document title seclusion policy · 2017-01-11 · ntw(c)10 – seclusion policy – v04.3 –...

Document Title Seclusion Policy

Reference Number NTW(C)10

Lead Officer

Executive Director of Nursing and Operations

Author(s) (name and designation)

Robin Green Directorate Manager Inpatient Care

Allison Armstrong Service Manager Community Services

Dennis Davison

Service Manager, Forensic Services Nina Detlif

Ward Manager, Children and Young Peoples' Services

Ratified by Trust Policy Group

Date ratified October 2015

Implementation Date January 2016

Date of full implementation

January 2016

Review Date January 2019

Version Number V04.3

Review and Amendment

Log

Version Type of change

Date Description of change

V04 Update Jan 16 Updates re: MHA-Code of Practice; within Sections: 3-7, 9, 12-13, 16-17, 19, 22-23

V04.1 Update Feb 16 Inclusion of SP-PGN-02 – Long Term Segregation

V04.2 Update Apr 16 Updates within Sections,4, 5, 7, 9, 15-16, 19 and 22

V04.3 Update Jul 16 Inclusion of SP-PGN-03 – Music in Seclusion

This policy supersedes the following document

Reference Number Title

NTW(C)10 – V04.2 Seclusion Policy

Seclusion Policy

Section Contents Page No:

1 Introduction 1

2 Purpose 1

3 Duties and Responsibilities 1

4 Definition of Terms used 2

5 Principles 3

6 Working with Patients 5

7 Procedure, recording, and monitoring for seclusion 7

8 Access and Egress of Seclusion Room 8

9 Review of seclusion 9

10 Discontinuation of seclusion 11

11 Room Used for Seclusion 11

12 Rapid Tranquillisation and Seclusion 12

13 During the Night 12

14 Training 13

15 Audit, Monitoring and Review 14

16 Human Rights Issues 15

17 Identification of Stakeholders 16

18 Equality impact assessment 16

19 Implementation 17

20 Standards / Key Performance Indicators 17

21 Fair Blame 17

22 Associated documentation 17

23 References 18

Standard Appendices – attached to policy

Appendix A Equality and Diversity Assessment Tool 19

Appendix B Communication and Training Checklist and Training Needs Analysis

21

Appendix C Audit and Monitoring Tool 24

Appendix D Policy Notification Record Sheet - click here

Seclusion Policy

http://nww1.ntw.nhs.uk/services/?id=2550&p=2780&sp=1

Appendices - listed separate to policy

Number Description Issue Date Issued Review

date

Appendix 1 Seclusion Record 1 Jan 16 Jan 19

Appendix 2 Seclusion Care Plan 1 Jan 16 Jan 19

Appendix 3 Seclusion Review and flowchart

2 April 16 Jan 19

Appendix 4 Seclusion Sites 3 Sept 16 Jan 19

Appendix 5 Seclusion Accommodation – Gold Standards

1 Jan 16 Jan 19

Appendix 6 Seclusion Training (Power point)

2 April 16 Jan 19

Appendix 7 Seclusion Audit Tool 1 Jan 16 Jan 19

Appendix 8 Seclusion Key Card 2 April 16 Jan 19

Practice Guidance Note – listed separate to policy

PGN Number Description Issue Date Issued

Review Date

SP-PGN-01 Seclusion Room Cleaning PGN

1 Feb 15 Feb 18

Appendix 1 Rapid Clean 1 Feb 15 Feb 18

Appendix 2 Seclusion Room Log Sheet 1 Feb 15 Feb 18

Appendix 3 Seclusion Room Cleanliness Checklist

1 Feb 15 Feb 18

SP-PGN-02 Long Term Segregation PGN

3 Nov 16 Apr 17

Appendix A Initial Record of Long Terms Segregation (LTS)

1 Jun 16 Apr 17

Appendix B Recording start-end of LTS 1 Jun 16 Apr 17

Appendix C Review of LTS 1 Jun 16 Apr 17

Appendix D Observation of LTS 1 Jun 16 Apr 17

Appendix E Audit Documentation 1 Jun 16 Apr 17

Appendix F Flowchart – Determining LTS 1 Jun 16 Apr 17

SP-PGN-03 Music in Seclusion 1 Jul 16 Jul 19

http://nww1.ntw.nhs.uk/spider/services/files/1408457982NTW(C)10%20-%20App1-RecordOfSeclusion-Issue3-Jul14.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1408529700NTW(C)10%20-%20App2%20-%20SeclusionCarePlan-Issue2-Jul14.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1408530064NTW(C)10-App3%20-%20SeclusionRev-Flowchart-Issue2-Jul14.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1421318045NTW(C)10-App4%20-%20SeclusionSites-Issue3-Jan15.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1408530195NTW(C)10%20-%20App5%20-%20Seclusion%20Review-V03-correct.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1408530336NTW(C)10-App6%20-%20Seclusion%20Training%20-%20Issue3-Jul14.pdf

http://nww1.ntw.nhs.uk/spider/services/files/1403606998NTW(C)10%20-%20App7%20-%20Audit%20Tool%20-Issue%202%20-%20Jul%2014.doc

NTW(C)10

Northumberland, Tyne and Wear NHS Foundation Trust NTW(C)10 – Seclusion Policy – V04.3 – Updated index – IssNov16

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1 INTRODUCTION 1.1 Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW) is

committed to promoting the welfare and well being of patients and staff. As a part of this there is often a requirement to balance the need for patient and staff safety against the need to ensure maximum freedom of movement for patients. This in turn places a duty on the Trust to establish clear policies to govern the practice of seclusion within clinical areas.

1.2 This policy has been developed and should be read in conjunction with the

Mental Health Act (MHA) Code of Practice1 and National Institute for Health and Care Excellence (NICE) Guidance Clinical, Guideline 25, Violence: the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments2.

2 PURPOSE 2.1 This policy aims to:

Provide guidance when seclusion is used.

Identify the frequency and duration of seclusion and minimise any possible anti-therapeutic effects of seclusion.

Ensure patient care is safe and effective during seclusion. 3 DUTIES AND RESPONSIBILITIES 3.1 The Chief Executive has overall responsibility for health and safety within

Northumberland, Tyne and Wear NHS Foundation Trust. 3.2 Group Directors will have responsibility for : 3.2.1 Identifying risks and ensuring appropriate action is taken thereby reducing

risks.

3.2.2 Arranging training and information to an appropriate level for all staff in the recognition, prevention and management of aggression and violence.

3.2.3 Identification of specialised training needs, including Prevention and Management of Violence Aggression (PMVA), Search Training, Seclusion Awareness Training, Rapid Tranquillisation Training, Observation Training and Immediate Life Support Training.

1 Mental Health Act Code of Practice – Department of Health 2015

2 Violence: the short-term management of disturbed/violent behaviour in psychiatric inpatient settings

and emergency departments; NICE 2005

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3.2.4 Ensuring the reporting is in line with the Trust’s policy, NTW(O)05 - Incident, including serious untoward incidents), recording; investigation and improvement actions of all incidents of seclusion.

3.2.5 Ensuring a culture is adopted in which staff are supported in terms of desired

outcomes following any incident (e.g. Staff Side representation, post incident support, prosecutions or temporary re-deployment).

3.2.6 Continuous monitoring of all aspects of the above safety system. 3.3 Clinical staff must familiarise themselves with the seclusion policy and act in accordance with the stated requirements. 3.4 Ward managers are responsible for ensuring all staff are aware that the seclusion room is to be kept in good working order in readiness for use; necessary documentation is completed, staff are adequately trained and employ the use of post incident support/incident review. 3.5 Clinical staff can seek advice from the Positive and Safe Steering Group,

PMVA Team and the Training Department regarding specific patient care plans, and techniques regarding transfer to seclusion, etc

4. DEFINITION OF TERMS USED 4.1 “Seclusion refers to the supervised confinement and isolation of a patient,

away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.

4.1.1 If a patient is confined in any way that meets the definition above, even if they have agreed to or requested such confinement, they have been secluded and the use of any local or alternative terms (such as ‘therapeutic isolation’) or the conditions of the immediate environment do not change the fact that the

patient has been secluded.”3 4.2 Other terms which are associated with managing violence and aggression are

clarified below.

4.2.1 De-escalation – reduction in intensity of a conflict (within the clinical setting) (see 4.2.2, 10.5.1, 11.2.1).

4.2.2 De-escalation room/area – area available adjacent to a seclusion room for use during the episode of seclusion including time spent as part of compliance testing or as part of the de-escalation plan after seclusion has been initiated. (See 4.2.3, 10.5.1, 11.2.1).

4.2.3 Prolonged period of seclusion: an episode of seclusion which is in excess of 48 hours.

3 Mental Health Code of Practice, Department of Health 2015, paragraphs 26.103 and 26.104

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4.2.4 “Long-term segregation refers to a situation where, in order to reduce a sustained risk of harm posed by the patient to others, which is a constant feature of their presentation, a multi-disciplinary review and a representative from the responsible commissioning authority determines that a patient should not be allowed to mix freely with other patients on the ward or unit on a long-term basis. In such cases, it should have been determined that the risk of harm to others would not be ameliorated by a short period of seclusion combined with any other form of treatment. The clinical judgement is that, if the patient were allowed to mix freely in the general ward environment, other patients or staff would continue to be exposed to a high likelihood of serious injury or harm over a prolonged period of time. Where consideration is being given to long-term segregation, wherever appropriate, the views of the person’s family and carers should be elicited and taken into account. The multi-disciplinary review should include an IMHA in cases where a patient has one. “4 (See practice guidance note (PGN), SP-PGN-02 - Long-term Segregation, which sits with this policy)

5. PRINCIPLES

Seclusion should only be used where de-escalation measures alone have proved insufficient

5.1 Where possible when determining if seclusion is necessary, the following factors should be taken into account, clinical need, safety of patient and others, and, where possible, Advance Statements and agreed care plans. Seclusion must be a reasonable and proportionate response to the risk posed by the patient. Consideration should be given to using Seclusion and/or Rapid tranquillisation as alternatives to prolonged physical intervention as identified in each individuals care plan, as indicated by individual risk assessment.

5.2 Seclusion should not be used;

5.2.1 As a punishment or threat

5.2.2 As part of a treatment programme (See Section16.3)

5.2.3 Because of shortage of staff

5.2.4 Where there is a risk of suicide or serious self-harm or as the sole management of serious self harm

5.2.5 As sole management for violent or aggressive behaviour

5.3 The decision to use seclusion can be made in the first instance by a doctor, a suitably qualified approved clinician or the professional in charge of the ward. Where the decision to seclude is made by an approved clinician who is not a doctor or by the professional in charge of the ward, the medical approved clinician involved with the care of the patient or the duty doctor (or equivalent) will attend to complete the first medical review within one hour of the beginning of seclusion. If the patient is new to the service or there are concerns regarding the patient’s physical presentation then the first medical review must be undertaken without delay. Any problems in securing attendance (or if they don’t attend at all) should be forwarded to the Service Manager in accordance with the Trust Incident Reporting Procedure, see the Trust’s NTW(O)05 – Incident Reporting Policy and PGNs.

4 Mental Health Code of Practice, Department of Health 2015, paragraph 26.150

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5.4 Where the decision to seclude is taken by the Psychiatrist the first medical

review will be the review they took immediately before authorising seclusion; a medical review within the hour will not be necessary in this instance.

5.5 Where seclusion is so short that the medical approved clinician involved with

the care of the patient or duty doctor (or equivalent) does not visit before seclusion has ended then this must be written onto the Seclusion Record.

5.6 Seclusion will be for the shortest time possible and will be reviewed at least

every two hours. The patient will be made aware that reviews will take place at least every two hours, as detailed in the seclusion register.

5.7 An initial multi-disciplinary review of the need for seclusion will be carried out

as soon as practicable after the seclusion begins. If the patient is secluded for more than 8 hours consecutively, or, 12 hours over a period of 48 hours, then there will be a further independent multidisciplinary review by professionals who were not involved in the incident that lead to the seclusion (See Section 9).

5.8 The bedding allowed to be used during seclusion will be tear resistant

seclusion blankets. Under no circumstances should other bedding such as sheets or pillows be used during an episode of seclusion. The only mattress allowed to be used will be a tear resistant, foam filled mattress with an integral pillow.

5.8.1 Only vandal resistant/tamper proof furniture (if required during long term

seclusion, e.g. chair) is allowed to be used during an episode of seclusion within the seclusion room.

5.8.2 Urine bottles and bedpans will be available where the risk assessment does

not allow access to en-suite facilities or where these facilities are not integral to the seclusion suite.

5.9 A patient’s clothes will only be removed when they are secluded if it is felt

that this may compromise their safety and the safety of others, based on risk assessment. Alternative seclusion clothing must be anti-tear (available from Patient Safety), and will be considered only on an individual patient basis. A clinical judgement will be made concerning what clothing or other items the patient is able to keep during the episode of seclusion.

5.10 Each area must assess the required amount of seclusion clothing required

based on risk assessment and frequency of seclusion episodes. 5.11 Seclusion Clothing used must be kept solely for this purpose and if to be

reused it should be laundered via the Trust laundry after each use. If the clothing is soiled, bloody or from a patient with an infection the seclusion clothing should still be sent to the Trust laundry in a red bag as per laundry policy and not destroyed.

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5.12 A patient in seclusion will be allowed to keep personal items of religious or

cultural significance (such as items of jewellery) as long as they do not compromise their safety or the safety of others. But where clothes/jewellery need to be removed this is done so by staff members of same sex as the patient, where possible and in a manner which preserves dignity and maintains safety. This may be pre-planned in terms of PMVA team approach and should be addressed in the care plan and consideration to entry and egress should be taken (See Section 8).

5.13 If new seclusion blankets and mattresses are required they must be ordered via the Patient Safety Department.

5.14 Female patients should not be secluded in a male only ward/villa and a male patient should not be secluded in a female ward/villa. Only in exceptional/emergency circumstances seclusion on a different sex ward may be authorised by a Director. The discussion must be clearly documented in the patient’s record. Where a patient is secluded on another ward, a discussion should take place between the nurse in charge of both wards and Ward Managers or on-call equivalent to ensure that the seclusion facility is available, and consideration should be given to how the patient will be taken to seclusion. Where possible, the involvement of PMVA Trainers should be sought.

5.15 In those service areas that provide mixed gender Wards, and have seclusion

facilities, a Delivering Single Sex Accommodation (DSSA) local Ward protocol should be in place. These local protocols will be established to ensure that the privacy and dignity of all patients is upheld at all times (See the Trust’s policy, NTW(C)40 - Dignity In Care). Specific reference should be made, within the DSSA local protocol, that establishes good practice in regards to maintaining patient’s privacy and dignity when using such seclusion facilities. The use of DSSA protocols, on mixed gender wards, in regards to the use of seclusion will be routinely reviewed via the Ward’s Risk Register review process

5.16 Seclusion should only be used in hospitals and in relation to patients detained

under the Act. If an emergency situation arises involving an informal patient and, as a last resort, seclusion is necessary to prevent harm to others, then an assessment for an emergency application for detention under the Act should be undertaken immediately.

6. WORKING WITH PATIENTS 6.1 Patients should be given the opportunity to become involved in their treatment,

including the short term management of disturbed/violent behaviour. A risk assessment should be completed to identify those people at risk of disturbed/violent behaviour.

6.2 Where possible an advanced statement will be developed and incorporated

into the care plan which may reflect a service user’s preference for seclusion rather than restraint or medication following an assessment of mental capacity.

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6.3 The patient will be treated with dignity and respect at all times. 6.4 The reasons for using seclusion must be explained to the patient at the

earliest opportunity. 6.5 A record of the seclusion care plan is referenced within documentation

(Appendix 1 – Record of Seclusion) 6.6 An individualised seclusion care plan will be devised on the Health Care

Record at the point of initiation of seclusion. This care plan must be reviewed at each use of seclusion and re-assessed at each Review of Seclusion to ensure that it continues to meet all identified needs. Appendix 2 is the minimum care plan principles which must be reviewed and added to as appropriate at each seclusion episode/review. The patient will be helped to re-integrate into the ward milieu at the earliest safe opportunity; this will be reflected in the care plan to ensure reintegration is effective and monitored. In view of the potentially traumatising effect of seclusion, care plans should provide details of the support that will be provided when the seclusion comes to an end.

6.7 The patient’s views on the incident of use of seclusion should be used to

identify alternative ways of promoting de-escalation and managing their disturbed behaviour. Collecting patient’s views will reflect their individual communication needs for example documentation of a verbal account or facilitated using talking mats/symbols etc. this may form part of a post incident support scenario. These views will be integrated into an individualised seclusion care plan by the nursing team and will be filed in the patient record or stored electronically.

6.8 In order to ensure that seclusion measures have a minimal impact on a

patient’s autonomy, seclusion should be applied flexibly and in the least restrictive manner possible, considering the patient’s circumstances. Where seclusion is used for prolonged periods then, subject to suitable risk assessments, flexibility may include allowing patients to receive visitors, facilitating brief periods of access to secure outside areas or allowing meals to be taken in general areas of the ward. The possibility of facilitating such flexibility should be considered during any review of the ongoing need for seclusion. Particularly with prolonged seclusion, it can be difficult to judge when the need for seclusion has ended. This flexibility can provide a means of evaluating the patient’s mood and degree of agitation under a lesser degree of restriction, without terminating the seclusion episode

6.9 Where it has been agreed in the care plan that family members will be notified

of significant behavioural disturbances and the use of restrictive interventions, this should take place as agreed in the plan

6.10 If the patient has an IMHA, they should also be notified of the seclusion and

be given the opportunity to participate in reviews (See Section 9.6.1)

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7. PROCEDURE, RECORDING, MONITORING FOR SECLUSION 7.1 The decision to use seclusion can be made in the first instance by a doctor, a

suitably qualified approved clinician or the professional in charge of the ward. 7.2 Where the decision to seclude is made by an approved clinician who is not a

doctor or by the professional in charge of the ward, the medical approved clinician involved with the care of the patient or duty doctor (or equivalent) will be notified at once and should attend in accordance with paragraph 5.3 of the policy unless the seclusion is only for a very brief period (no more than 30 minutes).

7.3 During the hours 0900 - 1700, the ward must inform the Clinical Nurse

Manager (CNM) when a patient has been secluded, as soon as is practicable. The CNM will make arrangements to attend the seclusion or agree to delegate to the ward manager / point of contact / duty (cover) manager.

7.4 Out of hours 1700 - 0900, the ward must inform the identified Point of Contact

for the locality or Night Coordinator after 20.30 when a patient has been secluded, as soon as is practicable. The Service Manager/Directorate Manager on call should only be contacted in exceptional circumstances. The Point of Contact will make arrangements to attend the seclusion initiation (and reviews). In exceptional circumstances (dependant on locality), it may be necessary to agree to delegate this responsibility to another nurse e.g. Band 6/7 on site the reasons for this should be recorded on seclusion documentation.

7.5 It is mandatory that a patient be monitored by constant eyesight observations.

In some areas there is non-recordable CCTV. If clinically indicated as being in the best interest of the patient then observations may be temporarily completed by appropriately trained staff viewing the CCTV monitor within the seclusion lobby. This must be agreed as being in the patient’s best interest and reflected in the Care Plan stating the reason why observations would be via the CCTV monitor, duration and patient presentation / risk factors deeming this appropriate. Staff will not leave their observation duties until a replacement member of staff arrives to take over the observation of a patient. It is the responsibility of those observing the patient to ensure that continuous observations take place during handover.

7.6 A documented report must be made at least every 15 minutes or more

frequently if required subject to the patient’s presentation. 7.7 The appropriately trained individual (see 14) will monitor and record the

condition and behaviour of the patient and take accurate up to date records of behaviour, compliance, communication and interactions and any change to these; and a record of physical observations (cross reference with the Trust’s NTW(C)02 Management of Rapid Tranquillisation Policy). Where a patient appears to be asleep in seclusion, the person observing the patient should be alert to and assess the level of consciousness and respirations of the patient as appropriate. Any professional taking over responsibility for observing a patient in seclusion should have a full handover, including details of the incident that resulted in the need for seclusion and subsequent reviews.

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7.8 A detailed contemporaneous indelible record of seclusion will be made on the seclusion record (Appendix 1 – Record of Seclusion), see Section 15.1. A step by step account of seclusion should be made including the rationale for the episode of seclusion.

7.8.1 The green (top copy) to be filed in the patient record in the electronic support

file (purple file) together with the green copy of the corresponding observation and review of seclusion records; middle copy to be forwarded to the relevant Service Manager; the bottom copy to be forwarded to Patient Safety Department.

7.9 When seclusion has ended, signatures from ward manager (or deputy ward

manager), CNM and RC should be sought as soon as possible on the next working day. Any problems in obtaining signatures must be raised through the service manager.

7.10 Staff must only use centrally provided seclusion documentation forms when

recording seclusion information.

Under no circumstances should this documentation be downloaded from the intranet

7.11 Record of Seclusion books are classed as controlled stationary and each form

therefore has a unique number. It is vitally important that staff using continuation books accurately transfer the unique number from the seclusion form to all related paperwork (record of observations, record of review etc).

7.12 Record of Seclusion, Review of Seclusion and Seclusion Record of

Observation books can be obtained from the Patient Safety Department, St Nicholas Hospital. These documents are controlled stationary and as such have a unique number and logging system which will identity the ward area which has been given each book and each seclusion episode contained within that book.

8. ACCESS AND EGRESS OF SECLUSION ROOM 8.1 It will be necessary for staff to safely enter and exit the seclusion

room, either as:

a planned occasion

or

unplanned occasion

8.2 Planned occasions include such events as review of seclusion (see 9), to administer medications, offer food and drink, personal hygiene etc.

Unplanned occasions include response to the patient’s observed clinical presentation (See Sections 7.5, 7.6, 7.7), response to rapid tranquillisation (See Sections 12.1.1, 12.1.2), physical wellbeing and any risk to the patient's health, safety and well-being.

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8.3 In the event that a patient's head becomes covered, staff must enter the seclusion room immediately or at the earliest and safest opportunity. Such a scenario should be treated as an emergency and staff should call for urgent assistance from colleagues if necessary. 8.4 In the event of any identified risk to the patient, the seclusion room must be entered at the earliest and safest opportunity taking into account any risk to the staff. 8.5 Adequate call facilities should be available to staff observing a patient in these circumstances i.e. to summon support from other staff immediately as and when required (See Section 12.1.2). 8.6 Additional resources may be needed if the risk posed by the patient is greater than the current staff in situ. Whilst waiting for assistance, the continuous observation and engagement of the patient must continue to enable a full assessment of the presenting risks.

8.7 Seclusion room entry and egress are techniques which are covered in Prevention and Management of Violence and Aggression (PMVA) Training. The application of these techniques must be considered and prepared prior to entry of the seclusion room. 9. REVIEW OF SECLUSION 9.1 The findings of the monitoring of seclusion and the presenting clinical risk will

determine the need for seclusion to continue and must be considered in the review of seclusion. The following process must be followed:

9.2 An initial multi-disciplinary review of the need for seclusion should be carried out as soon as practicable after the seclusion begins. If it is concluded that seclusion needs to continue, the review should establish the individual care needs of the patient while they are in seclusion and the steps that should be taken to bring the need for seclusion to an end as quickly as possible.

9.3 If a decision to continue with seclusion is made following the initial multi- disciplinary review, the need to continue seclusion should be reviewed: 9.3.1 Every 2 hours from point of seclusion by 2 registered nurses (1 of whom was

not involved in the decision to seclude – where this is not possible it must be agreed with CNM/SM and DM and documented on the ‘Review of Seclusion’.

9.3.2 Every 4 hours from point of seclusion by a doctor alongside the registered

nurse (See Section 13). 9.3.3 Continuing four-hourly medical reviews of secluded patients should be carried

out until the first (internal) Multi-Disciplinary Team (MDT) has taken place

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9.3.4 Following the first internal MDT review, further medical reviews should continue at least twice in every 24-hour period. Medical reviews should be carried out by a doctor, for example the patient’s responsible clinician if they are medically qualified, a medically trained approved clinician or a duty doctor. Any duty doctor will have access to an on-call approved clinician for advice if required.

9.3.5 Medical reviews provide the opportunity to evaluate and amend seclusion care plans, as appropriate (See MHA/Code of Practice, paragraph 26.147 re care plans). They should be carried out in person and should include, where appropriate:

a review of the patient’s physical and psychiatric health

an assessment of adverse effects of medication

a review of the observations required

a reassessment of medication prescribed

an assessment of the risk posed by the patient to others

an assessment of any risk to the patient from deliberate or accidental self-harm, and

an assessment of the need for continuing seclusion, and whether it is possible for seclusion measures to be applied more flexibly or in a less restrictive manner

9.3.6 The MHA - Code of Practice 2015 recommends that MDT reviews should take place once in every 24-hour period of continuous seclusion. NTW’s stance is that this may take place with one of the required medical reviews or in addition to the medical reviews.

9.4 The timing for review should be sequential from the start of seclusion not from the time each subsequent review takes place. Seclusion reviews (2 hourly / 4 hourly) are separate in terms of review times from multi disciplinary and independent review (See Section 9.6.1).

9.5 Appendix 3 - Seclusion review with flowchart; identified elements which be considered within and included (where possible) the patient’s notes as part of the review process.

9.6 If the seclusion continues for more than:

8 hours consecutively; or

12 hours intermittently over a period of 48 hours

9.6.1 An independent multi-disciplinary review will be completed by a doctor or suitably qualified approved clinician (or identified deputy) and nurses and other professionals who were not directly involved in the decision to seclude the patient or in the prior incident. IMHAs (in cases where the patient has one) will also be invited to partake in the review. The arrangement of the independent MDT Review is to be agreed by the RC and the ward manager or delegates. The outcome of this review, timescales for further multi disciplinary review, and rationale for timescales, must be recorded in the patient record should this fall outside of the Seclusion Policy review process and will be escalated via Service Manager.

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9.6.2 If the need for seclusion is disputed by any member of the multidisciplinary

team, following initial discussion with Ward Manager, the matter will be referred to a Point of Contact / Clinical Nurse Manager/ Service Manager/Directorate Manager by the nurse in charge at the point of dispute. The Directorate / Service Manager will then provide advice. During this time seclusion should continue.

10. DISCONTINUATION OF SECLUSION 10.1 The patient must remain in seclusion only as long as absolutely necessary.

The nurse in charge of the seclusion makes the decision to end the seclusion, following agreement with MDT were possible. The end of seclusion must be recorded on the Seclusion Record of Observation form by the nurse in charge of seclusion.

10.2 The observation level should be reviewed and recorded by the Nurse in Charge and the doctor at termination of seclusion 10.3 The FACE Risk Assessment Profile must be revised if required following an

episode of seclusion. 10.4 The end of seclusion is defined as when the patient is no longer presenting a risk necessitating seclusion and can leave the room if they wish to do so. If the door has been locked up to this point the door must now be unlocked and opened. 10.5 A period of compliance testing may be included prior to seclusion ending as discussed and agreed by the MDT i.e. what is required about the patient’s presentation for seclusion to end, during the review of seclusion.

10.5.1 Compliance testing may take place in a seclusion room, or where available, a

de-escalation room within the seclusion area. Time spent in compliance testing within seclusion room or de-escalation area will be included in the total seclusion episode timeframe and recorded as such. (See Sections 4.2.3, 4.2.4, 11.2.1)

10.6 Wherever possible, consideration should be given to end seclusion prior to the patient falling asleep. This must be based on the presenting clinical risk and clinical risk history, and the rationale to continue or end seclusion entered into the seclusion record. 10.7 The Nurse in Charge is to ensure cleaning of seclusion room as outlined in the

practice guidance note, SR-PGN-01 - Seclusion Room Cleaning, which sits with this policy.

11. ROOM USED FOR SECLUSION 11.1 Seclusion should be in a safe, secure and properly identified room where the patient cannot harm themselves, accidentally or intentionally, identified on Appendix 4 – Seclusion sites.

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11.2 The Trust has an established set of standards for new, refurbished and

existing seclusion rooms. Directorates have responsibility to address the seclusion facilities against these standards and undertake risk assessment and subsequent management of shortfalls. (Appendix 5 – Seclusion Accommodation – Gold Standard) - This is in line with CB 26.109 COP.

11.2.1 Where seclusion rooms have a de-escalation area; this area is to be managed

under the same standards as the seclusion room. (See Sections 4.2.3, 4.2.4, 10.5.1)

12. RAPID TRANQUILLISATION AND SECLUSION

Rapid tranquillisation should be considered only if de-escalation and other measures have failed to calm the patient (see Trust’s policy, NTW(C)02 – Rapid Tranquillisation)

12.1 The use of seclusion with rapid tranquillisation is not absolutely

contraindicated, except in the case of a pregnant woman. However the following advice must be carefully considered and followed:

12.1.1 If the patient is secluded, the potential complications of rapid tranquillisation

will be taken particularly seriously. Any medication administered to a patient in seclusion must be administered following the Trust’s policy NTW(C)17 - Medicines Management and appropriate monitoring completed.

12.1.2 The patient will be monitored by constant eyesight observation by staff who are appropriately trained (See Section 14). Vital signs must be monitored, blood pressure, pulse and respiratory rate should be recorded at regular intervals, agreed by medical and nursing staff until the patient becomes active again. If the patient appears to be asleep, more rigorous monitoring is required including the use of a pulse oximeter. Adequate call facilities should be available to staff observing a patient in these circumstances i.e. to summon support from other staff when required.

12.1.3 If patients cannot (due to risk) or are not willing to participate in monitoring of vital signs, this needs to be recorded in seclusion record.

12.1.4 Where a patient appears to be asleep in seclusion, the person observing the

patient should be alert to and assess the level of consciousness and respirations of the patient as appropriate.

12.1.5 Once rapid tranquillisation has taken effect, seclusion will be re-assessed and

ended if appropriate.

13. DURING THE NIGHT 13.1 The need for a four-hour medical review until an MDT review has been

completed is cited in the Code of Practice, Mental Health Act, as good practice. However to enable on call junior medical staff to have uninterrupted rest wherever possible, between the hours of 2300 and 0700 hours, and whilst balancing the needs of the patient, the following principles must apply:

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13.2 Between the hours of 2300 and 0700, the registered nurse will assess the

following: 13.2.1 If the patient is awake, the doctor must attend the ward to conduct the review,

alongside the registered nurse. 13.2.2 If the patient is asleep, the doctor does not need to attend for reviews, unless

asked to do so by the Registered nurse in charge of the ward (as per MHA code of practice).

13.2.3 In this instance two registered nurses will conduct the review. They will

conduct a risk assessment and if safe to do so, open the door and enter the room, to establish if the patient is breathing, safe, the room is tidy and comfortable.

13.2.4 They will assess the need for seclusion to continue. The reason for seclusion

(and risks) should have been sufficiently subsided or dealt with prior to the person sleeping, for seclusion to be terminated whilst the person is asleep. If seclusion is terminated or they have concerns regarding the patient’s physical presentation they must seek medical assistance. If they have concerns about the patient’s mental state they must contact the on call psychiatrist.

13.2.5 The Seclusion Record must be completed. 13.2.6 The doctor will need to make arrangements to review the patient at 7a.m

should the patient continue sleeping through the night. If the patient should wake earlier, then the doctor will need to attend for sequential (time) seclusion review.

13.2.7 It is not practical to undertake an MDT review (senior doctor, nurses and other

professionals) during the aforementioned hours. This will be conducted as soon as practical.

13.3 Between the hours of 2300 and 0700 the Night Co-ordinator will be informed of seclusion and attend at the initiation and review of seclusion. The Service Manager/Directorate Manager on call should only be contacted in exceptional circumstances by the Night Co-ordinator. Update of occurrence of seclusion between these times should be given to the Service Manager/Directorate Manager on call by email the next day at 7.30am. This does not exclude the need for management support to clinical situations should it be required by the Night Coordinator.

14. TRAINING 14.1 All staff expected to use seclusion as determined by risk assessment and the

unit’s operational policy, must receive Seclusion Awareness Training. Training will include appropriate monitoring arrangements for patient placed in seclusion and awareness of the legal framework that authorises seclusion. A Seclusion awareness training package (Appendix 6 – Seclusion Training PowerPoint) is available to be cascaded in teams by the band 6 nurse and must be repeated every three years or in line with significant policy change

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14.2 The Trust will ensure that all staff has access to appropriate levels of training, it is the responsibility of each Group Director to ensure staff attend. Levels of training are identified in the training needs analysis (see Appendix B) and are included within the Essential Training Guide which forms part of Trust policy, NTW(HR)09 – Staff Appraisal Policy, Practice Guidance Notes. Training will be updated/repeated if identified through supervision process or there have been any significant changes to practice and/or policy.

14.3 All those involved in the administration, prescribing, and monitoring of a patient receiving seclusion must receive training to a minimum of Immediate Life Support (ILS – Resuscitation Council UK) (covers airway, Cardio-Pulmonary Resuscitation (CPR) and use of automated defibrillators).

14.4 All staff will have access to competent internal legal advice in relation to the management of any aspect of disturbed behaviour. This is available through line management.

15. AUDIT/MONITORING COMPLIANCE 15.1 Once the seclusion has ended:

Record of Seclusion

o Green (top) copy to be to be filed in the patient record in the electronic support file (purple file) together with the green copy of the corresponding Record of Observation and Review of Seclusion records

o Middle copy to be forwarded to the relevant Service Manager

o Bottom copy to be forwarded to Patient Safety Department

Seclusion – Record of Observation

o Green (top) copy to be filed in the patient record in the electronic support file (purple file) in the service specific section together with the green copy of the Record of Seclusion form and green copy of the Review of Seclusion record

o Duplicate copy to remain in the Record of Observation book

Review of Seclusion

o Green (top) copy to be filed in the patient record in the electronic support file (purple file) in the service specific section together with the green copy of the Record of Seclusion form and green copy of the Record of Observation records

o Duplicate copy to remain in the Review of Seclusion book

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15.2 An entry must be made into the patient’s progress notes and Face Risk

Assessment updated.

15.3 A quarterly report will compiled by Nursing and Operations for the Positive and Safe Steering Group using Appendix 7 – Seclusion Audit Tool.

16. HUMAN RIGHTS ISSUES 16.1 A key issue is to ensure that there is immediate therapeutic necessity, or

immediate necessity due to safety, for seclusion whenever it is used. This interacts with human rights law.

16.1.1 The unnecessary use of seclusion may constitute a breach of an individual’s

right to a private life under Article 8. 16.1.2 Paragraph 26.106 of the Code of Practice states that Seclusion should only be

used in hospitals and in relation to patients detained under the Act. If an emergency situation arises involving an informal patient and, as a last resort, seclusion is necessary to prevent harm to others, then an assessment for an emergency application for detention under the Act should be undertaken immediately.

16.2 Seclusion should only be considered once de-escalation and other strategies

have failed to calm the patient. This is a management strategy and is not regarded as a primary treatment technique. When determining if to use seclusion clinical need, safety of patient and others, and where possible, advance statements should be taken into account. Seclusion must be a reasonable and proportionate response to the risk posed by the service user.

16.3 In exceptional circumstances some patients may have an agreed seclusion

care plan, which recognises that the use of seclusion is part of the agreed treatment strategy (See Trust policy NTW(C)34 – Mental Capacity Act Policy, practice guidance note – MCA-PGN-02 - Advance Decision to Refuse Treatment and Advance Statements) for the patient; this must be agreed as either:

a preferred treatment option by the patient

and / or

a multi disciplinary team clinical strategy, based on presenting risk

16.4 NICE Guidelines (February 2005) relating to the short term management of

disturbed/violent behaviour in psychiatric inpatient settings states:

‘…there are real dangers with physical intervention in any position. Physical intervention should be avoided if at all possible. Physical intervention should not be used for prolonged periods, and should be brought to an end as soon as possible’

and

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‘…to avoid prolonged physical intervention, consider rapid tranquillisation or seclusion (where available) as alternatives’ in the light of NICE Guidelines seclusion can form part of a treatment or management plan’

16.5 This treatment or management plan must follow the principles of the management violence and aggression, rapid tranquillisation, observation and seclusion policies.

16.6 The treatment or management plan should be developed in collaboration with members of the clinical team. This should then be reviewed as part of the individual’s treatment/care plans e.g. Care Program Approach/ward round/MDT. On each and every occasion all the sections of the care plan should be reviewed by the professionals implementing seclusion to ensure the care plan meets the needs of the patient at the time.

16.7 Seclusion treatment or management plans must be forwarded to the Positive and Safe Steering Group for information to enable an awareness of practice and to contribute towards the seclusion audit.

17 IDENTIFICATION OF STAKEHOLDERS

17.1 This policy has been reviewed in line with the Trust’s policy, NTW(O)01 – Development and management of procedural documents as was circulated for Trust wide consultation to the following:-

Corporate Decision Team

Local Negotiating Committee

Consultant Psychiatrists

Community Services Group

Specialist Care Group

Inpatient Care Group

Psychological Services

Medical Directorate

Group Business Meeting

Safeguarding

Trust Allied Health Profession Services

Finance, IM&T, Estates and Performance

Staff-side

Trust Pharmacy

Workforce

Communications 18 EQUALITY IMPACT ASSESSMENT

18.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

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19 IMPLEMENTATION

19.1 Seclusion Awareness training has already been facilitated and performance managed by Group Quality and Performance framework via Dashboards for all areas with Seclusion Rooms and across other inpatient services.

19.2 A document to identify and address the changes in V04 of this policy will be shared with Ward Managers to cascade throughout the teams being available for staff by October 2015. Compliance should be recorded at a local level and scrutinised by the Ward Manager.

19.3 In accordance with Training Dashboard requirements for update of Seclusion Awareness Training, the revised Seclusion Awareness Training package (Appendix 6) will be used to refresh teams from January 2015 or before.

20 STANDARDS/KEY PERFORMANCE INDICATORS 20.1 The Healthcare Commission and the Mental Health Act Commission require

assurance and information relating to the management of seclusion within the Trust. Clinical information maybe considered by the NHS litigation authority. Key performance indicators within service specifications maybe outlined relating to the use of seclusion. It is therefore required that records are maintained as specified within the seclusion policy.

21 FAIR BLAME 21.1 The Trust is committed to developing an open learning culture. It has

endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

22 ASSOCIATED DOCUMENTATION

NTW(C)02 Rapid Tranquilisation Policy

NTW(C)10 Seclusion Policy, practice guidance note

o SP-PGN-02 - Long-term Segregation

NTW(C)11 Search Policy

NTW(C)16 Recognition, Prevention and Management of Violence and Aggression Policy

o PMVA-PGN-01 – Safe use of Mechanical Restraint Equipment

NTW(C)19 Observation Policy

NTW(C)34 Mental Capacity Act Policy, PGN

o MCA-PGN-02 – Advance Decisions/Statements

NTW(C)40 Dignity in Care Policy

NTW(O)01 Development and Management of Procedural Documents Policy

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NTW(O)05 Incident Policy

NTW(HR)09 Staff Appraisal Policy, plus PGNs

o SA-PGN-01 – Training Development Needs Analysis

o SA-PGN-02 – Appraisal-Annually Earned Pay Points

Mental Health Act Code of Practice

MHAC Biennial Report

NICE Guidance Clinical Guideline 25, Violence: the short-term management of disturbed/violent behaviour in psychiatric inpatient settings and emergency departments

Relevant Local Policies

23 REFERENCES

Mental Health Act Code of Practice 2015

MHAC Biennial Report

NICE Guidance Clinical Guideline 25,

Immediate Life Support - Resuscitation Council UK

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Directorate

Chris Rowlands August 2015 August 2018 Nursing

Policy to be analysed Is this policy new or existing?

NTW(C)10 – Seclusion Policy Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

Seclusion is the supervised confinement of a service user in a room, which may be locked to protect others from significant harm. Its sole aim is to contain severely disturbed behaviour, which is likely to cause harm to others.

When determining if to use seclusion clinical need, safety of service users and others and, where possible, advance directives and care plans should be taken into account. Seclusion must be a reasonable and proportionate response to the risk posed by the service user. Consideration should be given to using Seclusion (where available) and/or Rapid tranquillisation as alternatives to prolonged physical intervention.

Associated documentation

Recognition, Prevention and Management of Violence and Aggression Serious untoward Incident Policy Observation Policy Rapid Tranquilisation Policy Search Policy Mental Health Act Code of Practice MHAC Biennial Report NICE Guidance Clinical Guideline 25, Violence: the short-term management of disturbed/violent behaviour in

psychiatric inpatient settings and emergency departments Relevant Local Policies Advance Statements

Who will be affected? e.g. staff, service users, carers, wider public etc

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Will need to ensure that interpreters are available for people who are Deaf / Deaf-Blind. Need to ensure that the space used for seclusion is accessible and has good access to accessible toileting facilities.

Sex

Race Need for interpreters to explain what is happening where English is not the first language

Age Possible access issues for older people

Facilities will need to be age-appropriate (Children and young people)

Gender reassignment

(including transgender)

Possible dignity considerations (who is the named nurse etc.) for a transgender person

Sexual orientation

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Religion or belief Need to ensure that seclusion will not interfere with person’s requirements for prayer etc.

Marriage and Civil Partnership

Pregnancy and maternity

Carers

Other identified groups

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard policy process

How have you engaged stakeholders in testing the policy or programme proposals?

Through standard policy process

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Appropriate author/policy review team

Summary of Analysis Considering the evidence and engagement activity you listed above please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Policy promotes good relations between different groups within the community, based on mutual understanding and respect

Monitor the use of seclusion with regard to the issues raised on the previous page. Ensure that rooms used for seclusion and their facilities can be suitably accessed by a person with a physical impairment. Trust wide audit of seclusion to ensure the uniformity of its approach, to be backed by clear training on when its use is appropriate

Consultation with those people who are secluded is on-going. We will monitor those responses and act accordingly

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Does not unlawfully discriminate against equality target groups

Advance equality of opportunity Promote good relations between groups What is the overall impact? Addressing the impact on equalities Not Applicable – though policy ensures that dignity of

patients is respected and that their Human Rights are maintained

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: C Rowlands Date: August 2015

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committee designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing Policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

Observation aspects of service user, Recording procedure Monitoring and reporting

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc.

Please identify the risks if training does not occur.

Implementation of policy in to clinical practice as defined by NICE guidelines and Mental health act code of practice. ‘All staff expected to use seclusion as determined by risk assessment and the unit’s operational policy, must attend mandatory training in the use of seclusion. Training will include appropriate monitoring arrangements for service users placed in seclusion and awareness of the legal framework that authorises seclusion. This will be provided by the Trust.’

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

Staff involved in the use of seclusion - nursing and medical staff

Is there a staff group that should be prioritised for this training / awareness?

Awareness of policy contents and application of policy in clinical practice

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning

Awareness session for those affected by the new policy

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

See Policy authors

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Appendix B – continued

Training Needs Analysis

No Service Area Staff/Professional Groups Level of Training Frequency of

Training

1 ECT Department Qualified Nursing Unqualified Nursing Medical

Awareness of policy only 3 yearly

Administration Ancillary Technical Scientific and Professional


2 Adult Acute Mental Health

Inpatient Service

Qualified Nursing Unqualified Nursing Medical

Awareness of policy, documentation, role, seclusion management plans and Trust reporting systems

3 yearly



3 Adult Forensic Inpatient Service



3 yearly



4 Child and Adolescent

Mental Health Inpatient Service



3 yearly



5 Continuing Care and

Rehabilitation Inpatient Service



3 yearly



6 Older People’s Inpatient Service



3 yearly



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No Service Area Staff/Professional Groups Level of Training Frequency of

Training

7 Learning

Disabilities Treatment Inpatient Service

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary

Technical Scientific and Professional

Awareness of policy only

3 yearly

8 Mother and

Baby Inpatient Service

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary



3 yearly

9 Regional

Neuropsychiatry Inpatient Services

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary



3 yearly

10 Child Mental

Health Inpatient Service

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary



3 yearly

11 Cognitive and Behavioural Therapies

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary



3 yearly

12 Neuropsychiatry

and Rehabilitation

Inpatient Service

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Administration

Ancillary



3 yearly

13 Regional Eating

Disorders Inpatient Service

Qualified Nursing

Unqualified Nursing

Medical


3 yearly

Should any advice be required, please contact:- 0191 223 2216 (internal 32216)

Copy of completed form to be sent to:

Training and Development Department, St. Nicholas Hospital

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Appendix C Monitoring Tool

Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

NTW(C)10 – Seclusion Policy – Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will

usually be via the relevant

Governance Group).

1. Identified staff receive seclusion awareness training

3 Yearly cascade training local level

Clinical Nurse Managers will be responsible to maintain a record of staff trained which will be shared with Training Department and uploaded onto Dashboards for ease of audit.

Reportable on dashboards

Dashboard figures are monitored within Groups at Quality And Performance for compliance issues and action within Groups.

2. Audit of use of seclusion within designated time frames with associated action plan

Quarterly audit of all seclusion records by Nursing and Operations

Reportable to Group Q and P and PMVA Steering Group

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.