document title seclusion policy… · 3/1/2020 · 4.2 the code of practice differentiates...

Document Title Seclusion Policy

Reference Number CNTW(C)10

Lead Officer

Executive Director of Nursing and Chief Operating Officer

Author(s) (name and designation)

Dave Hately Associate Director

Inpatient Central Services CBU

Mark Cookson Clinical Manager

Inpatient South Services CBU

Ratified by Business Delivery Group

Date ratified Apr 19

Implementation Date Apr 19

Date of full implementation

Apr 19

Review Date Mar 20

Version Number V05.3

Review and Amendment

Log

Version Type of change

Date Description of change

V05.1 Update May 19 Removal of Appendix 10 – amendments at points 5.10 and 20.2

V05.2 Review Oct 19 Governance changes

V05.3 Update Jan 20

Changes to 5.3, 7.6, 7.10, 15.3. 8.2.1, 8.6.1. 7.2, 7.3, 7.5, 8.3.4, 8.5.3, 10.4, Section 12, 13.3.

Updated Appendix 1, 4, 5 and 7.

Updated Appendix C.

Removed Appendix 9.

This policy supersedes the following document

Reference Number Title

CNTW(C)10 – V05.2 Seclusion Policy

CNTW(C)10

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 4

7 Authorising and Initiation of Seclusion 6

8 Review of seclusion 8

9 Access and Egress of Seclusion Room 11

10 Discontinuation of seclusion 12

11 In cases of emergency 14

12 Room Used for Seclusion 14

13 Transferring patients to another seclusion facility on site or on another site

14

14 Rapid Tranquillisation and Seclusion 15

15 During the Night 16

16 Training 17

17 Audit, Monitoring and Review 17

18 Human Rights Issues 18

19 Identification of Stakeholders 19

20 Equality impact assessment 19

21 Implementation 19

22 Standards / Key Performance Indicators 19

23 Fair Blame 20

24 Associated documentation 20

25 References 21

Standard Appendices – attached to policy

Appendix A Equality and Diversity Assessment Tool 22

Appendix B Communication and Training Checklist and Training Needs Analysis

23

Appendix C Audit and Monitoring Tool 27

Appendix D Policy Notification Record Sheet - click here

http://nww1.ntw.nhs.uk/services/?id=5950&p=5539&sp=5545

CNTW(C)10

Seclusion Policy

Appendices - listed separate to policy

Click HERE for the links

Number Description

Appendix 1 Seclusion Training (Power point)

Appendix 2 Seclusion Record

Appendix 3 Seclusion Care Plan

Appendix 4 Seclusion Review and flowchart

Appendix 5 Seclusion Sites

Appendix 6 Seclusion Accommodation – Gold Standards

Appendix 7 Seclusion Mattresses

Appendix 8 Seclusion Audit Tool

Practice Guidance Note – listed separate to policy

PGN Number Description

SP-PGN-01 Seclusion Room Cleaning

SP-PGN-02 Long Term Segregation

SP-PGN-03 Music in Seclusion

SP-PGN-04 Use of Tear Resistant Clothing & Blankets

https://www.cntw.nhs.uk/about/policies/seclusion-policy-appendices/

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

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust NTW(C)10 – Seclusion Policy – V05.3 Jan 2020

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1 INTRODUCTION 1.1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/CNTW)

is committed to promoting the welfare and wellbeing 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 Practice 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 departments.

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 Cumbria

Northumberland, Tyne and Wear NHS Foundation Trust. 3.2 Group Directors will have responsibility for :

Identifying risks and ensuring appropriate action is taken thereby reducing risks.

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

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.

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

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).

Continuous monitoring of all aspects of the above system.

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3.3 Clinical / medical 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 Seclusion 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 The Code of Practice Chapter 26.103 defines seclusion as “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.”

The definition continues in Chapter 26.104 to indicate that “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. It is essential that they are afforded the procedural safeguards of the Code”

Any interventions that meet the definition of seclusion, including such interventions that occur outside of designated rooms must be treated as seclusion and safeguards implemented.

4.2 The Code of Practice differentiates Seclusion from Long-term Segregation within

Chapter 26.150.

“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. “

The Trusts standards for the initiation, reporting, observation and ending of a period

of Long-term Segregation can be found in Practice Guidance Note (PGN), SP-PGN-02 - Long-term Segregation, which sits with this policy.

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The Trusts Seclusion Training Package (Appendix 1) demonstrates the key differences between seclusion and Long-term Segregation.

4.3 Other terms which are associated with managing violence and aggression are clarified below (see Sections 10.6 and 13.3).

De-escalation – reduction in intensity of a conflict (within the clinical setting).

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.

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

4.4 The Code of Practice defines the following ages:

Child – under 16 years of age.

Young Person – 16 or 17 years old.

5. PRINCIPLES

5.1 “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” Code of Practice 26.106.

5.2 The Code of Practice (26.105) indicates that “Seclusion should only be undertaken in

a room or suite of rooms that have been specifically designed and designated for the purposes of seclusion and which serves no other function on the ward”. If seclusion occurs outside of the designated seclusion room then this must be brought to the immediate attention of the CBU. The discussion must be clearly documented in the patient’s health record along with the clinical reasons, including the benefits for the patient and any perceived risks for this departure from the Code of Practice. The location of the episode of seclusion must also be clearly recorded on the Record of Seclusion documentation (Appendix 2). (See Section 12 Room used of seclusion).

5.3 A child (12 years and under) should not be secluded in a locked room, including their

own bedroom (NG10 1.7.26). If seclusion occurs then this must be brought to the immediate attention of the CBU/Second on-call.

5.4 Seclusion should not be used;

As a punishment

Because of a shortage of staff

As part of a treatment programme (See Section 18.3) Code of Practice 26.107 5.5 Seclusion should never be used solely as a means of managing self-harming

behaviour. “Where the patient poses a risk of self-harm as well as harm to others, seclusion should be used only when the professionals involved are satisfied that the

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need to protect other people outweighs any increased risk to the patient’s health or safety arising from their own self-harm and that any such risk can be properly managed. Code of Practice 26.108.

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

proved insufficient. 5.7 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.

5.8 The Code of Practice Chapter 26.111 indicates that “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”. For those episodes of prolonged periods of seclusion flexibility may include, subject to risk assessment, patients receiving visitors, brief access to outside secure areas or allowing meals to be taken in general areas of the ward. This flexibility can assist with evaluating the patient’s mood / level of behavioural disturbance in a less restrictive environment and without terminating the seclusion.

5.9 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.

5.10 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, CNTW(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.

See Local Site Protocol.

6. WORKING WITH PATIENTS 6.1 The patient will be treated with dignity and respect at all times. 6.2 The Code of Practice Chapters 26.161 and 26.163 indicates that “Patients should

never be deprived of appropriate clothing with the intention of restricting their freedom of movement, neither should they be deprived of other aids necessary for their daily

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living.” And that “The requirement to wear tear-proof clothing should never be a blanket rule within a service.”

6.3 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 tear resistant. Guidance on the principles of use, the necessary details and rationale required for every occasion that tear resistant clothing is offered or provided, the monitoring, MDT decision making, record keeping and the storage, laundering and ordering arrangements for tear resistant clothing can be found in CNTW SP-PGN-04 Use of Tear Resistant Clothing and Blankets.

6.4 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 13.8).

6.5 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.

6.6 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.

6.7 The reasons for using seclusion must be explained to the patient at the earliest

opportunity. 6.8 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.

6.9 A record of the seclusion care plan is referenced within documentation (Appendix 2

– Record of Seclusion) 6.10 An individualised seclusion care plan will be devised on the Health Care Record at

the point of initiation of seclusion. 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.

6.11 ‘The patient should be supported to contribute to the seclusion care plan and steps

should be taken to ensure that the patient is aware of what they need to do for the seclusion to come to an end’ Code of Practice 26.148.

6.12 An immediate post-incident / post seclusion debrief should be conducted in-line with

Trust Policy (CNTW (C)13 Positive and Safe Management of Post Incident Support and Debrief.

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6.13 The Trusts Reducing Restrictive Interventions: POSITIVE PRACTICE PROCESS should be used in debrief with the patient after the episode of seclusion or any restrictive practice.

6.14 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.

6.15 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.

6.16 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.

6.17 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 8).

7. AUTHORISING AND INITIATION OF SECLUSION 7.1 Decisions about whether to seclude a child or young person (see 5.3) should

be approved by a senior doctor and reviewed by the MDT at the earliest opportunity (NG10 1.7.24). If approval cannot be sought prior to seclusion commencing, this must be brought to the immediate attention of the senior doctor (medical) and reviewed by the MDT at the earliest opportunity.

7.2 The decision to seclude an adult can be made in the first instance by a Psychiatrist,

an approved clinician who is not a medical doctor or the professional in charge of the ward.

7.3 The person authorising (initiating) seclusion should have seen the patient

immediately prior to the commencement of seclusion” (Code of Practice 26.114). 7.4 Where the decision to seclude is made by an approved clinician who is not a medical

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 immediately in order that they can attend within one hour of the beginning of seclusion in order to complete the first medical review (Code of Practice 26.116).

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The phone-call to the doctor (medical):

May be undertaken by any member of the team, not necessarily the nurse in charge or the nurse who initiated the seclusion.

Should alert the doctor to the name of patient, place of seclusion, time of initiation of seclusion; and therefore the time by which the doctor is expected to attend.

7.5 The patient’s responsible clinician (RC) should be informed of the seclusion as soon

as practicable.

7.6 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 medical attendance (or if they don’t attend at all) should be forwarded to the Point of Contact/First on-call out of hours in accordance with the Trust Incident Reporting Procedure, see the Trust’s CNTW(O)05 – Incident Reporting Policy and PGNs.

7.7 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 (Code of Practice 26.116).

7.8 The nurse in charge will decide what the patient can / cannot take into seclusion; this

must be clearly documented on the Record of Seclusion (Appendix 2) with the rationale documented within the individual health record.

See Section 6.3 and 6.4 re clothing and religious items within the episode of seclusion.

7.9 During the hours 0900 - 1700, the ward must inform the Clinical Manager (CM) when

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

7.10 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 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. The Second on-call should only be contacted in exceptional circumstances not routinely for initiation or reviews.

7.11 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

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observation of a patient. It is the responsibility of those observing the patient to ensure that continuous observations take place during handover.

7.12 A documented report, using the Seclusion: Record of Observation documentation

(Appendix 2) must be made at least every 15 minutes or more frequently if required subject to the patient’s presentation.

7.13 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, physical health, food and fluid intake and interactions including therapeutic interventions and any change to these; and a record of physical observations (cross reference with the Trust’s CNTW(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.

7.14 A detailed contemporaneous indelible record of seclusion will be made on the

seclusion record (Appendix 2 – Record of Seclusion), see Section 10.10. A step by step account of seclusion should be made including the rationale for the episode of seclusion.

7.15 Staff must only use centrally provided seclusion documentation when recording

seclusion information. Record of Seclusion, Review of Seclusion and Seclusion Record of Observation books can be obtained from the Safety Department.

The Record of Seclusion books are controlled stationary and as such have a unique number and logging system which identities the ward area which has been given each book and each seclusion episode contained within that book.

It is vitally important that staff using continuation books accurately transfer the unique number from the Record of Seclusion to all related paperwork (Record of Observation, Review of Seclusion).

Under no circumstances should this documentation be downloaded from the intranet

7.16 An individualised seclusion care plan will be devised on the Health Care Record at the point of initiation of seclusion (see Section 6.9). 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.

The date and time of review at each use of seclusion will also be captured on the Record of Seclusion documentation.

Appendix 3 is the minimum care plan principles which must be reviewed and added to as appropriate at the initiation of each seclusion episode and at each review.

8. REVIEW OF SECLUSION 8.1 The Code of Practice outlines a series of reviews that should be instigated for every

episode of seclusion. The “reviews provide an opportunity to determine whether

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seclusion needs to continue or should be stopped, as well as to review the patient’s mental and physical state” (Code of Practice 26.126).

8.2 NURSING REVIEW 8.2.1 Nursing reviews should be completed every 2-hours from the commencement of

seclusion by two registered nurses, one of whom was not involved in the decision to seclude. Where this is not possible it must be agreed with Clinical Manager and Associate Director and documented on the ‘Review of Seclusion’. This would be agreed by the Point of Contact / First on-call out of hours.

8.2.2 One of the two registered Nurses involved in the 2-hourly nursing review should be a nurse from the part of the register in which best represents the patient’s needs, i.e. mental health or learning disability.

8.2.3 Nursing reviews will:

Ensure the patient is safe.

Ensure there are no physical health concerns which require review / medical review.

Include physical health monitoring (Respirations, Oxygen sats, Pulse and Blood Pressure) if the patient is compliant and where safe to do so. If the patient is not compliant or it is unsafe to enter the seclusion the reason for not completing Oxygen sats, Pulse and Blood Pressure should be clearly documented on the Record of Seclusion / Review of Seclusion and within the patient electronic record.

As a minimum, Respirations should always be completed.

8.2.4 The outcome of the Nursing Review should be documented on the Review of Seclusion documentation, including the reason the seclusion should continue.

8.2.5 The timing for review should be sequential from the start of seclusion not from

the time each subsequent review takes place. 8.3 MEDICAL REVIEW 8.3.1 The first medical review will be completed by the doctor (medical) within 60 minutes

of the initiation of seclusion unless the seclusion was initiated by the Psychiatrist (See Section 7.7).

8.3.2 If seclusion is to continue the clinical team should agree a seclusion care plan. A list

(Appendix 2 Seclusion Care Plans) although not exhaustive, outlines the main issues to consider when developing a seclusion care plan.

8.3.3 Medical reviews should continue every 4 hours from the point of seclusion by a

doctor (medical) alongside the registered nurse (for medical reviews during the night see Section 15).

8.3.4 Four-hourly medical reviews should be sequential from the start of seclusion not from

the time each subsequent review takes place. Reviews should continue until the first

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Internal Multi-Disciplinary Team (MDT) review has taken place, following which further medical reviews should be completed at least twice in every 24-hour period (Code of Practice 26.132). Medical reviews should be carried out by a medical 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. Where the responsible clinician is not a medical doctor, they should be included in a medical review once in a 24-hour period (or the covering on-call approved clinician during out of hour’s periods if required).

8.3.5 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.

8.3.6 The outcome of the Medical Review should be documented on the Review of Seclusion documentation, including the reason the seclusion should continue.

8.4 INTERNAL MULTI-DISCIPLINARY TEAM REVIEW

8.4.1 INITIAL INTERNAL MDT REVIEW The Code of Practice (26.137) indicates that “The first MDT meeting should be held

as soon as is practicable.” This should be within 24-hours of the seclusion commencing (See Section 14 for membership of the initial MDT should the review fall outside of usual working hours). 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.

8.4.2 SUBSEQUENT INTERNAL MDT REVIEW The Code of Practice (26.139) indicates that internal MDT reviews should take place

once in every 24-hour period of continuous seclusion. CNTW’s stance is that this may take place with one of the required medical reviews or in addition to the medical reviews.

8.4.3 Membership of the Internal MDT review to include medical staff, nursing staff and

staff from other disciplines who would normally be involved in the patient’s reviews. Membership out of hours (overnight, weekends and public holidays) may be limited

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to medical and senior nursing staff (Point of Contact for the locality / Night Co-ordinator or delegate – See Section 15).

8.4.4 The outcome of the Internal MDT Review should be documented on the Review of

Seclusion documentation, including the reason the seclusion should continue.

8.4.5 The seclusion care plan should also be evaluated and amended as appropriate (Code of Practice 26.140).

8.5 INDEPENDENT MULTI-DISCIPLINARY REVIEW

8.5.1 An initial internal multi-disciplinary review (See Section 8.4) of the need for seclusion

will be carried out as soon as practicable after the seclusion begins. 8.5.2 If the patient is secluded for more than:

8 hours consecutively or

12 hours intermittently over a period of 48 hours

then an additional Independent MDT review should be completed promptly but by the end of the next working day. The arrangement of the independent MDT review is to be agreed by the RC and the ward manager or delegates.

8.5.3 The Independent MDT review should be completed by a medical doctor or non-medical AC/RC (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 the review. Good practice indicates that the Independent MDT consult with staff involved in the original decision to seclude the patient (Code of Practice 26.142).

8.5.4 If the Independent MDT review concludes that the “seclusion needs to continue, the

review should evaluate and make recommendations, as appropriate, for amendments to the seclusion plan” (Code of Practice 26.143). The Review of Seclusion documentation should be completed.

8.5.5 The outcome of the Independent MDT review, timescales for further Independent

MDT review and rationale for timescales, must be recorded in the patient record.

8.6 ALL REVIEWS

8.6.1 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 Manager / Associate Director by the nurse in charge at the point of dispute who will provide advice. During this time seclusion should continue. Out of hours, referral through the Point of Contact / First on-call initially.

8.6.2 Appendix 4 (Seclusion review and flowchart) identifies elements to consider for

inclusion within the patient records as part of the review process.

9. ACCESS AND EGRESS OF SECLUSION ROOM

9.1 It will be necessary for staff to safely enter and exit the seclusion room, either as:

a planned occasion

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or

unplanned occasion

9.2 Planned occasions include such events as review of seclusion (see 8), to administer medications, offer food and drink, personal hygiene etc.

Unplanned occasions include response to the patient’s observed clinical presentation (See Sections 7.11, 7.12, 7.13), response to rapid tranquillisation (See Section 14), physical wellbeing and any risk to the patient's health, safety and well-being.

9.3 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.

9.4 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. 9.5 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 14.1.2).

9.6 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.

9.7 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.

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

The Code of Practice (26.144) indicates that “Seclusion should immediately end when a MDT review, a medical review or the Independent MDT Review determines it is no longer warranted.

The Code of Practice also indicates “….that where the professional in charge of the ward feels that seclusion is no longer warranted, seclusion may end following consultation with the patient’s responsible clinician or duty doctor. This consultation may take place in person or by telephone”

10.2 “Seclusion ends when a patient is allowed free and unrestricted access to the normal

ward environment or transfers or returns to conditions of long-term segregation.” (Code of Practice 26.145).

10.3 The end of seclusion must be recorded on the Seclusion Record of Observation form

by the nurse in charge of seclusion. 10.4 The observation level should be reviewed and recorded by the Nurse in Charge and

the patient’s responsible clinician or duty doctor at termination of seclusion.

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10.5 The FACE Risk Assessment Profile must be revised if required following an episode of seclusion and an entry made in the patient’s progress notes.

10.6 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.

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 4.3 and 13.3)

10.7 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.

10.8 Following the end of seclusion 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.

10.9 Following the end of seclusion a post seclusion debrief should be offered to the

patient (see 6.12 and 6.13). 10.10 When seclusion has ended, signatures from ward manager (or deputy ward

manager), Clinical Manager / Associate Director and RC should be sought as soon as possible on the next working day. Any problems in obtaining signatures must be raised through the Associate Director.

10.11 The Nurse in Charge is to ensure that the Seclusion Paperwork is filed / forwarded to

the Safety Team as detailed below:

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 Associate Director. o Bottom copy to be forwarded to Safety Team within 5 working days of the

end of the episode of seclusion.

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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11. IN CASES OF EMERGENCY

11.1 A care plan and prevention and management of violence and aggression (PMVA)

plan including Section 17 leave must be developed in order to plan for the event of any emergency situations, including medical emergency and in the event of a fire a designated safe area or alternative facilities must be identified and all involved personnel made aware of this. Consideration may be required by the MDT as to the potential need for the use of Emergency Restraint Equipment.

12. TRANSFERRING PATIENTS TO ANOTHER SECLUSION FACILITY ON SITE OR ON ANOTHER SITE.

12.1 If the patient is to be moved to another seclusion suite on the same site to continue

the episode of seclusion:

Continue using the same seclusion documentation (i.e. do not commence a new Record of Seclusion).

Document on the Record of Seclusion (Page A) the name of the seclusion suite to which the patient has been transferred.

Document in the Record of Observation.

If physical interventions are required complete the Incident Record as usual.

12.2 If the patient is to be moved to another seclusion suite on a different site:

Discontinue the episode of seclusion and start a new episode of seclusion on the site/ward to which the patient has been transferred.

13. ROOM USED FOR SECLUSION

13.1 Seclusion should be in a safe, secure and properly identified room where the patient

cannot harm themselves, accidentally or intentionally. Appendix 5 identifies the seclusion sites across the Trust.

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

seclusion rooms in line with the Code of Practice 26.109. Locality Care Groups have responsibility to address the seclusion facilities against these standards and undertake risk assessment and subsequent management of shortfalls. See Appendix 6 – Seclusion Accommodation – Gold Standard.

13.3 Any adaptations to the standards for new, refurbished and existing seclusion rooms

such as security fixtures and fittings must be discussed through the Seclusion Steering Group with the involvement of the Seclusion Steering Group Chair, Safety Team and Estates.

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

the same standards as the seclusion room. (See Sections 4.3 and 10.6). 13.5 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 (See 12.9 and 13.10).

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13.5.1 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.

13.5.2 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.

13.6 A clinical judgement will be made concerning what clothing or other items the patient

is able to keep during the episode of seclusion (See Section 6.3 and 6.4). 13.7 Each area must assess the required amount of tear resistant clothing required based

on risk assessment and frequency of seclusion episodes. 13.8 Tear resistant 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 (See SP-PGN-04 Tear resistant blankets and clothing).

13.9 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 9).

13.10 If new tear resistant blankets are required they must be ordered as indicated in SP-

PGN-04 Tear Resistant clothing and blankets). 13.11 If a new mattress is required due to damage etc. Appendix 7 outlines the process to

follow in the event that a replacement mattress is required for an episode of seclusion.

14. 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, CNTW(C)02 – Rapid Tranquillisation)

14.1 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:

14.1.1 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 CNTW(C)17 - Medicines Management and appropriate monitoring completed.

14.1.2 The patient will be monitored by constant eyesight observation by staff who are

appropriately trained (See Section 7.12, 7.13). 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 and at 2-hourly nursing reviews. If the patient appears to be asleep, more rigorous monitoring is required including the use of a pulse oximeter. There is an expectation that

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Respirations will always be recorded (See Section 9.2 and 9.3). Adequate call facilities should be available to staff observing a patient in these circumstances i.e. to summon support from other staff when required.

14.1.3 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. 14.1.4 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.

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

if appropriate. 14.1.6 Physical health observations (Respirations, Oxygen sats, Pulse and Blood Pressure)

should be taken at each review (where the patient consents and if safe to do so) and at the end of a period of seclusion.

15. DURING THE NIGHT

15.1 The need for a four-hour medical review until an initial internal MDT review has been completed is cited in the Code of Practice 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:

15.2 Between the hours of 2300 and 0700, the registered nurse will assess the following: 15.2.1 If the patient is awake, the doctor must attend the ward to conduct the review,

alongside the registered nurse. 15.2.2 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).

15.2.3 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.

15.2.4 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.

15.2.5 The Review of Seclusion Record must be completed. 15.2.6 After 7am reviews should be completed in line with Section 8. 15.2.7 It is not practical to undertake an MDT review (medical staff, nursing staff and staff

from other disciplines who would normally be involved in the patient’s reviews) during the hours 23:00 and 07:00 unless the MDT is the initial MDT review which should be

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completed within 24-hours of the seclusion commencing (see Section 8.4). 15.2.8 Subsequent MDT reviews should be planned ahead to ensure that patients have a

MDT review once in every 24-hour period of continuous seclusion. 15.3 Between the hours of 2300 and 0700 the Night Co-ordinator will be informed of the

seclusion and attend at the initiation and review of seclusion. The Second 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 Second 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.

16. TRAINING

16.1 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 1 – Seclusion Training Power Point) 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

16.2 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, CNTW(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.

16.3 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).

16.4 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.

17. AUDIT/MONITORING COMPLIANCE

17.1 Once the seclusion has ended the seclusion paperwork must be filed in the patient

electronic support file (purple file) / forwarded to the Safety Team as outlined in Section 10.11.

17.2 The Middle (duplicate) copy of the Record of Seclusion will be retained by the Associate Director / Clinical Manager for auditing purposes. The paperwork can be confidentially destroyed (following communication from the Seclusion Steering Group) once the quarterly report to which the Record of Seclusion pertains has been reported via Business Deliver Group – Safety.

17.3 A quarterly report will compiled by Safer Care for the Positive and Safe

Implementation Group using Appendix 8 – Seclusion Audit Tool.

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18. HUMAN RIGHTS ISSUES

18.1 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.

18.1.1 The unnecessary use of seclusion may constitute a breach of an individual’s right to

a private life under Article 8. 18.1.2 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.

18.2 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 patient.

18.3 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 CNTW(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

18.4 NICE Guideline NG10 Violence and aggression: short term management in mental health, health and community settings indicate:

NICE Guideline NG10 relating to the short term management of violence and aggression in mental health, health and community settings provides clear guidance on manual restraint with particular reference to ensuring manual restraint does not interfere with the patients airway, breathing, circulation and ability to communicate, when extra care is required for example if the patient is physically unwell and to consider alternative interventions to restraint which should not be used routinely for more than 10 minutes.

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

18.6 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.

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18.7 The Seclusion Steering Group encourages staff to share seclusion treatment or management plans with the Group particularly where staff require advice or assistance with ideas to support the service where there are issues identified with the workings of the Seclusion Policy.

19. IDENTIFICATION OF STAKEHOLDERS

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

Business Delivery Group

Corporate Decision Team

Commissioning and Quality Assurance

Communications, Finance, IM&T

Internal Audit

Local Negotiating Committee

Medical Directorate

North Locality Care Group

Central Locality Care Group

South Locality Care Group

North Cumbria Locality Care Group

NTW Solutions

Safer Care Group

Workforce and Organisational Development

Staff-side

20. EQUALITY IMPACT ASSESSMENT

20.1 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.

21. IMPLEMENTATION

21.1 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.

21.2 Ward Managers to cascade throughout the teams from April 2019. Compliance should be recorded at a local level and scrutinised by the Ward Manager.

21.3 In accordance with Training Dashboard requirements for update of Seclusion Awareness Training, the revised Seclusion Awareness Training package (Appendix 1) will be used to refresh teams from March 2019 or before.

22. STANDARDS/KEY PERFORMANCE INDICATORS

22.1 The Healthcare Commission and the Mental Health Act Commission require

assurance and information relating to the management of seclusion within the Trust.

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Clinical information may be 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.

23. FAIR BLAME

23.1 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.

24. ASSOCIATED DOCUMENTATION

CNTW(C)02 Rapid Tranquilisation Policy

CNTW(C)10 Seclusion Policy

SP-PGN-02 - Long-term Segregation

SP-PGN-04 Use of Tear Resistant Clothing and Blankets

CNTW(C)11 Search Policy

CNTW(C)16 ‘Positive and Safe’ - Recognition, Prevention and Management of Violence and Aggression Policy

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

CNTW(C)19 Engagement and Observation Policy

CNTW(C)34 Mental Capacity Act 2005, PGN

MCA-PGN-02 – Advance Decision to refuse Treatment and Advance /Statements

CNTW(C)40 Dignity in Care

CNTW(O)01 Development and Management of Procedural Documents

CNTW(O)05 Incident Policy

CNTW(HR)09 Staff Appraisal Policy SA-PGN-01 – Training and Development Needs Analysis Process and Attendance Management

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

CNTW(C)13 Positive and Safe Management of Post Incident Support and Debrief

Mental Health Act Code of Practice

MHAC Biennial Report

NICE Guideline (NG10) Violence and Aggressions: short-term management in mental health, health and community settings

Relevant Local Policies

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25. REFERENCES

Mental Health Act Code of Practice 2015

NICE Guideline 10, Violence and aggression: short-term management in mental health, health and community settings

Reducing Restrictive Interventions: POSITIVE PRACTICE PROCESS

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 / Locality

Chris Rowlands Apr 2019 Jan 2020 Trustwide

Policy to be analysed Is this policy new or existing?

CNTW(C)10 – Seclusion Policy V5.3 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 Guideline 10, Violence and aggression: short-term management in mental health, health and community

settings 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: Christopher Rowlands Date: Jan 2019

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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?

Change to 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, NHS Solutions 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 All mainstream Inpatient beds including Autism Inpatient beds

Qualified Nursing Unqualified Nursing Medical

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

3 yearly



3 Secure Care Inpatient Services



3 yearly



4 Specialist Children and Young Peoples Services



3 yearly



5 Specialist Mental Health Inpatient Services



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



3 yearly


Awareness of policy only

3 yearly

8 Mother and Baby Inpatient Service



3 yearly



3 yearly

9 Regional Neuropsychiatry Inpatient Services



3 yearly



3 yearly

10 Child Mental Health Inpatient Service



3 yearly



3 yearly

11 Cognitive and Behavioural Therapies



3 yearly



3 yearly

12 Neuropsychiatry and Rehabilitation Inpatient Service



3 yearly



3 yearly

13 Regional Eating Disorders Inpatient Service



3 yearly

Should any advice be required, please contact:- 0191 245 6770 (internal 56777)

Option 1

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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.

CNTW(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 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 Locality Quality Standards Group 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 Safer Care Directorate

Reportable to BDG – Safety, Locality CBU’s and Positive and Safe Implementation 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.