DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Policies Review and Approval Group Date ratified: 4 June 2019 Name of originator/author: Admission and Discharge Policy Review Group Name of responsible committee/individual:

Clinical Policies Review and Approval Group

Unique Reference Number: 494 Date issued: 12 July 2019 Review date: June 2022 Target Audience Inpatient areas

Admission, Transfer and Discharge Policy

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CONTENTS

SECTION PAGE NO

1. INTRODUCTION 3

2. PURPOSE 3

3. SCOPE 4

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4

5. PROCEDURE/IMPLEMENTATION 6

6. RAISIING CONCERNS / FEEDBACK 11

7. PATIENT IDENTIFICATION 11

8. INFECTION CONTROL 12

9. MEDICINES MANAGEMENT ON ADMISSION 12

10. SMOKING STATUS 12

11. TRANSFER OF PATIENTS 12

12. DISCHARGE FROM HOSPITAL 14

13. DISCHARGE AGAINST MEDICAL ADVICE 16

14. RISK ASSESSMENT 19

15. MANAGEMENT OF A PATIENTS MEDICINES ON DISCHARGE / TRANSFER 20

16. TRAINING IMPLICATIONS 21

17. MONITORING ARRANGEMENTS 21

18. EQUALITY IMPACT ASSESMENT SCREENING 22

19. LINKS TO ANY ASSOCIATED DOCUMENTS 22

10. REFERENCES 23

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1. INTRODUCTION

Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) is a diverse organisation providing both physical and mental health services. The Trust recognises that admission, transfer and discharge from hospital should take place in a planned and structured way regardless of speciality. It should be equitable and patient centred, with patients, families and carers feeling well orientated and secure in their environment. Because discharge planning often begins at admission, these processes regularly require a multidisciplinary and multi-agency approach. For this reason, good communication is seen as essential in ensuring there is a seamless process where all involved, the patient and where possible and appropriate, their family or carers, feel they have received high quality care, risks are managed and they are able to contribute fully to the discharge process. The Trust recognises the contribution that effective discharge/transfer care planning makes to high quality service provision, continuity of care and the recovery journey. Hospital discharge may not be the point of discharge from care, but a transfer in the location of delivery of care.

2. PURPOSE The purpose of this policy is to: • Provide a unified admission, transfer and discharge process identifying

and outlining how the core components of effective practice are to be delivered across diverse services and geographical areas and to provide an overarching framework to support local Standard Operating Procedures (SOPs) and/or Procedural Documents.

• Ensure patients families and carers are directly involved with decisions and choices to be made about their care.

• To ensure discharge is planned at the earliest opportunity and considered from admission onwards.

• To support compliance with national and local guidance, ensuring all necessary health and social care needs are met.

The policy addresses aspects of orientation, assessment and discharge planning which can result in a safe and effective patient stay.

2.1 Definition A person is defined as an inpatient: a) When they are able to give valid consent b) Are formally admitted under the Mental Health Act (1983) (MHA) c) Admitted under a Best Interest Decision under the Mental Capacity

Act 2005 (MCA) and ensure the assessment and decision is evidenced in line with Trust MCA Policy.

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3. SCOPE This document will apply to all healthcare staff working in the Trust’s in-patient areas, including managers, nurses, doctors and allied health professionals or whichever professional first makes contact with the patient and initiates assessment of their needs. This includes when assessment begins prior to the actual admission to the hospital.

The Trust provides a diverse range of in-patient services as outlined below: • St John’s Hospice • Neuro Rehabilitation Services • Intermediate Care Services • Forensic Services • All Age Mental Health services • Drug and Alcohol Rehabilitation (New Beginnings) • Coral Lodge – Locked Rehabilitation Unit

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1 Board of Directors

The Board of Directors is responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for admission, transfer and discharge of patients.

4.2 Chief Executive The Board of Directors delegates to the Chief Executive the overall responsibility for effective risk management in the Trust, meeting all statutory requirements and adhering to guidance issued.

4.3 Care Group Directors and Associate Nurse Directors The Care Group Directors and Associate Nurse Directors are the designated leads with responsibility for the implementation of this policy and national and local guidance. • Disseminating, implementing and monitoring this policy and the local

standard operating procedure within their services • Facilitating collaborative working between in-patient and community

services in order to provide high quality patient care • Monitoring any trends, themes or concerns raised during the admission

process and taking action as appropriate to reduce or prevent risks and to improve the patient experience

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4.4 Lead Clinician Depending on the inpatient area the responsible person could be a Doctor, a nurse or an Allied Health Professional. It is their responsibility to ensure: • They are involved in the admission, discharge or transfer of the patient in

consultation with carer(s) and the multi-disciplinary team. • That admissions, transfer and discharges are carried out in line with the

relevant service’s Standard Operating Procedure or local procedural documents.

• That all required information is shared with appropriate healthcare

professionals i.e. GP as detailed in the local service SOP. As a minimum the following information must be shared:

• Medication • Patient Discharge Against Medical Advice • A copy of the Patient’s Discharge/Transfer Letter

• The Local Security Management Specialist (LSMS) is informed at the

earliest opportunity of the admission of a formal/informal active prisoner.

4.5 Ward Managers /Modern Matrons/Service Managers The Ward Manager/Service Manager is responsible for: • Informing the Local Security Management Specialist at the earliest

opportunity of the admission of a formal/informal active prisoner.

• Informing all staff through local induction of the Trust’s Admission, Discharge and Transfer Policy and relevant local procedures or standard operating procedures

• Recording and monitoring standards to ensure compliance with Trust

policy for Admission, Transfer and Discharge.

• Monitoring, recording and reporting delays in transfer of care as per agreed Trust process.

• Ensuring good communication between inpatient and community

agencies.

• Ensuring National and Local Guidance is adhered to.

4.6 Local Security Management Specialist (LSMS) Once notification by the lead clinician, ward manager/service manager or modern matron has been received the LSMS must attend that specific ward

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and liaise with the prison officers to carry out a joint risk assessment based on the prisoner’s history obtained from the Police to define responsibilities of staff during the patients’ care and continued detention. This will be reviewed at regular intervals.

4.7 All RDaSH Staff Staff who come into contact with patients are seen by doctors, nurses, allied health professionals, pharmacists, psychologists, bank staff and agency workers, students and volunteers. All are expected to ensure that each person coming into their care and their carers is treated with dignity and respect. Members of the multidisciplinary team including external agencies, the patient and their family or carers should be aware of and involved in the admission, transfer and discharge process in a timely manner. All clinical and non-clinical staff involved in the admission, discharge/transfer of a patient to and from Trust services, should ensure local and national guidance in relation to this are adhered to.

4.8 Care Coordinator (Mental Health) In line with the RDaSH Care Programme Approach policy, the Care Coordinator should stay involved throughout admission and support discharge planning. Where the Care Coordinator is not available, a deputy should be in place.

5. PROCEDURE/IMPLEMENTATION The procedural elements covered by this policy are generic to all inpatient areas and which any patient being admitted to an inpatient ward within the Trust should expect to receive them. Care Groups should use their accompanying local procedures or SOP’s relating to admission, transfer and discharge which will provide specific detail. This policy should be read in conjunction with: • Patient Identification Policy | RDaSH NHS Foundation Trust • Safe and Secure Handling of Medicines Policy • Infection Prevention and Control manual (as relevant) • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) Policy • Clinical Risk Assessment and Management Policy • Mental Capacity Act (2005) • Mental Capacity Act Policy • Mental Health Act (1983) (as relevant) • Care Programme Approach Policy

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• Deprivation of Liberty Policy and SOP

5.1 Admission

Admission to hospital can be a difficult time for both the patient and their carers and can bring on feelings of vulnerability. For this reason it is important that we make people feel safe and secure and that they feel that they have received personal and individualised care. In recognising the diversity of the organisation, there may be times when specific departments have separate admission arrangements. See below for guidance. All admissions should follow national and local procedures and Standard Operational Policies (SOP). Guidance in relation to additional admission arrangements:

*Coral Lodge, Amber Lodge and Jubilee Close – all admissions are agreed through NHS England commissioning arrangements.

*Emerald Lodge is a stand-alone unit. Patients should be admitted in a pre-planned and organised way with no out of hours admissions. All those being admitted should have an up to date risk and needs assessment reflecting appropriateness of the environment.

*St Johns Hospice – Patients will be triaged and assessed prior to admission and patient needs will be determined in line with policies and clinical judgement relating to patient need.

*New Beginnings – Admissions are elective and as such are organised in advance with the appropriate team.

5.2 Pre-Admission

Health and social care practitioners should explain to the person, and where relevant, their family and carers what type of care they might receive. Discussions may cover: • Place of care • Daily routines (including the use of medicines and equipment)

Any restrictions they may be subject to whilst on the ward. • Any known risks including safeguarding and any additional support

required. • Whether they may need an advocate to support them when

communicating their needs and preferences • Advance Statements or Advanced Decisions to refuse treatment in place. • What contingency plans may be required. • End‑of‑life care wishes Prior to a patient being admitted, ensure that where possible they understand the reason for admission and how long they may need to be in hospital.

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5.3 Assessing Patients and Admission to Hospital There are only 3 lawful ways in which an assessing clinician can admit a patient to hospital (without the intervention of the Courts) 1) Informally (the patient gives fully informed consent) 2) Under the Mental Capacity Act 2005 For those patients who lack the capacity to make the decision to be admitted to hospital, staff should on admission ensure that the principles of the Mental Capacity Act 2005 have been followed: • that an assessment of capacity has been undertaken and documented

and • that where the decision to admit the patient is made in the best interests

of the person, that there is a record of this 3) Under the Mental Health Act 1983 For those patients who are formally admitted to an Inpatient Ward under a section of the MHA 1983, staff must adhere to the requirements of the MHA 1983 and the MHA Code of Practice 2015.

5.4 Admission to Inpatient Area • Where a patient has been admitted under a Best Interest Decision (MCA

2005), consideration also whether the patient being deprived of their liberty and staff should consider making an Urgent Authorisation under the Deprivation of Liberty Safeguards (DoLS). See Deprivation of Liberty Policy for further information.

Patients should be provided with the name of the doctor under whom they have been admitted and a member of staff identified who will lead on their care. They should also be informed when they are likely to see the person who will be managing their care.

• Patients should be informed of what treatment they are likely to expect.

• Patients should be orientated to the ward environment including toilets, washing facilities and the nurse call system. An information pack should be provided which outlines ward routines including visiting times. See Visiting of Inpatient Areas Policy.

• Carers should also be provided with information relating to ward routines, who to speak to and visiting arrangements.

• Where applicable, if the patient does not have a current mental health Care Coordinator, the ward staff should take on this responsibility until a

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Care Coordinator is assigned. • Physical assessment and examination should be completed as per local

arrangements (Mental Health Inpatient Wards should refer to the Minimum Standards for the Physical Assessment and Examination of Inpatients in Mental Health and Learning Disability Services Policy for guidance)

• Appropriate means of patient identification should be utilised in Line with the Patient Identification Policy.

• Within 24-48 hours, establish and identify any particular needs to be addressed during their inpatient stay. (It is important to establish if the patient has any communication requirements or is involved with other services – where appropriate, these services should be contacted and informed of the plan and ward staff should request any support that may be required).

• The vulnerability of individual patients should be assessed, if required advice may be sought from the appropriate Trust’s Safeguarding Team (Adult or Children) and support be put in place.

• Patients whose first language is not English will be offered access to appropriate interpreting services as and when required to ensure that they are not disadvantaged.

• Staff should establish if the patient has an Advance Statements or Advanced Decisions to Refuse Treatment. See Advance Statements and Advance Decisions to Refuse Treatment Policy for further information.

• With consent from the patient, families, carers or other relevant people should be informed of the care plan.

• All events should be clearly documented in the electronic patient record in line with the Healthcare Record Keeping Policy

• Through the Medicines Reconciliation process, the patients General Practitioner should be informed of admission and medication checked.

• Initial assessments specific to each speciality will be completed as per local procedure.

• Staff should establish if the patient has any religion, culture and spirituality needs.

5.5 What a patient should expect during their stay in hospital During their stay in hospital patients should expect to have their privacy, dignity and confidentiality respected and to be treated in a holistic person centred manner. Interventions should be purposeful and carried out with the patients consent where possible or under an appropriate legal framework. Communication between the multidisciplinary team should take place in a timely way to

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ensure care is streamlined and in most cases, recovery focussed, with the aim being towards successful discharge. At the earliest opportunity, the admitting team should provide the patient and their family, carer or advocate with an opportunity to discuss their care. Consideration should also be given to identify whether there is a need for reasonable adjustments to be made to accommodate the patient in hospital. This is in line with the Equalities Act 2010. Examples include: Providing communication aids (this might include an interpreter) • Ensuring there is enough space around the bed for wheelchair users to

move from their bed to their chair

• Single sex accommodation

5.6 Exceptional Circumstances

5.6.1 Prisoners (not detained under the MHA) or those detained by the Police When a prisoner or person lawfully detained by the Police, UK Border Agency or national security services is admitted to an inpatient unit, (other than Forensic Services) then the Relevant Modern Matron/ Service Manager, Safety Team and Associate Nurse Director are to be informed as soon as reasonably practicable, preferably within one working day. A risk assessment is to be carried out in conjunction with the detaining authority (Prison, Police etc.) which includes the potential risk to others, specific risks to staff, the presence of detaining authority guards, the use of mechanical restraints, restricting access to areas other than the bed area/ room, and to ascertain the required action if the person attempts to leave the ward/ department. For mechanically restrained persons (prisoners in chains etc.), an agreement between the detaining authority and the ward/department on the use of restraints, including when they are used, is to be documented in the care record. Ideally the person will be accommodated in a single room rather than multiple occupancy room; this will reduce anxiety of other patients, improve privacy for the person and make security management easier. Seclusion is not to be used for this purpose unless the clinical presentation indicates that seclusion would be a viable clinical intervention. The detaining authority (if necessary their medical department) are to be included in all discharge planning prior to discharge to ensure suitable arrangements are made.

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5.6.2 Children admitted to inpatient wards There may be occasions where those under the age of 18 require admission to inpatient wards. The legal framework governing the admission to hospital and treatment of children and young people under the age of 18 is complex, and those responsible for their care in hospital should be familiar with the relevant legislation as outlined within the Mental Health Act 1983, Mental Health Act Code of Practice 2015, Children Act 1989 and the Mental Capacity Act 2005. Information in regard to this can be found in the Care and Treatment of Children under the age of 18 on Adult Acute Mental Health Inpatient Areas Policy.

6. RAISING CONCERNS/FEEDBACK Patients should be informed that if they wish to raise concerns or are unhappy with any aspect of their care, they may raise the matter with any member of staff. If required they should also be signposted towards an Independent advocate who can support them with any such concern. Patients should be provided with information about Patient Advice and Liaison Service (PALS) and the complaints procedure. Patients should be supported should they wish to make a formal complaint. Patients should have access to Your Opinion Counts forms to allow them to provide feedback. See Complaints Handling Policy and Patient Advice and Liaison Service (PALS) Policy for further information.

7. PATIENT IDENTIFICATION The National Reporting and Learning System (NRLS) has recognised that patient misidentification is a widespread problem within healthcare organisations. Failure to correctly identify patients constitutes a significant risk to the organisation and poses a serious risk to patient safety. In areas where wristbands are not worn the relevant Service Areas must have a photograph for validating a patient’s identity. For those patients who are unable to provide their own details due to their current health or mental capacity a care plan must be written detailing the way of validating their identity. For further information see the Patient Identification Policy.

8. INFECTION CONTROL The Infection Prevention and Control Team (IPCT) should be contacted for advice and support ideally prior to admission if it is suspected that the patient may have an infection or pose an infection risk to themselves or others. Where this is not possible, the following timescales should be adhered to as a maximum:

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• Those being cared for onwards providing primarily physical healthcare should ideally contact the IPCT within 24 hours.

• Those being cared for onwards providing primarily mental health care this

timescale is within 48 hours.

The Infection Prevention and Control Manual is available for further information. Ensure that this is fully documented within the electronic record.

9. MEDICINES MANAGEMENT ON ADMISSION All patients who are admitted must have their medicines reconciliation and allergy status completed and documented within 24 hours or as soon as access to the primary care record is available, in line with NICE guidance and The Safe and Secure Handling of Medicines Policy. Upon completion, this should be indicated in the electronic patient record. Staff should understand what the patient is prescribed and what they are taking including medication which may not be prescribed. Consideration should be given to reviewing medication and any changes should be clearly documented with a clear rationale provided. See Safe and Secure Managing of Medicines Policy for further information.

10. SMOKING STATUS Patients should be informed that RDaSH is a non-smoking Trust. Exceptions to this should involve appropriate parties such as LSMS and senior staff and should be risk assessed. Staff should assess and record smoking status. If the patient is a smoker, general health advice on health benefits of stopping smoking should be provided, arrange support to accomplish this. If patient does not wish to stop smoking, the patient should be informed of the Patient and Visitor Harm Reduction Smoke Free Policy. This intervention should be recorded in care notes.

11. TRANSFER OF PATIENTS During an episode of inpatient care, the need may arise to transfer (handover) a patient to another care setting either within or outside the Trust. All such transfers should be well planned so that there is minimal interruption to the patients care. Any transfer should be carried out with the patients consent or using the appropriate legal framework. Where appropriate, the patient, carers and any legal representatives must be given adequate and timely information as to why the transfer is taking place. There also needs to be good communication between the Trust and the receiving hospital/unit, with the relevant case records being shared in a secure manner and a formal documented handover of care between the Trust and the receiving service. • Clear discussion in relation to transfer should take place and involve the

patient and carers and members of the multidisciplinary team.

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• Utilising agreed local procedures, ascertain the need and level of escorts to enable transfer.

• For those people receiving mental health care, the principles of the Care Programme Approach should be considered in line with the CPA framework and the RDASH CPA Policy.

• Information relating to medication management should be provided. • Where the patient is transferring to another hospital for medical care,

ascertain which information is required and provide relevant information to those who will receive the patient so that care can be continuous.

• Consideration should also be given to requirements relating to essential medication and availability of this. Contingencies should be made to ensure medication is available.

• Where the patient is transferred to RDaSH services following medical care, staff should ensure that they are aware of the persons physical health needs and that they can be managed in the setting they are returning to. Where there is uncertainty, discussion should be had with senior members of the team.

• Where there is capacity to consent the person’s wishes should be respected.

• If the patient is unable to give consent, an assessment of the person’s mental capacity should take place. If they lack capacity a ‘Best Interests’ decision is made.

• Where a patient is detained under the MHA (1983), the correct procedures and documentation should be completed and arrangements made in terms of managing risk and vulnerability of the patient. (see 11.2)

• Where the patient is subject to DoLS, the ward staff will cancel any existing authorisations or withdraw request if not authorised. See DoLS Policy and SOP for further information.

• Where relevant, other members of the multidisciplinary team should be made aware of the patients transfer.

• For any patients with an existing Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) or RESPECT order, the order should be reviewed upon arrival at RDaSH services. Upon transfer outside services, the original form must be sent with the patient and handed over to the receiving service.

A detailed record is to be made in the patients clinical records of all aspects of patient transfer, this should include: • All information provided to the receiving service • The date on which it was provided • Any additional information requested prior to the transfer • Discussion with the patient and carers about the planned transfer Wherever possible any transfer of care is to take place during normal working hours of 9-5 as this will allow time for the receiving clinical team to orientate the patient to their new surroundings.

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Staff should refer to their local procedure or SOP’s for the discharge/transfer of patients.

11.1 Out of Hours Transfer There may be occasions when a patient needs to be transferred outside of the hours of 9-5, to another ward or hospital. On these occasions the patient should be provided with an appropriate escort in line with their identified needs to ensure that their transfer occurs in a seamless way. Staff should refer to their local procedures or Standard Operating Procedures for the transfer.

11.2 Transfer to acute medical care of a patient detained under the Mental Health Act (1983) There may be times when due to physical care needs, a patient detained under a section of the Mental Health Act (MHA) 1983 may require to receive treatment on a General Hospital ward which cannot be appropriately provided on an inpatient ward within the Trust. In these circumstances the patient will be granted section 17leave to allow them to attend the General Hospital ward for treatment. Wherever possible, except in emergency situations, such transfers should be planned and staff should ensure that the transfers are undertaken in a safe and consistent manner. See Procedure for the Care and Treatment of a Patient Detained Under the MHA 1983 to a General Hospital Under Section 17 for further information.

12. DISCHARGE FROM HOSPITAL Discharge Planning The British Red Cross (2019) recognise that coming home from hospital can be an emotional experience filled with apprehension about managing health and medications. The planning of a patient’s discharge is fundamental to the provision of high quality health and social care, the recovery process and the effective use of resources. For some people, being discharged from hospital can be daunting and only one part of the recovery process. To ensure recovery continues in the right way, it is essential that the appropriate package of care following discharge has been planned and prepared for. This discharge planning process should begin at admission in elective situations and within 72 hours of admission in all other cases. It is important to identify any factors that would make a patient’s discharge or transfer problematic so that action can be taken early and contingencies made, this could include such things as special equipment. Prior to any patient being discharged their aftercare needs will have been fully assessed and discussed with them. It may also be appropriate to discuss with their

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relatives as they may be the ones providing care along with other carers or services. Correct discharge planning may prevent further unnecessary hospital admission. A decision has been made that a patient is ready for discharge. This criterion is likely to be met when: • The patient does not have or require an ongoing valid legal framework for

hospital inpatient care and wishes to leave and the statutory criteria to detain under the MHA is not met.

• All interventions/care plans for the disease/disorder giving rise to the admission has been initiated.

• The Multidisciplinary Team has been consulted and it has been agreed that an inpatient stay is no longer required to meet the patient’s continuing health needs and

• Where the patient has been detained under the MHA (1983) the Responsible Clinician determines whether an inpatient stay is no longer required.

• All assessments relevant to the patient’s needs which are the responsibility of the clinical team (including Decision Support Tool (DST) if the patient is not entitled to Section 117 Aftercare) have been completed appropriately and reported to the relevant commissioner where appropriate.

• Consideration is given to the aftercare plan to ensure patient safety is optimised and there is an appropriate balance between managing risk and enabling the patient.

12.1 Local Standard Operating Procedures / Transfer Checklists

Inpatient clinical areas should utilise their Standard Operating Procedure or other Procedural Documents to ensure discharge takes place in a seamless and timely manner.

12.2 Discharge from hospital From admission, or earlier if possible, the lead clinician should ensure liaison with other agencies who provide and are responsible for ongoing patient care in order to identify and address factors that could prevent a safe, timely discharge. This could include such things as homelessness, safeguarding, lack of suitable community placements or appropriate care plan. Once it has been agreed that the patient is medically and/or psychiatrically stable and has ready to be discharged from hospital, the discharge plan should be communicated to both the patient and those who will be providing care to the patient upon discharge, including the general practitioner. Any such information should consider risk, the appropriate legal framework such as MHA (1983) or MCA, the person's social and emotional wellbeing, as well as areas relating to daily living including: • Details about the condition

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• Information about medicines • Contact information after discharge • Arrangements for any continuing support • Details of other useful community and voluntary services. Where relevant, key practitioners should discuss with patients how they can manage their condition after their discharge. Consideration should be given providing any support and education, to both patient and carers. Where a package of care and a change of accommodation is being proposed to meet the patients care needs this can only be done: • With the patients consent • Where the patient lacks capacity, under a Best interest Decision (MCA

2005) • Under the legal framework of the Mental Health Act • A decision of the court

12.3 Discharge planning and end of life care needs Patients needing end‑of‑life care should be offered both general and specialist palliative care services, according to their needs and pathway. Patients who have end‑of‑life care needs are assessed and where appropriate, support is put in place so they can die in their preferred place. This should take into account any Advanced Statements/Advanced Decisions in place.

12.4 Other key considerations when planning discharge/transfer: • How the patient will get home • Requirements for the patient under the Mental Health Act (1983)

including Section 117 eligibility and aftercare arrangements. • 7 day follow up or DST and arrangements around who will facilitate this. • Accommodation (including consideration of the discharge of vulnerable

people from health or social care settings to a warm home) • Return of patient’s property • Medical certificates • Outpatient appointments/community follow up • Discharge summary/letter • DNACPR status or RESPECT • Information to be given to the receiving healthcare professional • Out of hours discharge process • Procedures for the management of delayed discharge • Cost of transferring a patient to another part of the country

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• Funding for any on-going care or services

13. DISCHARGE AGAINST MEDICAL ADVICE Should a patient request discharge against medical advice the following process should be followed: 1. A senior member of the nursing team should discuss this issue with the

patient and try to elicit their rationale for leaving, at the same time ascertaining the patient’s capacity to make the decision.

2. Where the person does have capacity, staff should utilise their local procedure for supporting an appropriate discharge. Staff have no power to make them stay unless they believe that the patient is suffering from a mental disorder, in which case the provisions of the Mental Health Act may be applied.

3. If the clinician believes that there is any question about the patients’

capacity to make this decision then they must undertake a full mental capacity assessment and document in line with the MCA policy. If the patient is found to lack capacity to make an informed decision regarding remaining in hospital then medical opinion should be sought.

4. The doctor should consider whether it is in the patient’s best interest to

remain in hospital. If this is the case then this is likely to lead to the patient being deprived of their liberty and staff should consider making an Urgent Authorisation under the Deprivation of Liberty Safeguards.

In all cases a full record of the assessment (including MCA) and any discussions must be documented in the patient’s records.

13.1 Where a patient lacks capacity Where staff are concerned that a patient lacks the capacity to make an informed decision with regards to remaining in hospital (and they do not meet the criteria for detention under the MHA 1983) a full assessment of their capacity in relation to this decision should be undertaken and documented as detailed in the Mental Capacity Act Policy. If the assessment concludes that the patient lacks capacity and the patient is still determined that they wish to leave, staff should consider making an Urgent Authorisation under the Deprivation of Liberty Safeguards which will provide authorisation to deprive the patient of their liberty for 7 days whilst the Supervisory Body process the request for a Standard Authorisation under the Deprivation of Liberty Safeguards. In circumstances where a patient has been admitted to a mental health/learning disability ward informally, and they subsequently express the wish to discharge themselves against medical advice, staff should consider the use of either section 5(2) or 5(4) (MHA ’83) to enable a full assessment

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under the MHA to take place. NB - Where a patient is expressing an objection to being in hospital for mental health treatment either verbal or non-verbal, DoLS is not applicable.

13.2 Patients who refuse discharge If a patient is refusing to be discharged and is not eligible for a review under the Continuing Health Care criteria, this must be discussed in the correct forum and with the patient and/or their carer where appropriate. Consideration must be given to each individual case, as whilst the purpose of the service is to support recovery the patient does not have the right to occupy an NHS bed indefinitely. The Service Manager/Matron must be informed and a multi-disciplinary review held to agree an appropriate strategy for discharge. Staff should refer to their local procedures or Standard Operating Procedures for the discharge/transfer of patients.

13.3 Discharge of a patient by their nearest relative Under the Mental Health Act (MHA) 1983, the nearest relative of a patient (as defined in Section 26 MHA 1983) or an acting nearest relative appointed by a county court (under Section 29 MHA 1983) has the right to request the patient’s discharge if they are detained for assessment or treatment under Part 2 of the MHA 1983 (i.e. Section 2, 3, Guardianship or a Community Treatment Order. See Discharge of a patient by their nearest relative procedure.

13.4 Discharge of patients who have no accommodation Wherever possible suitable accommodation should be considered and secured prior to a patient being discharged and all agencies should be explored. However, should this not be possible for any reason, the patient should be provided with appropriate advice and signposting to Local Authority Housing Departments or any local organisations who are known to provide housing advice. Staff should take into consideration what agencies will be available to the patient upon discharge and plan accordingly. Staff should also consider contacting the Safeguarding team for advice if they feel the person is vulnerable.

13.5 Delayed Discharges Information regarding delayed transfer of care (commonly referred to as delayed discharge) must be reported by all Trusts to identify patients who are in hospital beyond a time when it is clinically necessary for reasons of safety, level of need or treatment. A delayed transfer of care occurs when a patient is ready to leave hospital and is still occupying a bed. A patient is considered ready for transfer when ALL of the following criteria are met:

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• A clinical decision has been made that a patient is ready for discharge. • A Multi-Disciplinary Team (MDT) decision has been made that the patient

is ready for discharge. • The patient is safe to discharge. MDT in this context includes nursing and other health and social care professionals. It is acknowledged that circumstances surrounding discharge will vary and the MDT should consider the individual circumstances of the patient when determining if the discharge is delayed. This determination should consider the following factors against each of the criteria. There should be daily reporting of delayed discharges at ward level and delayed discharges can also be presented at the local ‘surge and escalation’ meetings which highlight issues Trust wide. Delayed Transfer of Care (DToC) information should also be shared within the local governance process providing information relating to current delays and the reason for the delay.

14. RISK ASSESSMENT Risk assessment is a continuous process and a formal assessment of risk must be completed and documented:- • At the point of referral • At each subsequent review of all patients • When prompted by a change of circumstances such as admission,

discharge, transfer between services, shared care, personal circumstances etc.

The Trust’s Clinical Risk Assessment and Management Policy provides a framework for the implementation of this policy and details procedural guidance which will not be duplicated here. Information to be given to the patient who is consenting, when they are discharged / transferred The provision of information should be used to support face to face communication and not replace it. Clear communication and collaboration is essential to an effective discharge/transfer planning process and the named nurse/care co-ordinator will provide the patient and their carers with: • A copy of the GP discharge summary of their care plan containing the

discharge/transfer/follow up information, which must be completed by medical staff/members of the multi-disciplinary team. More detailed follow up discharge summary may follow as per local procedure.

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• Information about the return of a patient’s property, medical certificate, outpatient appointments etc.

• A copy of any relevant information leaflets

• Contact numbers in case of an emergency (crisis)/for advice, including

out of hours contact numbers • Any necessary instruction/training in relation to any specific

medication/equipment required • The original DNACPR/RESPECT order should be given to the

patient/carer and/or the receiving service. Staff should ensure that where appropriate the patient/carer is aware of and fully understands the order.

NB: For patients or carers whose first language is not English or where there are other barriers to communication the information is to be given in a suitable format such as verbally via an interpreter, easy read documents or via a signer (for deaf patients).

15. MANAGEMENT OF A PATIENTS MEDICINES ON DISCHARGE / TRANSFER For patients who require medication on discharge, arrangements will be made by the Named Nurse or identified Healthcare Professional up to 24 hours in advance to obtain that medication in accordance with local standard operating procedures for the discharge/transfer and the Safe and Secure Management of Medicines Policy. The rationale for any changes to medication should be communicated to relevant parties including the patients General Practitioner. This should also convey when review is required, any ongoing monitoring needs and how long they are likely to be taking the medication. Any new and existing allergies should also be included in discharge communication. Information should be provided to the patient and relevant clinicians in regards to any additional monitoring required, for example the next date that a blood sample should be taken for Lithium monitoring or the date of their next injection. Patients and/or carers must be made aware of their medication management on discharge.

16. TRAINING IMPLICATIONS

Team meetings Practice Development Days One to one meetings / Supervision Local Induction Posters CPD sessions

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17. MONITORING ARRANGEMENTS

Area for Monitoring

How

Who by

Reported to

Frequency

Admission/ Discharge experience

Complaints Patient Safety and Investigations Team

Care Groups

Bi monthly

Admission/ Discharge experience

Your Opinion Counts Forms

Service Managers

Care Groups Governance Groups

Monthly.

Staff compliance with policy

Monitoring of admission documentation via management/ clinical supervision.

Ward Managers/ Service Managers

Service Managers escalated if required to Associate Nurse Directors.

Minimum bi monthly.

18. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this Policy’s webpage on the RDaSH Policy Library/Archive.

18.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be met No issues have been identified in relation to this policy.

18.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making

Indicate How This Will Be Achieved.

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process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

19. ASSOCIATED DOCUMENTS

• Infection Prevention and Control Policy • Mental Capacity Act 2005 Policy • Mental Health Act (1983) • Deprivation of Liberty Safeguards Policy • Advance Statements and Advance Decisions Policy • Patient Identification Policy • The Provision of Access to and use of Interpreter for Patients/Service Users

and Carers • Trust Smoke Free Policy • Safe and Secure Handling of Medicines Policy

20. REFERENCES Home to the Unknown – Getting hospital discharge right (2019) British Red Cross NICE Guidance Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (NG5) NICE Guidance (2015): Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NG27)