Date: June 2012
Standards for Low Secure Services
CCQI publication number: CCQI 130
The Quality Network ran a competition to find a piece of service user artwork to use on annual reports, standards and leaflets. This design was painted by a service user from Edenfield Centre. The team would like to thank all of the service users who submitted entries.
3 Preface 4 Method 5 A: Model of Care 7 1: Admission 7 2: Recovery 8
3: Physical Health Care 10
4: Discharge 11
B: A Safe Therapeutic Environment 12
1: Physical Security 12
2: Relational Security 13
3: Procedural Security 14
C: Service Environment 17
1: Environmental Design 17
2: Risk assessment and management 17
3: De-escalation and seclusion 18
4: Access to external spaces 19
5: Facilities for Visitors 19
D: Workforce 20
1: Capacity and capability 20
2: Training and continuing professional development 20
E: Governance 23
1: Reporting and management of adverse incidents 23
2: Business Continuity 23
F: Equalities 25
Appendix 1: Delegates, Standards Working Group 26 Appendix 2: Delegates, Standards Consultation Event 26
Appendix 3: Advisory Group 26
4
It is a pleasure to welcome these Standards for Low Secure Services developed
by the Quality Network. The Quality Network has worked closely with the
Department of Health following the consultation on ‘The Good Practice
Commissioning Guide for Low Secure Services’ which will provide guidance.
These standards will form the basis of the self-and peer-reviews in the recently
launched Quality Network’s dedicated low secure network. They are an
accessible way for services to engage in comprehensive on-going service
development and improvement for the benefit of patients in line with
Department of Health policy.
This new network will build on the Quality Network’s successful work with
medium secure services over the past six years. This work has been valued by
the specialised service commissioners and has provided demonstrable benefits in
terms of quality improvement. The dedicated quality network for low secure
services has the potential to further develop standards for these services and
through the peer-review process further improve quality. Over the next year
commissioners will be working closely with the Quality Network for Forensic
Mental Health Services to use these standards to provide an on-going national
structure for quality assurance and improvement in low secure services.
Ged McCann Phil Brian
Associate Director of Commissioning, Yorkshire and Humber Office,
North of England Specialised Commissioning Group,
Forensic and Secure Clinical Reference Group
Assistant Director (Specialised Mental Health),
West Midlands Office
Midlands and East Specialised Commissioning Group,
Advisory Group Quality Network for Forensic Mental Health Services
5
This third consultation draft of Standards for Low Secure Services has been developed by the Quality Network for Forensic Mental Health Services directly from the ‘Low Secure Services: Good practice commissioning guide – consultation draft’ Department of Health, February 2012. In addition some standards from the ‘Implementation Criteria for Recommended Specification: Adult Medium Secure Units’ (second edition CCQI 105) have been included. These standards have been developed with the purpose of forming the basis of the self- and peer-review questionnaires for the Quality Network for Forensic Mental Health Services low secure services self- and peer-reviews. Forming the foundation of the iterative annual review cycle the standards provide an accessible way for services to actively engage in on-going service development towards implementing the Department of Health recommendations.
The Development of the Standards
The standards have been developed in the following ways and stages:
1) The tense and where appropriate, the sentence structure of the Department of Health ‘Low Secure Services: Good practice commissioning guide – consultation draft’ has been edited. This provides user-friendly and easily accessible questions for use in self- and peer-review questionnaires.
2) Where these standards capture more than one criterion, the standard has been divided into separate criteria. This prevents ambiguous answers.
3) Where these standards make an ideal statement (e.g. ‘There should be….’) this has been edited to a statement of fact (e.g. ‘There is….’). This provides more user-friendly standards for the peer-review questionnaires.
4) The Standards for Low Secure Services have been mapped on to the Quality Network’s Implementation Criteria for Recommended Specification: Adult Medium Secure Units’. This enables comparison and avoids potential duplication.
5) The Standards for Low Secure Services have been mapped onto the Care Quality Commissions ‘Essential Standards of Quality and Safety’ (March 2010)1. This enables services to streamline the data collection process. The references denote the Outcome, Regulation and Prompt number onto which the implementation criteria have been mapped, following the format: Outcome Number, Regulation Number. Prompt Number, e.g. 1.17.1a denotes Outcome 1, Regulation 17, Prompt 1a.
6) On 27 March 2012 the Quality Network consulted an expert standards working group on a first consultation draft of these standards (see Appendix 1). Members of the working group were asked to identify omissions and to comment on clarity, measurability and importance. On the basis of feedback from this working group the Quality Network edited a second draft of the standards.
7) On 31 May 2012 the Quality Network consulted more widely at a standards consultation event on the second draft of these standards (see Appendix 2). Members of the event (which included patients) were asked to identify omissions, in particular, those in the ‘Implementation Criteria for Recommended Specification: Adult Medium Secure Units’ which did not appear in the Low Service Standards). Members were also asked to comment on clarity, measurability and importance. On the basis of feedback from this event the Quality Network edited this third edition of the standards.
7
A: Model of Care
1: Admission
A1.1
There are clear admission procedures which centre on a multi-disciplinary assessment process taking account of a patients’ care, treatment (including physical health treatments) and security needs.
27 4.9.4l 5.14.5a A97 A96 A85 G3 A1.2
There are clear inclusion criteria for the admission of patients to the unit which include all of the following:
i. A definable clinical risk to others or a legal requirement to be in custody
ii. Men and women aged 18 years and over and detained under the Mental Health Act.
iii. Prisoners or Immigration Act detainees meeting the criteria for detention under the Mental Health Act.
iv. People who will benefit from a period of rehabilitation.
v. People who may require a long period of rehabilitation.
vi. People who may have a history of offending behaviour with low levels of violence for example assault.
vii. People who do not require the degree of security provided by medium or high secure care.
viii. People with challenging behaviour.
ix. People with co-morbid substance misuse issues (past or current).
26
28 B7
A1.3
There are clear exclusion criteria for the admission of patients to the unit which include all of the following:
i. People under 18 years who do not meet criteria for detention under the Mental Health Act or require treatment in a specialist service for children and adolescents.
ii. People with a primary diagnosis of substance misuse without a secondary diagnosis of mental
illness, who are not engaging with substance misuse interventions.
iii. People requiring detention in medium or high security.
iv. People with complex needs who can be
managed and treated in adult services including psychiatric intensive care or rehabilitation services.
8
A1.4
Patients who receive low secure services also receive an assessment for additional specialist treatment if they have a primary diagnosis of dementia, a learning disability of sufficient severity to preclude them from actively engaging,
personality disorder, acquired brain injury or other neuro-cognitive deficits, Asperger’s and autistic spectrum disorder. 30 4.9.4b 4.9.4d 4.9.4n 6.24.6c A1.5
Where low secure care is not considered the most suitable option for an individual, service staff offer advice and guidance on the management of the patient where applicable.
31
A1.6
The provider identifies the responsible local
commissioner for every individual planned admission, even where the service user is known to the service.
4.9.4p B9
A1.7 All patients will have an initial care plan in place within
24 hours of admission. A95*
A1.8
All patients have a link person/care co-ordinator from their home area services whose responsibilities include the facilitation of ongoing links and the patient’s care pathway.
6.24.6a 6.24.6b
7.11.7b B10*
A1.9
There are clear criteria for admission to and transfer /discharge from services which will be agreed with commissioners and will be communicated to all referrers. The service ensures that the discharge procedures are operated in line with the pathway (appendix 4). 4.9.4c 4.9.4o 6.24.6a 6.24.6e 6.24.6g 7.11.7e E2*
2: Recovery
A2.1Using the Care Programme Approach (CPA), the multi-disciplinary team takes a comprehensive, recovery-focussed approach aimed at building resilience and preventing relapse.
32 1.17.1a 1.17.1b 1.17.1c 2.18.2a 4.9.4a 4.9.4e 4.9.4g 4.9.4n 4.9.4r 6.24.6a 16.10.16d 21.20.21a B13 A80 B2 A2.2
The recovery-focussed approach includes addressing accommodation, employment and learning needs, meaningful social contact and combating stigma.
32 1.17.1m 4.9.4a A94.5 A107
A2.3
The service makes provision for men and women aged over 18 years and complies with national guidance about and expectations governing the provision of single sex accommodation.
16 1.17.1a 4.9.4f 10.15.10a 10.15.10l E6 E7 F2w F3w F4w F9w
9
A2.4
There is evidence that the model of care and treatment focuses on risk management, engagement and
rehabilitation within a safe and secure environment.
17 1.17.1a 1.17.1b 1.17.1c 1.17.1f 1.17.1j 4.9.4a 4.9.4c 4.9.4e 7.11.7g 16.10.16b 16.10.16d A93 C3 C32 D9 A2.5
There are facilities for detained patients including those who require short periods of intensive care within a low secure environment.
19 1.17.1h
A2.6
There is provision for patients requiring a period of engagement and treatment away from the main patient group. This may include the provision of 1.17.1h (Essential Standards of Quality & Safety, CQC, 2010) for de-escalation and seclusion.
20 1.17.1h
A2.7 There are a variety of recreational activities and
occupational facilities available. 21
1.17.1h 4.9.4a 10.15.10a
A94.1 A94
A2.8 There is a dedicated secure external garden/court
yard which can be used for recreational activities. 21 10.15.10a 10.15.10m
A2.9
There are effective links with community organisations (e.g. housing, leisure, employment, education) and activities to support rehabilitation and sustainable discharge. 21 1.17.1m 6.24.6a 6.24.6c 7.11.7b C22 A2.10
There is evidence that the service places the patient at the centre of their care, supporting patient recovery and choice within the unit where this is clinically appropriate. 23 1.17.1a 1.17.1b 1.17.1c 1.17.1f 1.17.1j 4.9.4a 4.9.4c 4.9.4e 7.11.7d 16.10.16d D20 D2 D9 A2.11
Patients engage and participate in the formulating of, and ongoing review of, a multidisciplinary therapeutic evidence-based programme appropriate to their individual needs. 24 1.17.1a 1.17.1b 4.9.4a 16.10.16c 16.10.16d D19 A113
A2.12 Patients are given a copy of the management or care
plan. 1.17.1c 2.18.2a 2.18.2b 4.9.4c 21.20.21a A100 A2.13
There is a core day described in each patient's
individualised care plan (a description of the core day may also be found elsewhere e.g. in the ward
programme or individual timetables).
A101
A2.14 Patients receive information about medication and its
side effects. 25 1.17.1a 1.17.1e 4.9.4e 9.13.9d 16.10.16b A10w
A2.15 Treatments take into account the relevant NICE
10
A2.16 The programme of treatment includes psychological
sessions. A94.2*
A2.17 The programme of treatment includes substance
misuse therapy.
1.17.1l 4.9.4n
4.9.4o A94.3*
A2.18 The programme of treatment includes offence related
therapy. A94.4*
A2.19 The programme of treatment includes structured
activity programmes. A94.6*
A2.20 The programme of treatment includes structured
leisure time. A94.7
A2.21 The programme of treatment includes unstructured
free time. A94.8*
A2.22
There are facilities appropriate to the patient group, e.g. a pool table and board/console games are provided.
1.17.1h F12
A2.23 There are facilities for patients to make their own hot
and cold drinks and snacks. 5.14.5c F13
A2.24 Books and magazines are provided in recreation areas
for patients. F14
3: Physical Health Care
A3.1 Patients routinely undergo a full assessment of both
physical and mental health needs. 34
G3 A89 A1w
A3.2 Care and treatment plans reflect both mental
health and physical healthcare needs. 35 6.24.6c G3.1
A3.3 Patients have access to a comprehensive range of
primary healthcare services. 35 1.17.1i 6.24.6i G1 G5
A3.4
Patients undergo follow-up investigations and treatment for physical conditions identified in their assessment during their admission.
35 6.24.6c G4
A3.5 Patients have routine monitoring of medication
including those used for physical health issues. 35
9.13.9a 9.13.9b 9.13.9d
A3.6 Patients are supported in their personal care including
dental hygiene. 6.24.6j D1*
A3.7 The service meets screening targets expected of
primary care services. 36 G5 G4w
A3.8
The service provides general health promotion activities including screening, diet advice and the opportunity to exercise (with appropriate supervision).
36 1.17.1e 4.9.4a 5.14.5a 5.14.5c G5 G11 G15 G12 G13 F10 G4w
A3.9 The service provides targeted programmes on smoking
cessation and health promotion. 36 G6
A3.10 There is an identified duty doctor available at all times
to attend the unit. B31
A3.11
Patients have access to comprehensive primary and secondary care services to meet existing or newly developed physical healthcare and treatment needs.
22 1.17.1e 1.17.1i 4.9.4a 4.9.4p 6.24.6i 6.24.6j G1 G5 G4
11
4: Discharge
A4.1
Social workers, care coordinators and offender managers are actively involved in care planning processes for treatment on the unit and
post-discharge follow-up under Section 117 arrangements.
33 6.24.6c A123
A4.2 Discharge targets are agreed as part of the discharge
planning process. A121
A4.3 There is a multi-disciplinary assessment to determine
readiness for discharge/transfer. 4.9.4c B15*
A4.4
The multi-disciplinary team supports the patient to develop and maintain links with community-based organisations that can provide socially inclusive, mainstream activities. 33 1.17.1m 4.9.4a 6.24.6c 6.24.6i 7.11.7b C22 A4.5
The provider facilitates links to the home area services of each patient in terms of local statutory (health and social care) and voluntary services and maintains these to ensure timely and appropriate
discharge/transfer arrangements are put in place.
4.9.4a 4.9.4c
6.24.6i B11*
A4.6
When a patient needs to transfer to services for older people, a joint review is undertaken to ensure effective hand-over takes place.
4.9.4c A122
A4.7
The service ensures there are regular reviews for patients transferred from prison (a) on remand (b) on sentence to assess suitability for return to prison.
4.9.4c
12
B: A Safe Therapeutic Environment
B1
There is evidence that the three domains of security (physical, relational and procedural) are developed and managed in unison.
40 10.15.10c
B2
There is evidence that the three domains of security (physical, relational and procedural) are used to inform decisions about individual/population care.
40 10.15.10c
B3
The balance in emphasis between each domain of security (physical, relational and procedural) changes given the operational needs of the unit as a whole, or the needs of a particular patient and/or group of patients, and the setting in which the service is provided.
41 10.15.10c
1: Physical Security
B1.1 There is a clearly delineated external perimeter. 42 10.15.10c A1
B1.2
The external perimeter is designed to maintain service integrity, privacy, eliminate climb points and manage risk.
(The exact nature of the external perimeter, for example fence height, cladding, angled weld mesh topping, and anti-climb capping, is determined by the size, layout and location of the low secure service).
47 10.15.10a 10.15.10d A10 A18
A19.2
B1.3
Gates within the perimeter do not have bolts or opening mechanisms that can be used as footholds to assist climbing.
48 10.15.10a A15 A15.1
A15.3
B1.4
Where fencing forms all or part of the secure external perimeter, it conforms to BS358 and is a minimum height of 3 metres.
49 10.15.10a
B1.5 Access to the low secure unit for visitors, staff and
patients is via an airlock. 53 A31
B1.6 There is evidence that the secure external perimeter is
regularly checked. 43 A4
B1.7
There is a clearly defined internal perimeter (normally bounded by the secure doors leading to outside areas), which facilitates patients’ freedom of movement within the internal perimeter area.
46
B1.8 There are systems in place to ensure that buildings,
equipment and technology are well maintained. 42 10.15.10d
A7 A7.1 A20.1 F5
B1.9
Lockers are provided for staff away from the patient area for the storage of any items not allowed on the unit.
50 7.11.7m 10.15.10c
10.15.10f
B1.10 All keys, including those held at reception, are
controlled, issued and accounted for. 51 A13 A28
B1.11
All keys held by reception are accounted for at least
13
B1.12
Access to spaces where sharp implements e.g. kitchen knives, utensils, equipment or tools are available are to be controlled.
52 11.16.11c A71
B1.13 The use of sharp implements is monitored. 52 11.16.11c A71
B1.14
There is evidence that the staff team have current knowledge and understanding of the units’ physical security measures and mechanisms.
45 10.15.10c A92 C6
B1.15
There is evidence that the staff team have current knowledge and understanding of the procedures that support the units’ physical security measures and mechanisms for effective operation.
45 10.15.10c A92 C6
B1.16
There is evidence that the staff team have current knowledge and understanding of their own security responsibilities and those of the wider team.
45 10.15.10c C4
B1.17
There is evidence that the staff team have current knowledge and understanding of how relational and procedural measures impact on physical security.
45 10.15.10c
B1.18
There is evidence that the staff team have current knowledge and understanding of what constitutes the internal perimeter.
45 10.15.10c
B1.19
There is evidence that the staff team have current knowledge and understanding of alarm systems including those used for staff/patient safety and fire.
45 4.9.4d 5.14.5a 7.11.7a 7.11.7d 7.11.7k 9.13.9g 10.15.10a 10.15.10b 10.15.10e 10.15.10g 10.15.10h 14.23.14a C7
B1.20 There is a system in place for staff to report any
ligature points identified with prompt follow up action. 10.15.10p F9.1*
B1.21 There is a full-time security lead. A41*
2: Relational Security
B2.1
There is evidence that staff have a knowledge and understanding of their patients and of the
environment, and of the translation of that information into appropriate responses and care.
55 6.24.6b 22.4.22b
B2.2
There is evidence that the entire staff team works cohesively. This includes staff who do not have direct patient contact.
50
B2.3 All staff have an up to date enhanced CRB check. 12.21.12a 12.21.12d A88*
B2.4 There are clear and effective systems for
communication and handover within staff teams. 12.21.12b A102
B2.5
There are regular multi-disciplinary team meetings for clinical matters and administration, and the team is consulted on relevant management decisions such as developing and reviewing operational policy.
16.10.16c 16.10.16d 23.5.23a 24.6.24a
14
B2.6
There are regular meetings where staff discuss and reflect on relational security issues.
This includes as a minimum: discussion of boundaries, therapy, patient mix, patient dynamic, patient’s personal world, physical environment, visitors and other external communication and may be facilitated by the See, Think, Act Relational Security Explorer.
7.11.7g
12.21.12b B30
B2.7
All staff can demonstrate an understanding of their role in relation to meeting the complex needs of patients.
12.21.12a A108
B2.8
The induction training programme covers relational security.
This includes as a minimum material on: boundaries, therapy, patient mix, patient dynamic, patient’s personal world, physical environment, visitors and other external communication. This may be facilitated by the See, Think, Act training slides.
12.21.12b
14.23.14a C5
B2.9
There is annually updated staff training on relational security.
This includes as a minimum material on: boundaries, therapy, patient mix, patient dynamic, patient’s personal world, physical environment, visitors and other external communication. This may be facilitated by the See, Think, Act training slides.
A92
B2.10 Contact with visitors and other external communication
is regularly risk assessed. 7.11.7h 16.10.16b A51, A72, A93, C3
B2.11
There is a mechanism for measuring and monitoring relational security against established outcomes such as those in ‘See Think Act: Your guide to Relational Security’ (DH 2010).
Please refer to ‘We know we are getting it right when:’ sections in See, Think Act
2.18.2d
22.4.22c C17
B2.12
Staff have an understanding of their role in relation to Relational Security in respect of the alcohol and controlled or illegal substances policies.
101 7.11.7h RS. 1 RS. 2 RS. 3 RS. 4 RS. 5 B2.13
The unit has access to a range of education professionals which include teachers, a special educational needs co-ordinator, an educational psychologist, and career guidance.
1.17.1m A107
B2.14 The programme of treatment includes access to real
opportunities to work. 1.17.1m A94.5*
3: Procedural Security
B3.1
There is an up to date index of procedural security policies used in the low secure service, including contingency and business continuity plans.
64 10.15.10h A50
B3.2
Policies and procedures acknowledge the need for proportionality and discretion and are in accordance with the Mental Health Act Code of Practice and guidance issued by NICE and professional associations.
65 2.18.2d 22.4.22b
22.4.22c
B3.3
Policies, procedures and contingency plans are reviewed at least annually and updated where required.
15
B3.4
Staff have ready access to and demonstrate up to date knowledge of policies and procedures governing the service and guiding their practice.
66 C4
B3.5
There are operational policies and procedures governing, but not limited to, the safety of patients, visitors and staff, risk, adverse incidents and
operational management. 58 4.9.4b 6.24.6d 7.11.7a 9.13.9b 10.15.10b 10.15.10e F2 A93 A124 A125 B3.6
In addition to organisation-wide policies, there are specific policies and procedures tailored to meet the needs of the low secure service. These policies are authorised by the wider organisation’s senior management structure or board.
59 23.5.23a 24.6.24a
B3.7 Staff, patients and visitors feel safe on the unit. 60
B3.8
Staff, patients and visitors are clear about rules and policies governing any prohibited items including cameras and electronic devices and other items that may be restricted such as mobile phones.
60 10.15.10c A72
B3.9 There are policies governing access to and appropriate
use of the internet by staff and patients. 61 A73 F15
B3.10
Policies governing access to and appropriate use of the internet by staff and patients contain particular advice around the appropriate use of social networking sites, confidentiality and risk.
61 2.18.2a A73 F15
B3.11
There is a readily available policy for the authorisation and governance of practice of, searching patients, patient rooms, communal areas and visitors. This policy is in accordance with the requirements of the Mental Health Act Code of Practice.
62, 63 22.4.22c A51
B3.12 There is a policy on observation. A55*
B3.13 There is an anti bullying policy (for those who are
bullying and those who are bullied). 7.11.7a 14.23.14d A56*
B3.14 There is a policy on prevention of suicide and
management of self harm. 4.9.4l A57*
B3.15 There is a policy on transportation of patients (e.g. to
court or acute hospital). A58*
B3.16 There is a policy on the control of prescribed
medication and drugs.
9.13.9a 9.13.9b 9.13.9d 9.13.9e 9.13.9f 9.13.9g A64* B3.17
The unit has a robust policy on the use of and access to alcohol and controlled or illegal substances by patients and their visitors.
101 1.17.1l A62 A63
B3.18 Policies regarding alcohol and controlled or illegal
substances cover the role of Relational Security. 101
B3.19
Policies regarding alcohol and controlled or illegal substances cover the management of incidents where drugs and alcohol are brought in by patients and their visitors.
101 9.13.9b
B3.20 There is a policy on the prosecution of offences within
16
B3.21 There is a smoking policy. A67*
B3.22 There is a policy on the management of patient’s
monies. 7.11.7m A68*
B3.23 There is a policy on the censorship of material
including pornography. A69*
B3.24 There is a policy on the control of mail and use of
telephones. 10.15.10k A70*
B3.25 There is a policy on visiting procedures including child
protection issues. 7.11.7e A74*
B3.26 There is a policy on patient confidentiality. 2.18.2a 6.24.6b
6.24.6e A75*
B3.27 There is a policy for managing critical incident reviews.
4.9.4b 6.24.6d 16.10.16b 16.10.16c
A76*
B3.28 There is a policy for response to staff alarms. A83
B3.29 There is a policy on child visiting/child contact which is
annually reviewed. A128*
B3.30
There is a policy on safeguarding children which complies with National Quality Principles which is reviewed annually.
7.11.7a
22.4.22b A129*
B3.31 There is a clear written policy for referrals, admissions,
transfers and discharges. 4.9.4c 7.11.7e B8*
B3.32
There are clear policies on disciplinary and grievance procedure; whistle blowing policy, discrimination, harassment, bullying and violence.
7.11.7a 14.13.14d
16.10.16b C11*
B3.33 There is a clear complaints procedure.
1.17.1h 6.24.6f 7.11.7a 16.10.16a 17.19.17a 17.19.17e C1*
B3.34 There is a procedure regarding obtaining consent from
patients. 2.18.2a 2.18.2b 2.18.2c 2.18.2h 6.24.6e A81 B3.35
The procedure for resuscitation of patients is clearly documented, resuscitation equipment is available and its location is clearly identified.
11.16.11a 11.16.11c 11.16.11d 11.16.11h A82 B3.36
Staff demonstrate a working knowledge of mental health legislation and its application including their authority in relation to escorting patients outside the secure perimeter.
17
C: Service Environment
1: Environmental Design
C1.1
There is evidence of active planning for and consideration of the impact on the therapeutic environment and safety of ward size and layout, patient numbers and population.
68 7.11.7g 10.15.10f 10.15.10i 10.15.10a F16 F17 A45
C1.2 The patient and staff environment is homely, light and
bright. 69 10.15.10a
C1.3
All accommodation is provided in single rooms, with all new builds and upgrading programmes providing en-suite accommodation.
4.9.4f 10.15.10f
10.15.10l F3*
C1.4 There is a designated dining area. 5.14.5f F11
C1.5 There is a multi-faith room available for use by all
patients. 1.17.1i D7*
C1.6 There are unrestricted lines of sight and no concealed
unsecured areas. 69 10.15.10p A46
C1.7
Furnishings minimise the potential for fixtures and fittings being used as weapons, barriers or ligature points.
70 10.15.10p
C1.8
Doors in rooms used by patients have observation panels with integrated blinds/obscuring mechanisms. These can be operated by patients with an external override feature for staff.
71
C1.9 Staff can override any locks that are lockable from
the inside e.g. patient bedrooms and bathrooms. 73
C1.10 Patient bedroom and bathroom doors are designed to
prevent holding, barring or blocking. 73
C1.11
There are lockable facilities (with staff override feature) for patient’s personal possessions with maintained records of access.
74 7.11.7m 10.15.10c A66
C1.12 Patients have access to a telephone in a private area,
within the limits of safety and risk assessment. 7.11.7h D15
C1.13 Patients can wash and use the toilet in privacy unless
clinical risk prevents this. 10.15.10f 10.15.10m F3.1*
C1.14 There is a cleaning programme which is regularly
audited. 8.12 F1.1*
2: Risk assessment and management
C2.1
There is evidence of a multi-disciplinary approach to the identification, assessment and management of risk. 76 4.9.4a 4.9.4l 4.9.4n 5.14.5a A99 A89 C2.2
Individual risk management programmes are developed to identify the types of supervision, therapeutic intervention and treatment required.
18
C2.3
Risk management programmes can be readily adapted to meet a changed risk assessment resulting from adverse incidents, observed behaviour or concerns about security.
77 4.9.4n 6.24.6d 7.11.7h 9.13.9b 10.15.10c 14.23.14d 16.10.16b
C2.4 Risk assessment and management is informed by
relational security issues. 78
7.11.7h 10.15.10c 16.10.16b
C2.5 There is an agreed approach to risk assessment
including which planning tools are used. 79 7.11.7h 16.10.16b
C2.6
All staff working directly with patients are trained to incorporate risk identification and management into individual care, treatment and support plans.
81 13.22.13a 16.10.16b A86.1
C2.7
Staff are skilled at identifying and assessing potential risk factors/situations, planning how to manage identified risks and managing identified risks.
81 13.22.13a 14.23.14a
16.10.16b A86.1
C2.8
Risk reduction is assessed and evidenced through setting and monitoring treatment outcomes. These outcomes inform discussions with the Ministry of Justice (MoJ) regarding restricted patients, transferred prisoners and/or MAPPA (where relevant) and
subsequent decisions about:
i. escorted, unescorted or trial leave ii. rescinding leave
iii. failure to return from leave and absconding iv. remission to prison
v. transfer to higher level of security vi. discharge pathways
vii. s117 follow-up care requirements
viii.
preparation for Community Treatment Order(CTO) arrangements. 82 6.24.6b 16.10.16b 16.10.16d A115 A116 A117 A118 A119
3: De-escalation and seclusion
C3.1
There are clear policies and procedures governing the use of de-escalation techniques and the management of challenging behaviour including the appropriate use of control and restraint and of seclusion.
83 4.9.4q 7.11.7b 7.11.7f 7.11.7g 7.11.7h 14.23.14d A52 A53 A2w C3.2
There is evidence that the service has considered how best to provide appropriate de-escalation facilities and considered the need for providing an en-suite
seclusion room that will maintain the patient’s safety, privacy and dignity.
84 1.17.1a 1.17.1h 7.11.7i 10.15.10a 10.15.10f E6 A3w C3.3
Seclusion is only used as a last resort, and for the shortest clinically appropriate period. Its use is
monitored according to the Mental Health Act Code of Practice.
85 4.9.4q
C3.4
Where required rapid tranquilisation complies with NICE guidance (http://www.nice.org.uk/nicemedia/pdf/cg025fullguidel ine.pdf) 86 9.13.9a 9.13.9b 9.13.9d 9.13.9e 9.13.9g A54
19
4: Access to external spaces
C4.1
Access for patients to outside areas including secure gardens and courtyards is determined by an individual risk assessment and takes account of all factors that may assist escape, e.g. weather.
87 7.11.7h 10.15.10c
10.15.10m
C4.2
Staff facilitate safe access for patients to outside areas including those on s17 leave by implementing the following safeguards:
i. Consideration of appropriate staff supervision (numbers and skill mix) given the mix and number of patients outside or on leave at any one time.
ii. Retaining appropriate staffing levels and skill mix on the unit whilst patients are outside or on leave.
iii. Provision of appropriate escorts given the nature, purpose and location of leave.
88 1.17.1m 14.23.14c A60 A61
5: Facilities for Visitors
C5.1 There are facilities for visitors within the secure
perimeter. 89 10.15.10a
C5.2 There are separate, appropriately furnished facilities
for children’s visits. 89 10.15.10a
A128.1 A12w A13w
C5.4
There are lockers for visitors away from patient areas to store prohibited or restricted items whilst they are on the unit.
91 7.11.7m 10.15.10c
C5.5 All visitors access the unit by the main reception
airlock. 91
C5.6
The unit works with visitors and families on their health and well being, for example, coping with stress, conflict resolution and sustainable transport plans for visiting.
20
D: Workforce
1: Capacity and capability
D1.1
There is a cohesive multi-disciplinary team in place who have the capacity and capability required to meet the complex needs of patients.
92 13.22.13a A104 B17
B18
D1.2
There is a robust leadership structure in place which sets out professional, organisational and line
management accountabilities.
92 23.5.23a 24.6.24a C27 C27.1
D1.3
The staffing capacity is sufficient to deliver the care and treatment model and maintain a safe environment at all times.
93 7.11.7b 7.11.7g
13.22.13a
A110 B18
D1.4 The unit is staffed by permanent staff and agency staff
are used only in exceptional circumstances. A112
D1.5
Extra nursing cover is available when needed, e.g. there is access to additional on-call staff in an emergency.
A111
D1.6 The staff mix and ratios are sufficiently flexible to meet
the changing levels of risk. 93 13.22.13a A86.1 B18
D1.7
The multi-disciplinary team includes:
medical staff nursing staff social workers pharmaceutical staff psychologists art therapist psychotherapist occupational therapist
and education professionals.
94 A104
D1.8 The service has the capacity to respond to patient
need and gender specific issues. 95
1.17.1h 12.21.12b 13.22.13a A1w C4.1w E6w E7w
D1.9 All staff have a working knowledge of mental health
legislation and its application. 96 12.21.12b 22.4.22c C38
2: Training and continuing professional development
D2.1
The multi-disciplinary team has the capacity and capability to provide a range of multi-disciplinary therapeutic interventions and clinical treatments within the agreed model of care.
97 13.22.13a
D2.2
The staff at the service have completed the training and education recommended by their professional association or regulatory body.
21
D2.3
The staff at the service have completed the mandatory and appropriate non-mandatory training provided by the organisation. 97 4.9.4d 5.14.5a 7.11.7a 7.11.7d 7.11.7k 9.13.9g 10.15.10b 10.15.10e 10.15.10g 10.15.10h 14.23.14a C7
D2.4 There is a system in place to continually identify and
review staff training needs on an annual basis. 97
4.9.4d 12.21.12a 12.21.12b 14.23.14a 14.23.14c A90.1 B24
D2.5 Training needs are monitored within the staff appraisal
system. 97 4.9.4d 12.21.12a 12.21.12b 14.23.14a 14.23.14c A90.1 D2.6
There is annually reviewed training and development strategy, which includes the provision of security training.
14.23.14.a A91*
D2.7 There is a strategic plan for training, encompassing all
known initiatives and that is subject to regular review. 12.21.12b 14.23.14a C18.1*
D2.8 All staff receive supervision on a monthly basis. 97 14.23.14c A90 B28
D2.9 All staff receive training regarding Safeguarding
Children and Safeguarding Vulnerable Adults. 97
7.11.7a 7.11.7e 7.11.7i 12.21.12b 22.4.22b A130 A15w
D2.10 All staff receive equality awareness training. 97 12.21.12b C10
D2.11
Staff receive training on Physical Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms.
97 12.21.12b 14.23.14a C5
D2.12
Staff receive training on Procedural Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms.
97 12.21.12b 14.23.14a C5
D2.13
Staff receive training on Relational Security as part of the induction programme and prior to being issued with keys, swipe cards or other means of operating Physical Security mechanisms.
97 12.21.12b 14.23.14a C5
D2.14 All staff including non clinical staff receive training in
the management of violence and aggression. 97 12.21.12b 14.23.14d C8
D2.15
Training addressing the management of violence and aggression includes de-escalation techniques and the use of control and restrain procedures.
97 12.21.12b 14.23.14d C9
D2.16 All staff have a working knowledge of mental health
legislation and its application. 97 12.21.12b 22.4.22c C38
D2.17
Training is provided on disciplinary and grievance procedure; whistle blowing policy, discrimination, harassment, bullying and violence policies.
12.21.12b 14.23.14.a 14.23.14d 16.10.16b
22
D2.18
Training is provided on the management of relationships between patients and between patients and staff.
12.21.12b
14.23.14.a C13*
D2.19 Training is provided on the user perspective and user
participation. 12.21.12b 14.23.14.a C14*
D2.20
Staff are made aware of complaints that are relevant to their work and the outcome of the complaints process.
16.10.16a 16.10.16c
17.19.17a D14
D2.21 Staff take up of supervision and support is regularly
monitored and audited. 12.21.12b 14.23.14c B27
D2.22
Frontline staff have regular supervision totalling at least one hour per week and are able to contact a senior colleague as necessary.
12.21.12b
14.23.14c B29
D2.23 There are records of robust clinical supervision. 14.23.14c C20*
D2.24 There is adequate time made available for supervision
23
E: Governance
1: Reporting and management of adverse incidents
E1.1
There is a structure in place for reporting, managing and investigating Serious and Untoward Incidents (SUIs). 98 6.24.6d 10.15.10e 16.10.16a 20.18.20f 20.18.20g A125 E1.2
The unit’s senior management are accountable for the unit’s Serious and Untoward Incident reporting, managing and investigating structure.
98 20.18.20b 23.5.23a
24.6.24a
E1.3
The unit uses the Department of Health and NPSA definition of a Serious and Untoward Incident to define SUIs within the service:
‘The definition of an adverse incident is an event or circumstance that could have or did lead to
unintended, unexpected harm, loss or damage’.
99
E1.4
All Serious Untoward Incident investigations are in line with guidance on the discharge of mentally disordered people and their continuing care in the community.
100
E1.5
There is a system in place to report incidents to the relevant commissioners in line with the lead
commissioners reporting policy on Serious and Untoward Incidents. This includes initial notification within 24 hours of the incident and a full detailed SUI report within 7 days of the incident.
10.15.10e 16.10.16a 20.18.20a 20.18.20f 20.18.20g A126*
E1.6 Untoward incidents are continually monitored to
identify trends and learning points.
4.9.4b 6.24.6d 9.13.9b 16.10.16a 16.10.16b 16.10.16c A127* E1.7
There are mechanisms in place to share learning beyond the immediate service/provider concerning incidents.
6.24.6d A127.1*
2: Business Continuity
E2.1
The unit has a contingency plan in place, which has been agreed with the police, regarding the reporting and managing of:
loss of control
serious operational failures including those
resulting from fire (in agreement with the local fire and emergency services)
escapes
absconds
failure to return and
hostage taking.
24
E2.2
The unit has contingency plans in place which outline the arrangements for maintaining service integrity and patient and staff safety in the event of an operational, security or systems failure.
103 10.15.10b 10.15.10h
E2.3
The business continuity plan incorporates the
contingency plans, which have been agreed with the police.
104 10.15.10h
E2.4
The business continuity plan addresses:
the chain of operational control
communications
patient and staff safety and security
maintaining continuity in treatment and
accommodation.
104 6.24.6a 6.24.6b
E2.5 There is a strategic approach to planning to meet the
service needs. C18*
E2.6
Clinicians and managers maintain good links with the Home Office and ensure their target
deadlines/requirements are met.
C23*
E2.7 There is a clinical governance strategy, which is
implemented. 16.10.16e C29*
E2.8 Contingency plans are annually tested by desktop
exercises. 6.24.6d A79*
E2.9
Contingency plans are tested by a live exercise
involving one or other of the emergency services every 24 months.
25
F: Equalities
F1 The service complies with equalities, mental health and
human rights legislation. 105
1.17.1g 7.11.7d 22.4.22b 22.4.22c C37 C38 F2
All operational and clinical procedures, processes and policies reflect the requirements of equalities, mental health and human rights legislation.
105 1.17.1g 7.11.7d 12.21.12a 22.4.22b 22.4.22c A84 C38 F3
There is an implemented policy to ensure systems are in place to allow for translation services and sign language. Written information must be provided in an appropriate number of languages and formats.
1.17.1a 1.17.1e 4.9.4e 17.19.17e D6* F4
Patients are provided with a range of information, in appropriate formats, regarding their rights under equalities, mental health and human rights legislation.
106 1.17.1a 1.17.1e 1.17.1g 4.9.4e 4.9.4g 16.10.16b 22.4.22c D6.1 D17 C41 A11w
F5 Patients have access to a range of appropriate advocacy
services. 106 1.17.1a 1.17.1c 1.17.1h 2.18.2a 2.18.2h 17.19.17a C42 D10 D1w
F6 There are systems and support to enable a successful
independent civil advocacy service to be operated. 1.17.1a D11*
F7 The service provides patients with information regarding
what patients can expect from the service. 107
1.17.1a 1.17.1e 1.17.1g 4.9.4e 4.9.4g 10.16.10b D17 F8
There is an implemented policy setting out the consultation and involvement of carers in the care provided.
1.17.1j 4.9.4a
16.10.16d D8*
F9 The unit’s policy and procedures are agreed through
discussion with the whole unit. 1.17.1a D23
F10
The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services.
1.17.1j
4.9.4b E1*
F11 Feedback from patients and carers is used to improve
the quality of the unit
1.17.1j 16.10.16a
16.10.16c D22
F12 Staff receive training in equality issues and their impact
upon patient care. 108 C10
F13 Staff understanding of equality issues are monitored
through the appraisal system. 108 14.23.14c
F14 Complaints are continually monitored to identify trends
26
F15
Systems are in place that ensure patients (particularly those vulnerable to exploitation e.g. financially, emotionally or sexually) are not subject to bullying by other patients or visitors or staff and that this is managed effectively.
C2*
F16 There is an implemented policy to meet the individual
cultural needs of patients.
1.17.1a 1.17.1b 1.17.1g 1.17.1i 2.18.2b 4.9.4a 5.14.5d D5*
F17 Staff demonstrate respect for patients.
1.17.1a 1.17.1b 1.17.1c 7.11.7i 17.19.17e D13 F18
Patients are encouraged to personalise their bedroom spaces appropriately. (Pictures of nude bodies or pictures of children may be inappropriate)
10.15.10a
10.15.10l D21
F19
Patients are provided with meals which are of a high quality, offer choice, address nutritional/balanced diet and specific dietary requirements and which are also sufficient in quantity, are varied and appealing and reflect individual’s cultural and religious needs. (Better Hospital Food – Department of Health 2004).
5.14.5a 5.14.5b 5.14.5c 5.14.5d 5.14.5f 5.14.5h F10.1*
28
First Name Surname Role Organisation
Nigel André Clinical Team Leader Northumberland Tyne and Wear NHS Foundation Trust
Phil Brian Head of Secure Services Commissioning West Midlands Commissioning Team Jean Callender Ward Manager Northumberland Tyne and Wear
NHS Foundation Trust Paul Cartmell
Diane Clayton
Sheryle Cleave Clinical Nurse Manager Northumberland Tyne and Wear NHS Foundation Trust Marc Cookson Clinical Nurse Manager Northumberland Tyne and Wear
NHS Foundation Trust
Maureen Cushley Senior Nurse Manager West London Mental Health Trust
Paul Gilluley Consultant Forensic Psychiatrist West London Forensic Service Stephen Godwin Deputy General Manager Ridgeway
Simon Lloyd Head of Clinical Services St. Andrew's Healthcare Carly Morgan Consultant Psychiatrist Janet Shaw Unit
Joanne Spears Clinical Team Leader Northumberland Tyne and Wear NHS Foundation Trust
Joseph Vella Consultant Psychiatrist Gerry Simon Clinic Neil Woodward Security Manager Ridgeway
29
First Name Surname Role Organisation
Paul Gilluley Chair QNFMHS Advisory Goup
Guy Cross Department of Health
Colin Reynolds Ward Manager Ash Ward
James Lee Consultant Forensic Psychiatrist Challenging Behaviour Service - Memorial Hospital Andrew Duff-Miller Consultant Psychiatrist Derby Ward
Anne Herbert Unit Manager Farmfield Hospital Shirish Bhatkal Consultant in Rehabilitation Psychiatry Horton Rehabilitation Services Lorna Elliot Modern Matron Horton Rehabilitation Services Zena Nasser Consultant Psychiatrist LSU Kent & Medway NHS & SC
Partnership Trust Melanie Evans Assistant Director North London Forensic Services Phil Shackell
Interim Deputy Director of Secure Commissioning (Specialised Mental Health and Learning Disabilities)
North of England
Specialised Commissioning Steven Woolgar Director of Policy and Regulation Partnerships in Care Chris Harden Group Security Officer Partnerships in Care Pratish Thakkar Consultant Forensic Psychiatrist Ridgeway
Jennifer Berry Commissioner
South Of England
Specialised Commissioning Group -Specialised Mental Health and Learning Disabilities
Adam Townsend Ward Manager St. Andrew's Healthcare Kate Axford Occupational Therapy Professional Lead The Dene and Pelham Woods David Munns Clinical Governance Manager St. Magnus
Phil Broxton Therapy Manager St. Andrew's Healthcare Naomi Collier Ward Manager St. Andrew's Healthcare Service User St. Andrew's Healthcare Mgcini Nkomo Senior Nurse West London Forensic Services Dumisani Lupahla Ward Manager St. Andrew's Healthcare Birmingham Syed Husain Consultant Forensic Psychiatrist Wickham Unit
Marcus
Hamilton-Holman Forensic Security Liaison Manager Shaftesbury Clinic Sallie Williams Ward Manager Shaftesbury Clinic Rick Driscoll Consultant Forensic and Rehabilitation Psychiatrist Thornford Park Hospital Johanna Tahti Doctor for female LS services Cygnet Hospital Beckton Peter Fornah Ward Manager for Female LS Services Cygnet Hospital Beckton Neil Woodward Security Manager Ridgeway
John McCarron Senior Nurse Shelton Hospital Shrewsbury James Alexander Security Manager Wells Road Centre Jackie Somers Ward Manager St. Andrew's Healthcare
30
Joseph Vella Consultant Psychiatrist Gerry Simon Clinic Hollis McClatchie Matron - Secure and Forensic Low Secure Services Hellingly and Chichester Low Secure Services Brian Mandisodza Registered Unit Manager Sutton's Manor
Seb Pringle Service User Expert QNFMHS
Arlena Ruben Charge Nurse and Recovery Lead The Dene and Pelham Woods Lina Aimola Research Fellow Royal College of Psychiatrists Alice Taylor consultant clinical psychologist North London Forensic Services Colette Hamer Service Manager St. Mary's Hospital Emmanuel Onukwube Clinical Services Manager Cygnet Hospital Beckton Gary Stobbs Registered Unit Manager North London Clinic Gordon Tsubira Senior Occupational Therapist St. Luke's Healthcare Imogen Mortiboys Clinical Services Manager St. Andrew's Healthcare Birmingham James Mullins Integrated clinical lead, forensic
mental health services (sept)
Robin Pinto Low Secure Unit
James Tighe Clinical Nurse Research Fellow The Bracton Centre Jeni Chamberlain Unit Manager Thornford Park Hospital John Scott Security Team The Dene and Pelham
Woods John Hall Forensic Case Manager Ridgeway John Abu Clinical Team Leader Sutton's Manor Kaysi Thinn Locum Consultant Forensic Psychiatrist Brockfield House
Keith Russell General Manager
Secure and Forensic Low Secure and Community Services Sussex Partnerships NHS Foundation Trust Larte Lawson Nominated Individual St. Luke's Healthcare Leanne Smith Lead Nurse Kemple View
Lisa Cairns Clinical Services Manager St. Andrew's Healthcare Nick Badoorally Ward Manager Jupiter House Low Secure and Forensic Services Patrick O'Sullivan Medical Director St. Magnus
Simon Lloyd Head of Clinical Services St. Andrew's Healthcare Steve Godwin Deputy Head of Service Ridgeway
Susan Guchu Clinical Team Leader Sutton's Manor
Further Acknowledgements:
We are grateful to Dr Stephen Pereira, Chair of NAPICU and Dr Faisil Sethi, Vice Chair of NAPICU for their advice and sight of the ‘NAPICU Response to Department of Health: Psychiatric Intensive Care Unit and Low Secure Services Good Practice Commissioning Guides: March 2012’ .
31
First Name Surname Role Organisation
Phil Brian Head of Secure Services Commissioning West Midlands Commissioning Team Rosie Ayub
Secure Services
Commissioning/ National QIPP Programme
Yorkshire and Humber Secure and Specialist Mental Health Commissioning Team Ian Carmichael Service User Expert Quality Network for Forensic Mental Health Services Sheryle Cleave Clinical Nurse Manager Northumberland Tyne and Wear NHS Foundation Trust Paul Gilluley Consultant Forensic Psychiatrist West London Forensic Service Stephen Godwin Deputy General Manager Ridgeway
Julian Haines Social Work Manager North London Forensic Service/ National Group for Social Work Managers in Secure Services Quazi Haque Group Medical Director Partnerships in care
Mary Harty
Consultant Forensic Psychiatrist & Associate Medical Director
South West London & St Georges Mental Health NHS Trust
Harry Kennedy
Executive Clinical Director & Consultant Forensic Psychiatrist
National Forensic Mental Health Service, Central Mental Hospital Jeremy Kenney-Herbert Clinical Director/Consultant
Forensic Psychiatrist
Reaside Clinic Mat Kinton Mental Health Act Policy
Advisor Care Quality Commission Clive Long Associate Director of Psychology and
Psychological Therapies St. Andrew’s Healthcare Janet Parrot Consultant Forensic Psychiatrist/Chair Forensic
Faculty Royal College of Psychiatrists Susan Riding Carer Representative Quality Network for Forensic Mental Health Services Pete Snowden Medical Director Partnerships in Care
32
Name Role
Sarah Tucker Programme Manager
Michael Gray Deputy Programme Manager - MSU
Sam Holder Deputy Programme Manager - LSU
Sarah Stubbs Project Worker
Ilham Sebah Project Worker
Service User Experts Abdirisak Hussein Alex Sunyata Ian Carmichael Pebble Carmichael Seb Pringle Carer Representatives Anita Trenfield Susan Riding