1.12 Patients have access to a telephone a private area, with the limits of safety and risk assessment. 7.11.7h D15 C1.13 C1.14 Patients can wash and use the toilet privacy unless clical risk prevents this. There is a cleang programme which is regularly audited. 10.15.10f 10.15.10m F16 F17 A45 F3* F3.1* 8.12 F1.1* C2.1 C2.2 2: Risk assessment and management There is evidence of a multi-disciplary approach to the identification, assessment and management of risk. Individual risk management programmes are developed to identify the types of supervision, therapeutic tervention and treatment required. 76 76 4.9.4a 4.9.4l 4.9.4n 5.14.5a 6.24.6c 16.10.16b A99 A89 17

C2.3 C2.4 C2.5 C2.6 C2.7 C2.8 Risk management programmes can be readily adapted to meet a changed risk assessment resultg from adverse cidents, observed behaviour or concerns about security. Risk assessment and management is formed by relational security issues. There is an agreed approach to risk assessment cludg which planng tools are used. All staff workg directly with patients are traed to corporate risk identification and management to dividual care, treatment and support plans. Staff are skilled at identifyg and assessg potential risk factors/situations, planng how to manage identified risks and managg identified risks. Risk reduction is assessed and evidenced through settg and monitorg treatment outcomes. These outcomes form discussions with the Mistry of Justice (MoJ) regardg restricted patients, transferred prisoners and/or MAPPA (where relevant) and subsequent decisions about: i. escorted, unescorted or trial leave ii. rescdg leave iii. failure to return from leave and abscondg iv. remission to prison v. transfer to higher level of security vi. discharge pathways vii. s117 follow-up care requirements viii. preparation for Community Treatment Order (CTO) arrangements. 77 78 79 81 81 82 4.9.4n 6.24.6d 7.11.7h 9.13.9b 10.15.10c 14.23.14d 16.10.16b 7.11.7h 10.15.10c 16.10.16b 7.11.7h 16.10.16b 13.22.13a 16.10.16b 13.22.13a 14.23.14a 16.10.16b 6.24.6b 16.10.16b 16.10.16d A86.1 A86.1 A115 A116 A117 A118 A119 C3.1 C3.2 C3.3 C3.4 3: De-escalation and seclusion There are clear policies and procedures governg the use of de-escalation techniques and the management of challengg behaviour cludg the appropriate use of control and restrat and of seclusion. There is evidence that the service has considered how best to provide appropriate de-escalation facilities and considered the need for providg an en-suite seclusion room that will mata the patient s safety, privacy and dignity. Seclusion is only used as a last resort, and for the shortest clically appropriate period. Its use is monitored accordg to the Mental Health Act Code of Practice. Where required rapid tranquilisation complies with NICE guidance (http://www.nice.org.uk/nicemedia/pdf/cg025fullguidel e.pdf) 83 84 4.9.4q 7.11.7b 7.11.7f 7.11.7g 7.11.7h 14.23.14d 1.17.1a 1.17.1h 7.11.7i 10.15.10a 10.15.10f 85 4.9.4q 86 9.13.9a 9.13.9b 9.13.9d 9.13.9e 9.13.9g A52 A53 A2w E6 A3w A54 18

C4.1 C4.2 4: Access to external spaces Access for patients to outside areas cludg secure gardens and courtyards is determed by an dividual risk assessment and takes account of all factors that may assist escape, e.g. weather. Staff facilitate safe access for patients to outside areas cludg those on s17 leave by implementg the followg safeguards: i. Consideration of appropriate staff supervision (numbers and skill mix) given the mix and number of patients outside or on leave at any one time. ii. Retag appropriate staffg levels and skill mix on the unit whilst patients are outside or on leave. iii. Provision of appropriate escorts given the nature, purpose and location of leave. 87 88 7.11.7h 10.15.10c 10.15.10m 1.17.1m 14.23.14c A60 A61 C5.1 C5.2 C5.4 C5.5 C5.6 5: Facilities for Visitors There are facilities for visitors with the secure perimeter. There are separate, appropriately furnished facilities for children s visits. There are lockers for visitors away from patient areas to store prohibited or restricted items whilst they are on the unit. All visitors access the unit by the ma reception airlock. The unit works with visitors and families on their health and well beg, for example, copg with stress, conflict resolution and sustaable transport plans for visitg. 89 10.15.10a 89 10.15.10a 91 91 7.11.7m 10.15.10c A128.1 A12w A13w D12* 19

D: Workforce D1.1 D1.2 D1.3 D1.4 D1.5 D1.6 D1.7 D1.8 D1.9 1: Capacity and capability There is a cohesive multi-disciplary team place who have the capacity and capability required to meet the complex needs of patients. There is a robust leadership structure place which sets out professional, organisational and le management accountabilities. The staffg capacity is sufficient to deliver the care and treatment model and mata a safe environment at all times. The unit is staffed by permanent staff and agency staff are used only exceptional circumstances. Extra nursg cover is available when needed, e.g. there is access to additional on-call staff an emergency. The staff mix and ratios are sufficiently flexible to meet the changg levels of risk. The multi-disciplary team cludes: medical staff nursg staff social workers pharmaceutical staff psychologists art therapist psychotherapist occupational therapist and education professionals. The service has the capacity to respond to patient need and gender specific issues. All staff have a workg knowledge of mental health legislation and its application. 92 13.22.13a 92 93 23.5.23a 24.6.24a 7.11.7b 7.11.7g 13.22.13a 93 13.22.13a A104 B17 B18 C27 C27.1 A110 B18 A112 A111 A86.1 B18 94 A104 95 96 1.17.1h 13.22.13a 22.4.22c A1w C4.1w E6w E7w C38 2: Trag and contug professional development D2.1 The multi-disciplary team has the capacity and capability to provide a range of multi-disciplary therapeutic terventions and clical treatments with the agreed model of care. 97 13.22.13a D2.2 The staff at the service have completed the trag and education recommended by their professional association or regulatory body. 97 14.23.14.a C15 20

D2.3 D2.4 D2.5 D2.6 D2.7 The staff at the service have completed the mandatory and appropriate non-mandatory trag provided by the organisation. There is a system place to contually identify and review staff trag needs on an annual basis. Trag needs are monitored with the staff appraisal system. There is annually reviewed trag and development strategy, which cludes the provision of security trag. There is a strategic plan for trag, encompassg all known itiatives and that is subject to regular review. 97 97 97 4.9.4d 5.14.5a 7.11.7a 7.11.7d 7.11.7k 9.13.9g 10.15.10b 10.15.10e 10.15.10g 10.15.10h 14.23.14a 4.9.4d 12.21.12a 14.23.14a 14.23.14c 4.9.4d 12.21.12a 14.23.14a 14.23.14c C7 A90.1 B24 A90.1 14.23.14.a A91* 14.23.14a C18.1* D2.8 All staff receive supervision on a monthly basis. 97 14.23.14c A90 B28 7.11.7a D2.9 7.11.7e All staff receive trag regardg Safeguardg A130 97 7.11.7i Children and Safeguardg Vulnerable Adults. A15w 22.4.22b D2.10 All staff receive equality awareness trag. 97 C10 D2.11 D2.12 D2.13 D2.14 D2.15 D2.16 D2.17 Staff receive trag on Physical Security as part of the duction programme and prior to beg issued with keys, swipe cards or other means of operatg Physical Security mechanisms. Staff receive trag on Procedural Security as part of the duction programme and prior to beg issued with keys, swipe cards or other means of operatg Physical Security mechanisms. Staff receive trag on Relational Security as part of the duction programme and prior to beg issued with keys, swipe cards or other means of operatg Physical Security mechanisms. All staff cludg non clical staff receive trag the management of violence and aggression. Trag addressg the management of violence and aggression cludes de-escalation techniques and the use of control and restra procedures. All staff have a workg knowledge of mental health legislation and its application. Trag is provided on disciplary and grievance procedure; whistle blowg policy, discrimation, harassment, bullyg and violence policies. 97 97 97 97 97 97 14.23.14a 14.23.14a 14.23.14a 14.23.14d 14.23.14d 22.4.22c 14.23.14.a 14.23.14d 16.10.16b C5 C5 C5 C8 C9 C38 C11.1* 21

D2.18 D2.19 D2.20 D2.21 D2.22 Trag is provided on the management of relationships between patients and between patients and staff. Trag is provided on the user perspective and user participation. Staff are made aware of complats that are relevant to their work and the outcome of the complats process. Staff take up of supervision and support is regularly monitored and audited. Frontle staff have regular supervision totallg at least one hour per week and are able to contact a senior colleague as necessary. 14.23.14.a 14.23.14.a 16.10.16a 16.10.16c 17.19.17a 14.23.14c 14.23.14c D2.23 There are records of robust clical supervision. 14.23.14c C20* D2.24 There is adequate time made available for supervision to be delivered. 14.23.14c C20.2* C13* C14* D14 B27 B29 22

E: Governance E1.1 E1.2 E1.3 E1.4 E1.5 E1.6 E1.7 1: Reportg and management of adverse cidents There is a structure place for reportg, managg and vestigatg Serious and Untoward Incidents (SUIs). The unit s senior management are accountable for the unit s Serious and Untoward Incident reportg, managg and vestigatg structure. The unit uses the Department of Health and NPSA defition of a Serious and Untoward Incident to defe SUIs with the service: The defition of an adverse cident is an event or circumstance that could have or did lead to untended, unexpected harm, loss or damage. All Serious Untoward Incident vestigations are le with guidance on the discharge of mentally disordered people and their contug care the community. There is a system place to report cidents to the relevant commissioners le with the lead commissioners reportg policy on Serious and Untoward Incidents. This cludes itial notification with 24 hours of the cident and a full detailed SUI report with 7 days of the cident. Untoward cidents are contually monitored to identify trends and learng pots. There are mechanisms place to share learng beyond the immediate service/provider concerng cidents. 98 98 99 100 6.24.6d 10.15.10e 16.10.16a 20.18.20f 20.18.20g 20.18.20b 23.5.23a 24.6.24a 10.15.10e 16.10.16a 20.18.20a 20.18.20f 20.18.20g 4.9.4b 6.24.6d 9.13.9b 16.10.16a 16.10.16b 16.10.16c 6.24.6d A125 A126* A127* A127.1* E2.1 2: Busess Contuity The unit has a contgency plan place, which has been agreed with the police, regardg the reportg and managg of: loss of control serious operational failures cludg those resultg from fire ( agreement with the local fire and emergency services) escapes absconds failure to return and hostage takg. 102 10.15.10e 10.15.10h A78 23

E2.2 E2.3 E2.4 E2.5 E2.6 E2.7 E2.8 E2.9 The unit has contgency plans place which outle the arrangements for matag service tegrity and patient and staff safety the event of an operational, security or systems failure. The busess contuity plan corporates the contgency plans, which have been agreed with the police. The busess contuity plan addresses: the cha of operational control communications patient and staff safety and security matag contuity treatment and accommodation. There is a strategic approach to planng to meet the service needs. Clicians and managers mata good lks with the Home Office and ensure their target deadles/requirements are met. There is a clical governance strategy, which is implemented. Contgency plans are annually tested by desktop exercises. Contgency plans are tested by a live exercise volvg one or other of the emergency services every 24 months. 103 10.15.10b 10.15.10h 104 10.15.10h 104 6.24.6a 6.24.6b C18* C23* 16.10.16e C29* 6.24.6d A79* 4.9.4b A79.1 24

F: Equalities F1 F2 F3 F4 F5 F6 F7 F8 F9 F10 F11 F12 F13 F14 The service complies with equalities, mental health and human rights legislation. All operational and clical procedures, processes and policies reflect the requirements of equalities, mental health and human rights legislation. There is an implemented policy to ensure systems are place to allow for translation services and sign language. Written formation must be provided an appropriate number of languages and formats. Patients are provided with a range of formation, appropriate formats, regardg their rights under equalities, mental health and human rights legislation. Patients have access to a range of appropriate advocacy services. There are systems and support to enable a successful dependent civil advocacy service to be operated. The service provides patients with formation regardg what patients can expect from the service. There is an implemented policy settg out the consultation and volvement of carers the care provided. The unit s policy and procedures are agreed through discussion with the whole unit. The views of patients, their carers and others are sought and taken to account designg, planng, deliverg and improvg healthcare services. Feedback from patients and carers is used to improve the quality of the unit Staff receive trag equality issues and their impact upon patient care. Staff understandg of equality issues are monitored through the appraisal system. Complats are contually monitored to identify trends and learng pots which are reviewed quarterly. 105 105 106 106 107 1.17.1g 7.11.7d 22.4.22b 22.4.22c 1.17.1g 7.11.7d 12.21.12a 22.4.22b 22.4.22c 1.17.1a 1.17.1e 4.9.4e 17.19.17e 1.17.1a 1.17.1e 1.17.1g 4.9.4e 4.9.4g 16.10.16b 22.4.22c 1.17.1a 1.17.1c 1.17.1h 2.18.2a 2.18.2h 17.19.17a C37 C38 A84 C38 D6* D6.1 D17 C41 A11w C42 D10 D1w 1.17.1a D11* 1.17.1a 1.17.1e 1.17.1g 4.9.4e 4.9.4g 10.16.10b 1.17.1j 4.9.4a 16.10.16d 1.17.1a 1.17.1j 4.9.4b 1.17.1j 16.10.16a 16.10.16c D17 D8* D23 E1* D22 108 C10 108 14.23.14c 16.10.16a C1.1* 25

F15 F16 F17 F18 F19 Systems are place that ensure patients (particularly those vulnerable to exploitation e.g. fancially, emotionally or sexually) are not subject to bullyg by other patients or visitors or staff and that this is managed effectively. There is an implemented policy to meet the dividual cultural needs of patients. Staff demonstrate respect for patients. Patients are encouraged to personalise their bedroom spaces appropriately. (Pictures of nude bodies or pictures of children may be appropriate) Patients are provided with meals which are of a high quality, offer choice, address nutritional/balanced diet and specific dietary requirements and which are also sufficient quantity, are varied and appealg and reflect dividual s cultural and religious needs. (Better Hospital Food Department of Health 2004). 1.17.1a 1.17.1b 1.17.1g 1.17.1i 2.18.2b 4.9.4a 5.14.5d 1.17.1a 1.17.1b 1.17.1c 7.11.7i 17.19.17e 10.15.10a 10.15.10l 5.14.5a 5.14.5b 5.14.5c 5.14.5d 5.14.5f 5.14.5h C2* D5* D13 D21 F10.1* 26

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Appendix 1: Delegates, s Workg Group First Name Surname Role Organisation Nigel André Clical Team Leader Northumberland Tyne and Wear NHS Foundation Trust Phil Brian Head of Secure Services West Midlands Commissiong Commissiong Team Jean Callender Ward Manager Northumberland Tyne and Wear NHS Foundation Trust Paul Cartmell Diane Clayton Sheryle Cleave Clical Nurse Manager Northumberland Tyne and Wear NHS Foundation Trust Marc Cookson Clical Nurse Manager Northumberland Tyne and Wear NHS Foundation Trust Maureen Cushley Senior Nurse Manager West London Mental Health Trust Paul Gilluley Consultant Forensic Psychiatrist West London Forensic Service Stephen Godw Deputy General Manager Ridgeway Simon Lloyd Head of Clical Services St. Andrew's Healthcare Carly Morgan Consultant Psychiatrist Janet Shaw Unit Joanne Spears Clical Team Leader Northumberland Tyne and Wear NHS Foundation Trust Joseph Vella Consultant Psychiatrist Gerry Simon Clic Neil Woodward Security Manager Ridgeway 28

Appendix 2: Delegates, s Consultation Event First Name Surname Role Organisation Paul Gilluley Chair QNFMHS Advisory Goup Guy Cross Department of Health Col Reynolds Ward Manager Ash Ward James Lee Consultant Forensic Psychiatrist Challengg Behaviour Service - Memorial Hospital Andrew Duff-Miller Consultant Psychiatrist Derby Ward Anne Herbert Unit Manager Farmfield Hospital Shirish Bhatkal Consultant Rehabilitation Horton Rehabilitation Psychiatry Services Lorna Elliot Modern Matron Horton Rehabilitation Services Zena Nasser Consultant Psychiatrist Kent & Medway NHS & SC Partnership Trust Melanie Evans Assistant Director North London Forensic Services Phil Shackell Interim Deputy Director of Secure Commissiong (Specialised Mental Health and Learng Disabilities) North of England Specialised Commissiong Steven Woolgar Director of Policy and Regulation Partnerships Chris Harden Group Security Officer Partnerships Pratish Thakkar Consultant Forensic Psychiatrist Ridgeway Jennifer Berry Commissioner South Of England Specialised Commissiong Group -Specialised Mental Health and Learng Disabilities Adam Townsend Ward Manager St. Andrew's Healthcare Kate Axford Occupational Therapy Professional The Dene and Pelham Lead Woods David Munns Clical Governance Manager St. Magnus Phil Broxton Therapy Manager St. Andrew's Healthcare Naomi Collier Ward Manager St. Andrew's Healthcare Service User St. Andrew's Healthcare Mgci Nkomo Senior Nurse West London Forensic Services Dumisani Lupahla Ward Manager St. Andrew's Healthcare Birmgham Syed Husa Consultant Forensic Psychiatrist Wickham Unit Marcus Hamilton- Holman Forensic Security Liaison Manager Shaftesbury Clic Sallie Williams Ward Manager Shaftesbury Clic Rick Driscoll Consultant Forensic and Rehabilitation Psychiatrist Thornford Park Hospital Johanna Tahti Doctor for female LS services Cygnet Hospital Beckton Peter Fornah Ward Manager for Female LS Services Cygnet Hospital Beckton Neil Woodward Security Manager Ridgeway John McCarron Senior Nurse Shelton Hospital Shrewsbury James Alexander Security Manager Wells Road Centre Jackie Somers Ward Manager St. Andrew's Healthcare 29

Alison Carr Ward Manager St. Andrew's Healthcare James Cooper Partnerships Lesley Wilson Service Co-ordator Brooklands Joseph Vella Consultant Psychiatrist Gerry Simon Clic Hollis McClatchie Matron - Secure and Forensic Low Hellgly and Chichester Secure Services Low Secure Services Brian Mandisodza Registered Unit Manager Sutton's Manor Seb Prgle Service User Expert QNFMHS Arlena Ruben Charge Nurse and Recovery Lead The Dene and Pelham Woods La Aimola Research Fellow Royal College of Psychiatrists Alice Taylor consultant clical psychologist North London Forensic Services Colette Hamer Service Manager St. Mary's Hospital Emmanuel Onukwube Clical Services Manager Cygnet Hospital Beckton Gary Stobbs Registered Unit Manager North London Clic Gordon Tsubira Senior Occupational Therapist St. Luke's Healthcare Imogen Mortiboys Clical Services Manager St. Andrew's Healthcare Birmgham James Mulls Integrated clical lead, forensic Rob Pto Low Secure mental health services (sept) Unit James Tighe Clical Nurse Research Fellow The Bracton Centre Jeni Chamberla Unit Manager Thornford Park Hospital John Scott Security Team The Dene and Pelham Woods John Hall Forensic Case Manager Ridgeway John Abu Clical Team Leader Sutton's Manor Kaysi Thn Locum Consultant Forensic Psychiatrist Brockfield House Keith Russell General Manager Secure and Forensic Low Secure and Community Services Sussex Partnerships NHS Foundation Trust Larte Lawson Nomated Individual St. Luke's Healthcare Leanne Smith Lead Nurse Kemple View Lisa Cairns Clical Services Manager St. Andrew's Healthcare Nick Badoorally Ward Manager Jupiter House Low Secure and Forensic Services Patrick O'Sullivan Medical Director St. Magnus Simon Lloyd Head of Clical Services St. Andrew's Healthcare Steve Godw Deputy Head of Service Ridgeway Susan Guchu Clical Team Leader Sutton's Manor Further Acknowledgements: We are grateful to Dr Stephen Pereira, Chair of NAPICU and Dr Faisil Sethi, Vice Chair of NAPICU for their advice and sight of the NAPICU Response to Department of Health: Psychiatric Intensive Unit and Low Secure Services Good Practice Commissiong Guides: March 2012. 30

Appendix 3: Advisory Group First Name Surname Role Organisation Phil Brian Head of Secure Services West Midlands Commissiong Commissiong Team Rosie Ayub Secure Services Commissiong/ National QIPP Programme Yorkshire and Humber Secure and Specialist Mental Health Commissiong Team Ian Carmichael Service User Expert Quality Network for Forensic Mental Health Services Sheryle Cleave Clical Nurse Manager Northumberland Tyne and Wear NHS Foundation Trust Paul Gilluley Consultant Forensic Psychiatrist West London Forensic Service Stephen Godw Deputy General Manager Ridgeway Julian Haes Social Work Manager North London Forensic Service/ National Group for Social Work Managers Secure Services Quazi Haque Group Medical Director Partnerships care Mary Harty Consultant Forensic Psychiatrist & Associate Medical Director South West London & St Georges Mental Health NHS Trust Harry Jeremy Mat Clive Janet Kennedy Kenney-Herbert Kton Long Parrot Executive Clical Director & Consultant Forensic Psychiatrist Clical Director/Consultant Forensic Psychiatrist Mental Health Act Policy Advisor Associate Director of Psychology and Psychological Therapies Consultant Forensic Psychiatrist/Chair Forensic Faculty National Forensic Mental Health Service, Central Mental Hospital Reaside Clic Quality Commission St. Andrew s Healthcare Royal College of Psychiatrists Susan Ridg r Representative Quality Network for Forensic Mental Health Services Pete Snowden Medical Director Partnerships Anita Trenfield r Representative Quality Network for Forensic Mental Health Services 31

Appendix 4: Project Team Name Role Sarah Tucker Michael Gray Sam Holder Sarah Stubbs Ilham Sebah Programme Manager Deputy Programme Manager - MSU Deputy Programme Manager - Project Worker Project Worker Abdirisak Husse Alex Sunyata Ian Carmichael Pebble Carmichael Seb Prgle Anita Trenfield Susan Ridg Service User Experts r Representatives 32

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