OBSERVATION AND ENGAGEMENT POLICY CL04 March 2019

OBSERVATION AND ENGAGEMENT POLICY MARCH 2019

This policy supersedes all previous policies for Observation

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Policy title Observation and Engagement Policy

Policy reference

CL04

Policy category Clinical

Relevant to All staff who are involved in the observation of service users, and those who manage them

Date published March 2019

Implementation date

March 2019

Date last reviewed

February 2019

Next review date

April 2021

Policy lead David Curren, Deputy Director of Nursing

Contact details Email david.curren@candi.nhs.uk

Accountable director

Linda McQuaid, Interim Director of Nursing and Quality

Approved by: Positive and Proactive Group & Quality Governance Committee

Ratified by: Quality committee March 2019

Document history

Date Version Summary of amendments

Mar 19 12

Stronger focus on inpatient units. Acknowledgement of different inpatient units models and requirements across the 3 Divisions. Clarification of competence assessment for close observations / scope of practice. Review of staff break requirements. Requirements for care plans aligned with comprehensive and risk assessment for service user on close observations. Emphasis on therapeutic activity – both structure activity and therapeutic relationships. Addition of review requirements (aligned with different Divisional requirements). Enhanced overview of risks considered, including risk of exploitation, abuse / sexual safety. Reviewed service user information. Addition of a policy summary for temporary staff. Medical staff would always be encouraged and contribute to the assessments but this can be nursing led. Audit needs incorporated and supported by an action plan

Membership of the policy development/ review team

Clinical Director (Acute), Senior Service Managers (R&R, Acute and SAMHS), Matrons, Ward Manager representation, Practice Development Nurses, Positive and Proactive Care Group

Consultation Matrons, Associate Divisional Directors, Practice Development Nurses, Ward Managers and Senior Service Managers, Service User Representative (via P&PC Group)

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DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet.

Contents Page

1 Introduction 1

2 Aims and objectives 1

3 Definitions 2

4 Duties 2

5 Levels of observation and their implementation 5

6 Assessment of Risk and Care Planning 9

7 Changes in Levels of Observation and Recording 9

8 Community and Rehabilitation Services - Guidance 11

9 Dissemination and implementation arrangements 11

10 Training requirements 12

11 Monitoring and audit arrangements 12

12 Review of the policy 13

13 References 13

14 Associated documents 13

Appendix 1: Equality Impact Assessment Tool 15

Appendix 2: Inpatient Monitoring Form – Day/Night 16

Appendix 3. Intermittent Observation monitoring Form 18

Appendix 4. Within Eyesight – Within Arms-length monitoring form

Appendix 5. Observation Audit

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Appendix 5. Patient Information Leaflet 22

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1. Introduction Observation is a process through which a person learns something about someone else by listening, interacting, trying to understand them and watching them. Observational skills are essential to gather information and make an accurate assessment of an individual patient’s needs. Observation is therefore placed firmly within the context of maximising safety/minimising risk as part of an overall therapeutic interaction between the member of staff and patient, which involves patients and carers to the maximum extent possible. An observation policy is the clearest way to help staff provide a consistent approach that all patients need, particularly when they are at their most vulnerable. Enhanced observation by its very nature is an intrusive act, and this policy needs to be enacted within the spirit of the Safety, Privacy and Dignity Policy. The Gender and Public Duty Act 2007 requires trusts to take account of gender at all times. This policy therefore defines ALL levels of observation in use throughout the Foundation Trust where enhanced observations take place. It highlights the responsibilities of individual members of the multidisciplinary team, clarifies the exact terminology to be used, sets standards for practice and provides a framework for audit. This is a trust wide policy which is relevant to all staff working in inpatient areas and the staff managing them.

2. Aims and objectives The aim of the policy is to define four distinct levels of observation and engagement, and to clarify the criteria for their use in practice, which will promote the physical and psychological well-being of the patient and at times safety of others. The policy primarily focusses on Acute, Rehabilitation and Services for Ageing and MH inpatient units. Crisis Houses and Community Residential Units use of observation is briefly summarised, and further detail can be found in these services’ Operational Policies. The objectives of this policy are to:

define the four levels of observation; describe the implementation of the Foundation Trust’s Risk Assessment Policy in

relation to the observation process; detail expectations of staff who will undertake the different levels of observation,

enabling them to safely and competently observe patients following adequate induction and competency training;

ensure that there are consistent decision making process when observations are

changed; attribute responsibility for recording observations in EPR Carenotes or on paper

forms; define the audit process.

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Safeguarding statement: The Trust is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults. All employees have a duty to be alert to potential vulnerabilities in children and adults, and to know what to do if they have concerns. All staff are expected to be aware of and implement the Trust’s safeguarding policies and procedures.

Please note: There is an information leaflet for patients at Appendix 5

3. Definitions

Risk assessment: is the gathering of information through processes of communication, investigation, observation and persistence; an analysis of the potential outcomes of identified behaviours. It includes identifying specific risk factors of relevance to an individual, and the circumstances in which they may occur. This process requires linking the context of historical information to current circumstances, to anticipate possible future change.

Engagement: Observation should be safe and therapeutic, but can be intrusive. Patients who experience enhanced observation have reported that it is potentially therapeutic if the staff involved actively engage them in the process, encouraging communication and listening, and conveying to the patient that they are valued and cared for Cardell & Pitula (1999). Recognition should also be made of the need for silence at appropriate times and as much privacy as can be safely achieved.

Observation: is a core nursing skill, which must be a two-way process, established between a patient and a nurse or support worker, which is meaningful, grounded in trust, and therapeutic for the patient. This relationship is considered to be the basis on which risk assessment, violence management and a programme of supportive observation can then be undertaken (Reference: Violence: The short term management of disturbed/violent behaviour in inpatient psychiatric settings and emergency departments; February 2005).

4. Duties

4.1 The Chief Executive

The Chief Executive through the Director of Nursing and Quality is responsible for:

Promoting and supporting the aims and objectives of this policy;

Providing resources for putting the policy into practice;

Ensuring there are arrangements for monitoring incidents linked to observation and that the Board reviews the effectiveness of the policy.

4.2 Directors and Associate Directors

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Clinical Directors and Associate Directors are responsible for the promotion and implementation of the Observation & Engagement Policy in all the inpatient service areas they manage.

4.3 The Ward Manager or Nominated Deputy

Should ensure that: All staff have read and understood the policy. (Please see Appendix XX;

Observation and Engagement Policy Summary which can be used for Band and Agency staff ward orientation)

All staff, including bank/agency staff, are trained in the use of the policy on induction and understand the meaning and application of the terms used for each level of observation.

Care is coordinated and practised within a safe ward environment; All staff are aware of patients on increased levels of observation; The competence of Band 2/3/4 staff and 3rd year mental health branch student

nurse is assessed and documented evidence is kept in clinical supervision notes. 4.4 The Shift Coordinator

Is responsible for:

Allocating a member of staff at the beginning and end of each shift who will jointly carry out a check of the ward and all patients with a member of staff from the adjacent shift (this staff member does not have to be a qualified member of staff)

Identifying all patients that require intermittent and within eyesight or within arms-length observation during that shift.

Assigning staff to carry out observations during the shift (General, Intermittent, Within Eyesight and Within arm’s length).

Ensuring that the assigned staff members has the clinical skills required to carry out that role in the best interests of the patient

Ensuring that the maximum time limit for within eyesight or within arm’s length observation by any nurse is no more than 1hour without a break (within an option of extending to 2 hours on night duty subject to individual assessment and agreement).

Setting up a rota system so that a designated nurse is available to undertake general observations on an hourly basis

Monitoring the needs of both the patient and the staff member carrying out the observation, and confirming this is summarised in a current and comprehensive care plan

Considering the patient’s cultural and religious needs, gender requirements and the patient’s right to choose the gender of their nurse when allocating staff to carry out observations and this is outlined in the Care Plan

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Ensuring that there is a review of the level of observations on a shift to shift basis, which may involve the duty doctor out of hours or any other experienced clinician.

Ensuring that the patient is informed of any changes in levels of observation and the reason for this.

When making any of these decisions consideration must be given to the patient’s cultural and religious needs and their right to choose the gender of their nurse, allowing for possible sexual inappropriateness of some patients with staff.

4.5 The nurse who accepts responsibility for within eyesight or within arm’s length observation will ensure that they:

Have read and understood the care plan and risk assessment, and review and

contribute to the care plan (in co-production with the patient when possible) to ensure it is current.

Have read and understood the standards of nursing required in the policy relating

to all levels of observation;

Use therapeutic engagement to::

o Facilitate engagement in activity on a one to one or group basis according to service user interests and based on individual assessment. Group attendance should be agreed in advance with the group facilitator. The staff member allocated to observations must continue with this level of observations throughout all activities.

o Offer 1:1 dialogue with the patient o Other key nursing interventions, including vital sign observation and

assistance with hygiene needs

Sign the observation monitoring and ensure the record is completed

Provide a verbal handover to the nurse that is taking over the observation, encouraging patient participation in handover when possible in the handover.

Staff must ensure their attention is fully focussed on this intervention at all times.

Request a medical review or other disciplinary review when indicated

4.6 Band 2 Staff, Band 3/4 worker and 3rd year Mental Health Branch Students

In addition to the above all staff are required to demonstrate that they:

Have read and understood the policy (with support from a Registered Nurse) Can demonstrate a comprehensive understanding of practice requirements

outlined in this policy Have a full understanding of the individual patients care plan, including risk

management, and know how and when to seek additional advice. 4.7 Responsibilities of the Ward Doctor

Has read and understood the policy;

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Discusses the review with the nursing staff on duty and documents the outcome; Provides guidance in patients notes for decision making out of hours or at

weekends as necessary; Contact the consultant for advice on difficult or controversial decisions.

Contributes to patient’s care planning re observation

If observations are of a medical nature only (i.e. physical observation of temperature, pulse, respirations or levels of consciousness) this needs to be carefully documented and communicated to the relevant nursing staff and out of hours’ medical cover.

4.8 Responsibilities of the Duty Doctor

Has read and understood the policy; Is involved in decisions regarding changes to levels of observation out of hours; Documents these changes in the patient’s notes.

4.9 Responsibilities of the Consultant Psychiatrist

Is involved in decisions during the working week:

Regarding initiation, discontinuation or changes in levels of observation in partnership with senior nursing colleagues

Contributes to the patient’s care planning re observation including the indications that would lead to reduction of observations out of hours

Note; Consultant authorisation to cease observations is not routinely required

5. Levels of Observation and their Implementation The multidisciplinary assessment of all patients admitted to inpatient services must

include an assessment of the level of observation required. The level of observation must also be reviewed following any significant event, or changes in mental state. NICE (National Institute for Clinical Excellence) in their 2005 Guideline on the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments recommends four levels of observation. These four levels of observations are used within the Trust:

5.1 General Observation

General observation is the minimum acceptable level of observation in inpatient units and meets the needs of most patients for most of the time. The patient maintains a sense of responsibility for structuring their day and negotiates their care plan around this with their primary nurse. Their allocated nurse for each shift must have knowledge of their general whereabouts and plans for the day, whether in or out of the

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ward/setting. At least once a shift the allocated nurse will sit down with the patient to assess their mental state. This session should include and document presentation and behaviours of the patient associated with risk. Half-hourly safety checks of all patients on the ward supplement General Observation. Safety checks are recorded on a form specifically designed for this process (see Appendices 2 and 3).

5.1.1 All patients must be checked every 30 minutes throughout the 24 hour period. The

whereabouts of each patient must be recorded on the standard half hourly chart. On each check the staff member must ensure that the patient is breathing

5.1.2 During a change of shift, two members of staff, one from the shift which is ending and one from the shift that is coming on duty will carry out the safety checks and both initial the Monitoring Form.

5.1.3 No cell in the monitoring form should be left blank after a round of general observation has been completed. Data should not be entered in hindsight.

Issues to consider are:

The likelihood of self-harm.

The physical health of the patient including known existing medical conditions

The level of medication that has been administered during that day especially rapid tranquillisation or Clopixol Acuphase

Administration of Controlled Drugs

The possibility that the patient is a fire risk

The patient is at risk of exploitation or abuse by others, including sexual safety concerns

5.1.4 In addition to checking each patient, the environment must be checked to ensure that

the fire exits and the doors to the male and female areas are working properly. 5.1.5 If the patient cannot be located during a check, then the person/s completing the

checks must notify the shift coordinator immediately. The shift coordinator will then be responsible for ensuring that a search of the Ward, building and grounds is conducted in order to locate the patient. (If the patient is not located then this will trigger the AWOL management process). The shift coordinator will ensure that the patient is documented as being AWOL on the monitoring form until such time that the patient is located as per the AWOL and Missing Persons Policy.

5.2 Intermittent Observation

Intermittent observation is used when patients are felt to be potentially, but not immediately at risk, for example patients with depression, but no specific plans to harm themselves or others, and may include those who have previously been at risk but are in the process of recovery. The need for intermittent observation is based on individual assessment.

Intermittent Observation must be used for 2 hours on all patients who have received rapid tranquillisation and for 72 hours after the administration of Clopixol Acuphase. A risk assessment (including the patient’s physical observations using the National Early Warning Score,NEWS2), will determine the level of observation to be used in the

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following 24 hour period. Refer to the Guidance for the use of Clopixol Acuphase in Adults policy. Intermittent observation can be undertaken out by a Registered Nurse, Band 2, 3 or 4 staff members or a 3rd year Mental Health Branch Semester student nurse who have been assessed to have the clinical competence to undertake close observation. The staff member is required to follow the guidelines for General Observations and additionally:

make contact with the patient approximately four times an hour; vary the time at which contact is made so that the patient cannot easily plan when

the next contact may be; work to the care plan, ensuring intrusion is minimised and positive engagement

takes place; be attentive to physical as well as psychological needs;

ensure the patient has an up to date Risk Assessment.

Documents observation on the observation monitoring form and provides a clinical summary in progress notes at least once per shift

5.3 Within Eyesight Observation

Within eyesight observation is used when a patient is assessed as being a potential danger to himself / herself or others. This is potentially intrusive but reflects the increased level of concern both for individual patients and for those in contact with them. Please note, the Rapid Tranquilisation Policy requires instigation of close observation if a patient refuses vital sign monitoring after rapid tranquilisation.

The following factors need to be considered when making an assessment to commence within eyesight observation on a patient:

absconding risk when there is a danger of harm to self or others; significant risk of physical violence; Suicide risk and/or self-harm.

Vulnerability to exploitation and abuse by others

Fire risk

Within eyesight observation can be carried out by a Registered Nurse, or a , Band 2, 3 or 4 staff members or a 3rd year Mental Health Branch Semester student nurse who have been assessed by the Nurse in charge to have the clinical competence required to undertake within eyesight observation.

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On occasion more than one nurse may be necessary, in which case they can be either qualified or a competent trained Band 2, Band 3/4 worker or a 3rd year Mental Health Branch Semester student nurse depending on the risk assessment

When undertaking within eyesight observation the staff member must:

accompany the patient on the ward and remain within eyesight at all times;

maintaining eye sight observation while the patient is using the toilet or bathroom is based on individual assessment and is summarised in the care plan that involves the patient whenever possible

be in sufficiently close proximity to react and intervene as necessary; review, develop and follow the care plan with the Registered Nurse and

multidisciplinary team; be attentive to physical as well as psychological needs;

Document hourly observations in the EPR progress notes

Care plans must provide guidance on observation requirements in relation to the patient’s bath, shower and toilet needs, and specifically if observation is required during these activities. In this instance safety needs are balanced with the dignity and privacy. It is good practice to ask all patients if they prefer an observer of the same or different gender, as far as is appropriate and staffing allows. In addition, ethnic, cultural and language differences need to be incorporated into the care plan, a copy of which should be given to the patient.

5.4 Within Arm’s Length Observation

Within arm’s length observation is used when a patient is assessed as being an immediate danger to himself / herself or others. Within arm’s length observation is very intrusive and can be distressing to patients and stressful for staff. This is an intensive intervention and routinely requires assessment of staff safety and well-being. Staff should have regular breaks with planned rotation of within arm’s length observation duties. If this level of observation is assessed to be unsafe the alternative use of within eyesight observation should be considered, and the rationale documented in the patient’s progress notes.

The following factors need to be considered when making an assessment to commence within arm’s length observation:

severe suicide risk or serious impulse to self-harm; significant risk to other patients or staff safety.

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Within arm’s length observation can be carried out by a Registered Nurse, Band 2, Band 3 or 4 staff member or a 3rd year Mental Health Branch Semester Student Nurse who have been assessed by the Nurse in charge to have the required understanding and clinical competence required to undertake this role. Allocation of this role will also reflect the individual patient’s risk assessment and broader care needs. On occasion more than one staff member may be required to undertake within eyesight observation, and this person must also be assessed to have the require clinical competence to undertake this role

When undertaking within arm’s length observation staff must:

accompany the patient around the ward at all times and in all places; ensure that the patient is always within arm’s length, as long as it is safe to do so; work to the care plan; be attentive to physical as well as psychological needs.

document hourly observations in the EPR progress notes

The care plan must have clear and precise instructions and there can be no deviations from the above, even in relation to bath, toilet and shower arrangements. A copy of the care plan must be given to the patient. The search policy is applied to ensure the patient does not have access to prohibited items.

6. Comprehensive Assessment, Care Planning and Risk Management and Documentation

The need for observations must be based on a robust and thorough assessment and care plan, including a risk management plan. Guidance on the can be found in the Clinical Risk Management Policy

In addition:

The rationale for the level of observations should be also documented on EPR Carenotes

All staff undertaking observations should have a comprehensive understanding of the service users’ care plan, including risk history

Patients receiving continuous (within eyesight or within arms-length) observation should have an hourly entry recorded in the EPR progress note. This should consider:

o activity o engagement with staff members o behaviour and mental state o changes to risk assessment and care plan.

The care plan should be reviewed each shift as a minimum standard

Information should be provided to the patient and family / significant other regarding observation (See appendix 5)

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7. Changes in Levels of Observation and Recording

All patients on either WITHIN EYESIGHT or WITHIN ARMS LENGTH observation must be reviewed at least every 12 hours to ensure that the observational level is appropriate to the patient’s needs and recorded on EPR Carenotes. Levels of observation for all patients must be considered at the beginning of each shift. The decision will be based on a review of the current care plan outlining the need and use of enhanced observations. It is the responsibility of the shift co-ordinator on each shift to ensure that the observation level has been reviewed every 12 hours as a minimum standard. A record of this review will be documented on EPR Carenotes. The level of observation is initially reviewed at 3 hours after commencement of within eye sight or within arm’s length observations, and on a shift by shift basis as a minimum standard thereafter. The review is undertaken during the shift to enable staffing planning. In the Acute Division it is recommended that review is linked to the Red to Green meetings. Review is undertaken by the Ward Manager with Matron input during working hours, and by the Nurse in charge, with support from the Duty Nurse and the on-call system when required after working hours. Review will include the medical assessment, current care plan, including risk assessment. Medical staff contribute to this review, as outlined in Sections 4.7, 4.8 and 4.9. In the Acute Division review of within eyesight or within arm’s length observations are reviewed by the Clinical Director when this exceed four days continuous observation Review requirements summary

Time frame Responsibility Note

Within 3 hours of commencement

Shift Coordinator

Each shift Shift coordinator and MDT, with support of senior staff

Occurs during the shift to enable staffing planning Linked to Red to Green Meeting (Acute Division)

After 72 Hours of continuous observation

Acute Matron; Ward Manager with Service Manager/Senior Service Manager (R&R)

Not applicable for SAMHS

After 4 days of continuous observation

Clinical Director (Acute Division only); MDT (Acute)

Not applicable for SAMHS

7.1 Increasing Levels of Observation

The decision to do this should be taken by the multidisciplinary team if possible. However, where there is cause for concern a Registered Mental Health Nurse may initiate or increase levels of observation. This action must be followed by a mental state examination and review of the care plan. On call medical staff can be used to support this decision making when required.

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7.2 Decreasing or Discontinuing Levels

All patients should be cared for in the least restrictive environments. It is recognised that increased levels of observation have the potential to be experienced as intrusive by some patients. Review of observation levels is undertaken by senior multi-disciplinary staff, including the nurse in charge. After hours the duty nurse and duty doctor support this clinical assessment and decision making with the nurse in charge.

7.2.1 All patients on increased level of observation (Intermittent, Within Eyesight or Within

Arm’s Length) must have a documented plan recorded on EPR Carenotes for decreasing or discontinuing levels of observation, which the medical and nursing teams have discussed and agreed.

7.2.2 In situation of uncertainty, advice can be sought from the Duty Consultant via on call

medical staff.

8. Crisis Houses and Community Residential Units

Observation is a key tool to maximise safety and minimise risk in all settings. In Crisis Houses and Community Residential Units staff have a duty of care to ensure that residents’ whereabouts are known throughout the day and night. This is managed in the context of service users’ voluntary status and individualised care plans. In principle within eyesight and arms-length observations are not used in community settings. The assessed need for this intervention would suggest a service user requires care in another setting (generally an inpatient unit). Each community service outlines observation and frequency of contact requirements in local guidance, such as an operational policy.

9. Dissemination and Implementation Arrangements

A current version of the policy can be found on the Trust intranet. All Directors, relevant Associate Directors, Lead Nurses and Ward Managers will be notified of any changes to the policy.

If you have any queries or seek clarification or support in the implementation of this policy please contact the Clinical & Corporate Policy Manager 020 3317 6561.

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10. Training Requirements / Implementation Plan

A local implementation plan is developed by the senior multi-disciplinary team

in each service setting

Existing meetings structures are used to implement the policy, including

quality forums and team business meetings

The policy should be routinely discussed in clinical supervision for inpatient

staff

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Implementation is monitored by the Head of Nursing (Acute and R&R),

Matrons and Senior Service Manager

A clinical audit is undertaken to review compliance with this policy (see

Appendix 4)

On line training will be developed by June 2019 to support implementation of

this policy and should be included in staff induction

11. Monitoring and Audit Arrangements

Elements to be

monitored

Lead How trust will monitor compliance

Frequency Reporting arrangements

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

Enhanced observation Audit (Appendix 4)

Matron/ward Manager

Audit

3 Monthly

P&PC Group

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12. Review of the policy

This policy will be reviewed in 2021 or earlier should practice change.

13. References

13.1 Department of Health (1999) Practice Guidance: Safe and Supportive Observation of Patients at Risk, Mental Health Nursing: Addressing Acute Concerns. London: The Stationery Office.

13.2 Department of Health (1999) Mental Health Act 1983, Code of Practice. London: The

Stationery Office. 13.3 National Institute for Clinical Excellence (2005) Violence, The Short-term management

of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments. NICE.

13.4 Mental Health Practice, Research & Practice (July 2002) Vol 5 No 10, Nursing

observations in the acute inpatient setting: A contribution to the debate. 13.5 Department of Mental Health and Learning Disability, (November 2007), A

Longitudinal Study of Conflict and Containment on Acute Psychiatric Wards, Report to the DH Policy Research Programme. City University London.

13.6 Gender and Public Duty Act 2007.

http://resource.nusonline.co.uk/media/resource/LARGE%20PRINT%20GEN%20DUTY%20LEAFLET.pdf

13.7 Suicidal Inpatient service user’s perceptions of therapeutic and non-therapeutic

aspects of constant observation: Psychiatric Services, 50(8) 1066-70: Cardell, R and Pitula, C.R (1999)

13.8 Gender and Public Duty Act 2007

14. Associated documents

Care Programme Approach Operational Policy: Camden and Islington Foundation Trust (October 2012).

Ligature Risk Management Policy: Camden and Islington Foundation Trust (May 2017)

Policy and Guidelines on Clinical Risk Assessment and Risk Management: Camden and Islington Foundation Trust (July 2012).

Safeguarding Adults Policy: Camden and Islington Foundation Trust (July 2017)

Search Policy: Camden and Islington Foundation Trust (July 2017).

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AWOL & Missing Persons Policy: Camden and Islington Foundation Trust (June 2015)

Management of Acutely Disturbed Adult Patients: Guidelines for Rapid Tranquillisation Policy: Camden and Islington Foundation Trust (April 2013).

Clopixol Acuphase Policy: Camden and Islington Foundation Trust (April 2013).

Standard Operating Procedure for recording enhanced observations on EPR Jun 2012).

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Appendix 1

Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

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Appendix 2

INPATIENT MONITORING FORM: DAYTIME GENERAL OBSERVATIONS

WARD: DATE: B

ED

PATIENT NAME

07:3

0

BO

TH

SIG

N

08:0

0

08:3

0

09:0

0

09:3

0

10:0

0

10:3

0

11:0

0

11:3

0

12:0

0

12:3

0

13:0

0

13:3

0

14:0

0

14:3

0

15:0

0

15:3

0

16:0

0

16:3

0

17:0

0

17:3

0

18:0

0

18:3

0

19:0

0

19:3

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

O/L

O/L

O/L

Safety Checks – Doors et al

STAFF SIGNATURE

AWB/ASB Awake in Bed/Asleep in Bed

B Bath/Shower - Ward CR Computer Room LR Laundry Room T Toilet - Ward EL Escorted Leave OTO OT off Ward

AWOL Absent Without Leave

BR Bedroom/Ensuite DR Dining Room/Area SR Sitting Room G Garden UEL Unescorted Leave WRR Ward Round Room

S Seclusion C Corridor QR Quiet Room FQR Female Quiet Room TR Treatment Room OL Overnight Leave MS Meeting Staff

A member of the nursing team on the ward carries this check out every half hour. The aim of the check is to note the whereabouts and safety of the patients on the ward. The check should include a check that patients who are asleep are breathing, and a safety check of the ward environment. Any concerns felt by the member of staff during the check should be reported immediately to the shift coordinator. This is in addition to any enhanced levels of observation. AT 07.30 hrs & 20:00hrs, delegated staff from both shifts will jointly check the patients and initial the monitoring form together.

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INPATIENT MONITORING FORM: NIGHTTIME GENERAL OBSERVATIONS WARD: DATE: B

ED

PATIENT NAME

20:0

0

BO

TH

SIG

N

20:3

0

21:0

0

21:3

0

22:0

0

22:3

0

23:0

0

23:3

0

00:0

0

00:3

0

01:0

0

01:3

0

02:0

0

02:3

0

03:0

0

03:3

0

04:0

0

04:3

0

05:0

0

05:3

0

06:0

0

06:3

0

07:0

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

O/L

O/L

O/L

Safety Checks – Doors et al

STAFF SIGNATURE

AWB/ASB Awake in Bed/Asleep in Bed

B Bath/Shower - Ward CR Computer Room LR Laundry Room T Toilet - Ward EL Escorted Leave OTO OToff Ward

AWOL Absent Without Leave

BR Bedroom/Ensuite DR Dining Room/Area SR Sitting Room G Garden UEL Unescorted Leave OTW OT on Ward

S Seclusion C Corridor QR Quiet Room FQR Female Quiet Room TR Treatment Room OL Overnight Leave MS Meeting Staff

A member of the nursing team on the ward carries this check out every half hour. The aim of the check is to note the whereabouts and safety of the patients on the ward. The check should include a check that patients who are asleep are breathing, and a safety check of the ward environment. Any concerns felt by the member of staff during the check should be reported immediately to the shift coordinator. This is in addition to any enhanced levels of observation. AT 07.30 hrs & 20:00hrs, delegated staff from both shifts will jointly check the patients and initial the monitoring form together.

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Appendix 3

Date Time Patient Location Staff Name Signature Comment on Interaction with Patient

AWB/ASB Awake in Bed/Asleep in Bed

B Bath/shower - ward CR Computer Room LR Laundry Room T Toilet - Ward EL Escorted Leave OTO OT off ward

AWOL Absent Without Leave BR Bedroom/En suite DR Dining room/area SR Sitting Room G Garden UEL Unescorted Leave WRR Ward Round Room

S Seclusion C Corridor QR Quiet Room FQR Female Quiet Room

TR Treatment Room

OL Overnight Leave MS Meeting Staff

This record must be completed at the point a service user is placed on intermittent observations, and four times per hour thereafter, for the duration that intermittent observations remain in place. Every 12 Hours the shift coordinator must review the level of observation and document this at the end of the form. DOB:……………………………….Date Observations Enhanced:…………...... Date Level Review:…………………..

Reason for Enhanced Observation:

Absconding Risk ☐ Physical Health ☐

Self-Harm/Suicide ☐ Risk to Others ☐

Rapid Tranquilisation ☐

Other, please Indicate:

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Patient Name:

Date Time Patient Location Staff Name Signature Comment on Interaction with Patient

Shift Co-ordinator Review

Date Staff Name Signature Intermittent Obs remain appropriate? (Y/N)

AWB/ASB Awake in Bed/Asleep in Bed

B Bath/shower - ward CR Computer Room LR Laundry Room T Toilet - Ward EL Escorted Leave OTO OT off ward

AWOL Absent Without Leave BR Bedroom/En suite DR Dining room/area SR Sitting Room G Garden UEL Unescorted Leave WRR Ward Round Room

S Seclusion C Corridor QR Quiet Room FQR Female Quiet Room

TR Treatment Room

OL Overnight Leave MS Meeting Staff

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Appendix 4

Close Observation Audit Tool Instructions

Select a service user currently or recently on close observation and complete the audit tool below

Service Users

NHS Number

D.O.B

Gender

Ward

Date of admission

Date observation

commenced

Reason for within

eyesight / arms-

length

observation

Audit completed

by

1. Answer each question answering yes or no.

Question Yes/No Comments

Does the patient’s care plan accurately reflect the need for the assigned observation level?

Does the patient’s risk assessment and management plan reflect the patient’s assigned level of observation?

Can the allocated nurse / staff member undertaking the observation outline the patient’s current care plan and risk management plan?

Can the allocated nurse

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/ staff member outline the key requirements of the allocated observation level outlined in the Observation & Engagement Policy?

For patient’s receiving within arms-length / within eyesight obs is there an -hourly summary made in the progress notes outlining the service users’ activity and mental state?

Was the need for the observation reviewed on a shift by shift basis, and summarised on Carenotes

Are staff relieved from this role on an hourly basis as a minimum standard during the day shift?

Intermittent observation

Is there a clear process for allocation of this role?

Is the summary form completed to date at the time of the audit?

General observation

Is there a clear process for allocation of this role?

Is the observation summary form completed to date at the time of the audit?

Comments

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Appendix 5

Within Arm’s Length Observation Staff will:

accompany the patient around the ward at all times and in all places;

ensure the patient is always within arm's length, as long as it is safe to do so;

continue to work to the patient’s care plan;

ensure the care plan has instructions in relation to shower and toilet arrangements.

Although this may feel intrusive, the safety of the patient is of paramount importance. In situations when Within Arm’s Length Observation is assessed to be unsafe for patients or staff, the use of Within Eyesight Observation will be considered with one or two staff members as an alternative.

Changes in levels of Observation

Enhanced levels of Observation are reviewed regularly (at least every 12 hours). Any changes to the level of observation will always be discussed with the patient. Increasing levels The decision to increase the level of Observation is made by members of the multi-disciplinary team whenever there is an increased risk to the patient or others on the ward. Decreasing levels/Discontinuing The multidisciplinary team will have a plan for decreasing the level of observation based on the patient’s safety. All patients on enhanced observation must be given verbal and written information about this intervention and a copy of their care plan. If you would like to know more about this intervention, please ask a member of staff on the ward.

OBSERVATION

&

ENGAGEMENT

POLICY

Patient and carers

information about

Observation levels in

hospital.

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Whilst you or a loved one is in hospital, staff aim

to provide a safe and support environment for

recovery.

This leaflet is designed to answer questions you may have on different levels of observation.

What is ‘Observation’?

Observation is an intervention that is designed to

reduce the risk of harm to patients. Staff have a

responsibility as part of their work to monitor

patients’ mood and wellbeing, including observing

how they are behaving and interacting, in order to

assess progress or act on any changes.

Levels of Observation

There are four levels of Observation:

1. General Observation

2. Intermittent Observation

3. Within Eyesight Observation

4. Within Arm’s Length Observation

Levels 2, 3 and 4 are considered enhanced

observation.

The Trust Observation & Engagement Policy

(2019) informs staff of when and how to use

Observation levels.

1.General Observation

General Observation is the minimum level for

inpatient wards and meets the needs of most patients

most of the time.

At least once a day, staff will meet with the patient to

work through their care plan, help plan daily activities

assess their mental state and wellbeing.and

It also involves half hourly checks of the whereabouts

and safety of each patient.

2. Intermittent Observation

Intermittent observation is used when a patient is assessed to be potentially, but not immediately, at risk to themselves or others. It is also routinely used after administering certain medications. Staff will:

Make contact with the patient at least 4 times an hour;

continue to work to the patient’s care plan;

ensure the care plan has clear instructions about any escorted time off the ward, and with whom.

3.Within Eyesight Observation

Within Eyesight Observation is used when a patient is assessed to be a potential danger to themselves or others. Staff will:

accompany the patient around the ward and remained within eyesight of them at all times;

continue to work to the patient’s care plan;

ensure the care plan has instructions in relation to shower and toilet arrangements.

Although this may feel intrusive, the safety of the patient is of paramount importance. Patients’ preferences about working with same or different gender staff will always be considered, if appropriate and staffing mix allows.

3. Within Arm’s Length Observation

Within Arm’s Length Observation is used when a patient is assessed as being an immediate danger to themselves or others. This is an intensive intervention carried out by one or two staff members together. It can be stressful for patients and requires frequent assessment of patient and staff safety and well-being.

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Appendix 6

SUMMARY: OBSERVATION AND ENGAGEMENT POLICY 2019

This summary is intended as a quick reference guide to key points of the policy.

The numbered subheadings correspond to the full Policy for ease of finding more detailed information.

1. Introduction Observation is a process through which a person learns something about someone else by listening, interacting, trying to understand them and watching them. Observational skills are essential to gather information and make an accurate assessment of an individual patient’s needs. Observation is therefore placed firmly within the context of maximising safety/minimising risk as part of an overall therapeutic interaction between the member of staff and patient, which involves patients and carers to the maximum extent possible.

2. Definitions

Risk assessment: is the gathering of information through processes of communication, investigation, observation and persistence; and analysis of the potential outcomes of identified behaviours. It includes identifying specific risk factors of relevance to an individual, and the circumstances in which they may occur. This process requires linking the context of historical information to current circumstances, to anticipate possible future change.

Engagement: Observation should be safe and therapeutic, but can be intrusive. Patients who experience enhanced observation have reported that it is potentially therapeutic if staff actively engage them in the process, encouraging communication, listening and conveying to the patient that they are valued and cared for (Cardell & Pitula,1999). Recognition of the need for silence should also be made at appropriate times and as much privacy as is safely achievable.

Observation: is a core nursing skill, which must be a two way process, established between a patient and staff, which is meaningful, grounded in trust and therapeutic. This relationship is considered to be the basis on which risk assessment, violence management and a programme of supportive observation can then be undertaken. 3. The Shift Coordinator Is responsible for:

Allocating a member of staff at the beginning and end of each shift who will jointly carry out a check of the ward and all patients with a member of staff from the adjacent shift (this does not have to be a qualified member of staff).

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Identifying all patients that require enhanced levels of observation

Assigning staff to carry out observations during the shift (General, Intermittent, Within Eyesight and Within Arm’s length).

Ensuring that the assigned staff members have the clinical skills required to carry out that roles in the best interests of the patient.

Ensuring that the maximum time limit for Within Eyesight or Within Arm’s Length observation by any staff is no more than 1 hour without a break (within an option of extending to 2 hours on night duty, subject to individual assessment).

Setting up a rota system so that the allocated staff member is available to undertake general observations on a half hourly basis.

Monitoring the needs of both the patient and the staff member carrying out the observation, and confirming this is summarised in a current and comprehensive care plan.

Considering the patient’s cultural and religious needs, gender requirements and the patient’s right to choose the gender of their observing staff member when allocating who to carry out observations and this should be noted in the care plan. Consideration of staff safety should also be given to the risk for possible sexual inappropriateness of some patients.

Ensuring that there is a review of the level of observations on a shift by shift basis, which may involve the duty doctor out of hours or other experienced clinicians.

Ensuring that the patient is informed of any changes in levels of observation and the reason for this.

4.5 The nurse who accepts responsibility for within eyesight or within arm’s length observation will ensure that they:

Have read and understood the patient’s care plan and risk assessment, and know how and when to seek additional advice.

Review and contribute to the care plan, in co-production with the patient when possible, to ensure it is up to date.

Have read and understood the Policy and understood the standards required in the relating to all levels of observation.

Use therapeutic engagement to:

Facilitate engagement in activity on a one to one or group basis according to patient's interests and based on individual assessment. Group attendance should be agreed in advance with group facilitator. The staff member allocated to observations must continue the required level of observation throughout all activities.

Offer 1:1 dialogue with the patient.

Offer other key nursing interventions, including vital sign observation and assistance with hygiene needs.

Sign the observation monitoring form and make a progress entry on Carenotes in a timely fashion.

Provide a verbal handover, encouraging patient participation where possible, to the nurse that is taking over the observation

Ensure their attention is fully focused on this intervention at all times.

4.6 Band 2 Staff, Band 3/4 worker and 3rd year Mental Health Branch Students will ensure that they: Have read and understood the policy (with support from a Registered Nurse). Can demonstrate a comprehensive understanding of practice requirements outlined in this policy. Have a full understanding of the individual patient’s care plan, including risk management, and know how and when to seek

additional advice.

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5. Levels of Observation and their Implementation The multidisciplinary assessment of all patients admitted to inpatient services must include an assessment of the level of observation required. The level of observation must also be reviewed following any significant event or changes in mental state. NICE (National Institute for Clinical Excellence) 2005 Guideline on the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments’, recommends four levels of observation. 5.1 General Observation General observation is the minimum acceptable level of observation in inpatient units and meet the needs of most patients for most of the time. The patient’s allocated nurse for each shift must have knowledge of their general whereabouts and plans for the day, whether in or out of the ward. At least once a shift the allocated nurse will sit down with the patient to assess their mental state. This session should include and document moods and behaviours of the patient that are associated with risk.

5.1.1 All patients must be checked every 30 minutes, throughout the 24 hour period. The whereabouts of each patient must be recorded on the ward’s monitoring form. There are separate forms for day time and night time recording. On each check the staff member must ensure that the patient is breathing.

5.1.2 During a change of shift, two members of staff, one from the shift which is ending and one from the shift that is coming on duty, will carry out the safety checks and both should initial the monitoring form. 5.1.3 No cell in the monitoring form should be left blank after a round of general observation has been completed. Data should not be entered in hindsight. 5.1.4 In addition to checking each patient, the environment must be checked to ensure that the fire exits and the doors to the male and female areas are working properly. Issues to consider are:

The likelihood of self harm.

The physical health of the patient including existing medical conditions.

The level of medication that has been administered during that day, especially rapid tranquillisation or Clopixol Acuphase.

Administration of Controlled Drugs.

The possibility that the patient is a fire risk.

The patient is at risk of exploitation or abuse by others.

5.1.5 If the patient cannot be located during a check, then the person/s completing the checks must notify the shift coordinator immediately. The shift coordinator will then be responsible for ensuring that a search of the ward, building and grounds is conducted. If the patient is not located, this will trigger the AWOL management process. The shift coordinator will ensure that the patient is documented as being AWOL on the monitoring form until such time that the patient is located, as per the AWOL and Missing Persons Policy.

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5.2 Intermittent Observation Intermittent observation is used when patients are felt to be potentially, but not immediately at risk, for example patients with depression, but no specific plans to harm themselves or others or those who have previously been at risk but are in the process of recovery. The need for intermittent observation is based on individual assessment. To implement intermittent observation staff must follow the guidelines for General Observations and additionally:

make contact with the patient approximately four times an hour;

vary the time at which contact is made so that the patient cannot easily predict when the next contact will be;

work to the care plan, ensuring intrusion is minimised and positive engagement takes place;

be attentive to physical as well as psychological needs;

ensure the patient has an up to date risk assessment;

document observation on the monitoring form and complete a progress notes in Carenotes, at least once per shift. Intermittent Observation must be used for:

2 hours after a patient has received rapid tranquillisation.

72 hours after the administration of Clopixol Acuphase.

A risk assessment which takes note of the patient’s physical observations using the National Early Warning Score (NEWS2), will determine the level of observation to be used in the following 24 hour period.

Refer to the Guidance for the use of Clopixol Acuphase in Adults policy and Rapid Tranquilisation Policy noting the requirement to instigate within eyesight observation if a patient refuses vital sign monitoring after rapid tranquilisation. 5.4 Within Eyesight Observation Within eyesight observation is used when a patient is assessed as being a potential danger to himself/herself or others. This is potentially intrusive but reflects the increased level of concern both for individual patient and for those in contact with them. The following factors need to be considered when making an assessment to commence within eyesight observation:

Absconding risk when there is a danger of harm to self or others.

Significant risk of physical violence.

Suicide risk and/or self-harm.

Vulnerability to exploitation and abuse by others.

Fire risk. Within eyesight observation can be carried out by a qualified nurse, a competent trained Band 2, Band 3/4 worker or a 3rd year Mental Health Branch Semester student nurse. On occasion more than one nurse may be necessary. When undertaking within eyesight observation the staff member must:

accompany the patient on the ward and remain within eyesight at all times;

be in sufficiently close proximity to react and intervene as necessary;

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review, develop and follow the care plan;

be attentive to physical as well as psychological needs;

document observation on the monitoring form and complete a progress notes in Carenotes. Care plans must provide clear and precise instructions in relation to shower and toilet arrangements. It is good practice to ask all patients if they prefer an observer of the same or different gender, as far as it is appropriate and staffing allows. In addition, ethnic, cultural and language differences need to be incorporated into the care plan. A copy of which should be given to the patient. 5.4 Within Arm’s Length Observation Within arm’s length observation is used when a patient is assessed as being an immediate danger to himself/herself or others. Within arm’s length observation is very intrusive and can be distressing to patients and stressful for staff. This is an intensive intervention and routinely requires assessment of staff safety and well-being. Staff should have regular breaks with planned rotation of within arm’s length observation duties. The following factors need to be considered when making an assessment to commence within arm’s length observation:

Severe suicide risk or serious impulse to self-harm.

Significant risk to other patients or staff safety. Within arm’s length observation can be carried out by a qualified nurse, Band 2, Band 3/4 worker or a 3rd year Mental Health Branch Semester student nurse who have been assessed by the Nurse in charge to have the required understanding and clinical competence required to undertake this role. On occasion more than one nurse may be necessary.

When undertaking within arm’s length observation staff must:

accompany the patient around the ward at all times and in all places;

ensure that the patient is always within arm’s length, as long as it is safe to do so;

work to the care plan;

be attentive to physical as well as psychological needs;

document observation on the monitoring form and complete a progress notes in Carenotes.

The care plan must have clear and precise instructions and there can be no deviations from the above, even in relation to bath, toilet and shower arrangements. A copy of the care plan must be given to the patient. The search policy is applied to ensure the patient does not have access to prohibited items.

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7. Changes in Levels of Observation and Recording All patients on either Within Eyesight or Within Arm’s Length observation must be reviewed at least every 12 hours to ensure that the observational level is appropriate to the patient’s needs and recorded on Carenotes. Levels of observation for all patients must be considered at the beginning of each shift. The decision will be based on a review of the current care plan outlining the need and use of enhanced observations. It is the responsibility of the shift co-ordinator on each shift to ensure that the observation level has been reviewed every 12 hours, as a minimum standard. A record of this review will be documented on Carenotes. The level of observation is initially reviewed 3 hours after commencement of within eye sight or within arm’s length observations, and on a shift by shift basis as a minimum standard thereafter. The review is undertaken during the shift to enable staffing planning. In the Acute Division it is recommended that the review is linked to the Red to Green meetings. Review is undertaken by the Ward Manager with Matron input during working hours, and by the Nurse in charge with support from the Duty Nurse when required after working hours. Reviews will include the medical assessment, current care plan and risk assessment. In the Acute Division, review of within eyesight or within arm’s length observations are reviewed by the Clinical Director when this exceeds four days continuous observation. Review requirements summary 7.1 Increasing Levels The decision to increase level of observation should be taken by the multidisciplinary team, where possible. However, where there is cause for concern a registered nurse may initiate or increase such levels. This action must be followed by a request to the ward doctor/duty doctor for a mental state examination to be made. On sites where there is out of hours phone contact with a doctor, the decision should be discussed as soon as possible over the telephone. 7.2 Decreasing or Discontinuing Levels

Time frame Responsibility Note

Within 3 hours of commencement Shift Coordinator

Each shift Shift coordinator and MDT, with support of senior staff

Occurs during the shift to enable staffing planning Linked to Red to Green Meeting (Acute Division)

After 72 Hours of continuous observation Matron Acute Division only

After 4 days of continuous observation Clinical Director Acute Division only

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All patients should be cared for in the least restrictive environments. Review of observation levels is undertaken as above and when safe and appropriate, observation is reduced or discontinued in line with least restrictive practice principles. All patients on increased level of observation (Intermittent, Within Eyesight or Within Arm’s Length) must have a documented plan recorded on Carenotes for decreasing or discontinuing levels of observation, which the medical and nursing teams have discussed and agreed.