Bed Rails Leicester Leicestershire and Rutland Policy Docum… · 10 Equipment Order through ICELS 19 11 Alternatives to Bed Rails 19 12 Arrangements on Transfer / Discharge 20 13

Bed Rails Leicester Leicestershire

and Rutland Policy

Approved By: Policy and Guideline Committee

Date of Original Approval:

19th June 2015

Trust Reference: E2/2015

Version: V3

Supersedes: V2 – January 2017 (review date extension)

Trust Lead: Vicky Osborne, Deputy Head of Nursing RRCV

Board Director Lead:

Carolyn Fox , Chief Nurse

Date of Latest Approval

25 October 2019 – Policy and Guideline Committee

Next Review Date: March 2023

Bed Rails Leicester Leicestershire and Rutland Policy

Page 2 of 43 V3 approved by Policy and Guideline Committee on 25 October 2019Trust Ref: E2/2015 Next Review: March 2023

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

Key Words: Bed, rails, adults, integrated policy

Version: 23

Adopted by: Quality Assurance Committee

Date Adopted: 21 May 2019

Name of Author: LPT – Steph O’Connell Lead Therapist, Community Health Services UHL – Mandy Gilhespie Specialist Nurse for Discharge ICELS – Julie Morley, Partnership Manager

Name of responsible Committee:

Patient Safety Group

Date issued for publication:

May 2019

Review date: November 2020

Expiry date: 1 May 2021

Target audience: All staff assessing patients / service users for the use of bed rails and working with patients / service users with bed rails

Type of Policy Clinical X

Non Clinical

Which Relevant CQC Fundamental Standards?

Regulation 15: Premises and Equipment. Regulation 12: Safe Care and Treatment. Regulation 9: Person Centred Care

Integrated Policy: Safe

Use of Bed Rails for

Adults




THIS IS A SHARED POLICY ACROSS LEICESTERSHIRE PARTNERSHIP NHS TRUST,

INTEGRATED COMMUNITY EQUIPMENT SERVICES, AND UNIVERSITY HOSPITALS OF

LEICESTER. THE DOCUMENT DESCRIBES THE STANDARDS FOR THE SAFE USE OF BED

RAILS.

Date Revision By Whom Version

13.04.15 Updates as agreed by Bed Rail Task & Finish Group to integrate LPT and ICES Bed Rail Policy

JEM 1

21.04.15 LPT considerations amended by Lead Nurse. Formatting and grammar changes made.

VP 2

24.04.15 Additions to appendices and associated changes within the text.

VP 3

1.5.15 Grammatical changes. Amended Fact sheet to Carers confirmation of information following feedback from LD.

VP 4

11.05.15 Additional circulation for ICES JEM 5

14.05.15 LPT front page for LPT – amendment to LPT training section 12.2.2.

VP 6

04.06.15 UHL NME group comments 4.2.1 Change director of nursing to chief nurse. 6.7. Risk assessment for bumpers added refers to 7.4 and 7.4.1. Updated distribution list, page numbers.

VP 7

08.06.15 Adult social care professional added to prescriber not just healthcare professional as OT’s working in social care are not considered healthcare professionals.

VP 8

16.10.15 Amendment to transfer of care section to reflect EMB comments and collective care agreement.

VP 9

13.11.15 Comments from MG LA county amended. VP 10

09.12.15 Updates to Section 4.3 and 11.3.2 JM 11

18.01.16 Update to section 5.2 and new appendix for City Council Bed Rail risk assessment

JM 12




Date Revision By Whom Version

07.02.18 REVIEW OF POLICY Amendments and updates as agreed by Bed Rail Task & Finish Group to review policy (reps from LPT, UHL and ICELS) Comments from AMH and LD included

SOC 15

08.02.18 Section 9 added – Safe Use of Trolley

Safety Rails Section 10 added - Equipment Ordered Through ICELS Section 4.2.1 amended

SOC 16

13.02.18 Section 10 added - Equipment Ordered Through ICELS, Agreed updates from ICELS amended and replaced in Section 12, Appendix 4, Appendix 5, Appendix 6

SOC 17

26.02.18 Revised Care plans amended and inserted – Appendix 2

SOC 18

05.03.18 ICELS amendments to Appendix 4 SOC 18

28.03.18 UHL amendments Amendment to 3.4 and typo corrected

SOC 20

23.04.18 Addition of LPT Due Regard and Privacy Impact Assessments

SOC 21

17.8.18 Updates from LPT Medical Devices Asset Manager

SOC 22

11.9.18 Amendments from County Social Care SOC 23

24.4.19 Amendments from PSG 17.4.19 Removal of reference to NPSA Entrapment noted as a Never Event

SOC 23




Key individuals involved in developing the document:

Name Designation

Julie Morley ICES Commissioning Manager

Steph O’Connell Lead Therapist Community Services, LPT

Sarah Clements Matron, Evington Community Hospital, LPT

Jennie Goode Matron City Community Services, LPT

Rachel Parker Learning Disabilities Occupational Therapist, LPT

Jane Martin Matron Learning Disabilities LPT

Mandy Gilhespie UHL Specialist Discharge Lead

Kerry Palmer LPT Medical Devices Asset Manager

Jenny Dolphin Clinical Governance Manager AMH/LD, LPT

Circulated to the following for comments:

Name Designation

Sue Deakin LPT M+H Safety Officer

Jo Nicholls Trust Lead for Quality, Risk and Patient Safety

Jude Smith CHS Head of nursing

Michelle Churchard-Smith AMH/LD Head of Nursing

Heather Darlow Clinical Governance & Quality Lead

Emma Wallis Associate Director of Nursing

Bernadette Keavney Health, Safety & Security Manager

Leona Knott Equality and Human Rights Co-ordinator

Suraiya Hassan Physiotherapy Professional Lead CHS

Sarah Latham Lead Nurse CHS inpatients

Laura Belshaw Lead Nurse MHSOP

Tracy Yole Lead Nurse CHS Community

Clare Armitage Lead Nurse Adult Mental Health

Sue Wyburn Occupational Therapy Professional Lead

Debbie Leafe Clinical Education lead

Cathy Booth CHS Inpatient Therapy Team Leader OT

Fern Barrell Risk Manager, LPT

Laura McNulty CHS Inpatient Therapy Team Leader Physiotherapy

Debbie Blaze Clinical Services Manager CINNS

Susannah Ashton Community Services Matron ICS

Sonia Sunner Community Matron East Central Hub

Miral Joshi Local Authority – City

Karen Walmsley Local Authority – County OT

Jan Barton Local Authority – County Reablement

Emma Jane Perkins Local Authority - Rutland

Lynn Dannatt Local Authority – County Reablement

Rita Thiem Team Leader Single Handed Care Team

NME group UHL

Equipment Management Board

ICELS, CCGs, Local Authorities representatives




Contents Section Content Page No.

Definitions that apply to this policy 7 Equality Statement 9 Due Regard 9

1 Summary 9

2 Introduction 9

3 Purpose of the policy 10

4 Duties within Organisations 10

5 Responsibility for Decision Making 13

6 Individual Patient / Service User Assessment 14

7 Risk of Entrapment 15

8 Safe Use of Bed Rails 17

9 Safe Use of Trolley Safety Rails 18

10 Equipment Order through ICELS 19

11 Alternatives to Bed Rails 19

12 Arrangements on Transfer / Discharge 20

13 Education and Training 23

14 Purchase and Disposal 23

15 Cleaning and Infection Control 24

16 Reporting Incidents 24

17 Dissemination 24

18 Monitoring Performance and Effectiveness 24

19 Links to Standards 25

20 Due Regard 25

21 Associated Documentation and Useful Reference Sites

26

Appendix 1 Bed Rail Risk Assessment Flow Chart 27

Appendix 2 Examples of Bed Rail Documentation Assessment and Plans – LPT, UHL, Leicestershire County Council and Rutland

28

Appendix 3 Bed Raid Risk Assessment – Leicester City Council staff only

31

Appendix 4 Transfer Arrangements Flow Chart 34

Appendix 5 Carers Confirmation Sheet for the Safe Use of Bed Rails

35

Appendix 6 MHRA safe use of bedrail measurements 37

Appendix 7 Training Requirements 38

Appendix 8 NHS Constitution 39

Appendix 9 Due Regard Assessment 40

Appendix 10 Privacy Impact Assessment 41




Definitions that Apply to this Policy:

ICELS Integrated Community Equipment Service. A jointly funded service across Leicester City Council, Leicestershire County Council, Rutland County Council and the NHS Clinical Commissioning Groups for Leicester City, West Leicestershire, East Leicestershire & Rutland.

This service provides equipment to eligible residents across Leicester, Leicestershire & Rutland following an assessment by a Health and/or Social Care Professional.

LLR Leicester, Leicestershire & Rutland

Prescribers/professionals Adult Social Care professionals employed by Leicester City Council, Leicestershire County Council, Rutland County Council and Healthcare professionals employed by Leicestershire NHS Partnerships Trust (LPT), University Hospitals of Leicester (UHL) with the ability to order equipment from ICES to meet patient need. Issued with a prescribing pin that enables them to order equipment from the ICES.

LPT Leicestershire NHS Partnership Trust

UHL University Hospitals of Leicester

MHRA Medicines and Healthcare products Regulatory Agency.

HSE Health and Safety Executive

NRS Nottingham Rehab Services – provider of community equipment service to LLR ICELS.

Restraint Is defined as ‘the intentional restriction of a person’s voluntary movement or behaviour’.

NHS Never Events Defined as serious largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers.

Capacity As defined by the Mental Capacity Act (MCA) 2005 this is the ability of an individual to understand and weigh up, retain and communicate the risks and benefits of bedrail usage. The requirement is that the individual should have information provided in a way that will support their understanding and comprehension to reach a decision, as set out in the MCA Code of Practice.

Bed rail(s) Rails affixed to the sides of a bed to reduce the risk of an individual falling out of bed. May also be referred to as ‘cot sides’, ‘side rails’ or ‘bed guards’.

This includes specialist bed rail systems, for example inflatable or meshes safety systems.




Bed rail bumpers (padding)/cot side bumpers/Cocoon systems

These are a padded air‐ permeable accessory or enveloping cover in design that are primarily used to prevent impact injuries; they can also reduce the potential for limb entrapment when securely affixed to the bed or rail. In some instances these themselves can become a hazard and introduce entrapment risks if they are able to move or compress.

Entrapment Where body parts, usually limbs, become trapped between rails or between the rails and the side of the mattress. It may be possible for the head to slip through the rails and may result in asphyxiation; although this risk is rare.

Adverse incident An event that causes or has the potential to cause, unexpected or unwanted effects involving the safety of the device user(s);including patients, staff or other person.

Ultra Low profiling bed (high/low bed)

Refers to an electronically operated bed that can be height adjusted to a level below that of a standard hospital bed, sometimes to floor level.

Due Regard Having due regard for advancing equality involves:

Removing or minimising disadvantages suffered by people due to their protected characteristics.

Taking steps to meet the needs of people from protected groups where these are different from the needs of other people.

Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.




Equality Statement The Leicester, Leicestershire and Rutland Integrated Community Equipment Service (ICELS), Leicestershire Partnership NHS Trust (LPT) and University Hospitals of Leicester (UHL), Leicester City Council, Leicestershire County Council, Rutland Council aim to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity.

Due Regard

LPT will ensure that Due Regard for equality is taken and as such will undertake an analysis of equality (assessment of impact) on existing and new policies in line with the Equality Act 2010. This process will help to ensure that:

• Strategies, policies and services are free from discrimination; • LPT complies with current equality legislation; • Due Regard is given to equality in decision making and subsequent processes; • Opportunities for promoting equality are identified.

Please refer to Due Regard Assessment (Appendix 7) of this policy.

1. Summary

The aim of this policy is to ensure the safety of all patients / service users using bed rails in all care settings, whilst promoting their independence and respecting their right to make their own decisions about their care.

The policy is a shared document across Leicester City Council, Leicestershire County Council, Rutland Council, University Hospitals of Leicester, Leicestershire Partnership NHS Trust, and the Integrated Community Equipment Loan Store (ICELS)

2. Introduction

Patients /service users may be at risk of falling, sliding or slipping from a bed for many reasons. Bedrails are one option available to help prevent persons’ from falling, slipping or sliding out of bed. The use of bed rails is not without risk. Each person who is at risk of falling, sliding or slipping out of bed should have a risk assessment completed to identify that the benefits of using bed rails outweighs the risks.

Bed rails must only be used to reduce the risk of a patient accidentally slipping, sliding, falling or rolling out of a bed / trolley when alternative




measures have been considered and risk assessments completed. Bed rails are not designed or intended to limit the freedom of a person and are not a form of restraint. Bed rails are not intended as a moving and handling aid,

(Unless they are integral bed rails which are deemed by the manufacturer to be suitable for this purpose. In this case a manual handling risk assessment must be completed. Note: NRS do not currently supply beds with integral bedrails.

It is recognized that some departments use trolleys to manage and transfer patients, these usually have safety rails to prevent patients falling off (Guidance is provided in section 9).

This Policy applies to health and social care professionals employed by Leicester City Council, Leicestershire County Council, Rutland Council, University Hospitals of Leicester, and Leicestershire Partnership NHS Trust and staff working with NRS and ICELS who are involved with individuals requiring and using bed rails.

3. Purpose of the Policy

The purpose of the policy is to:

3.1 Ensure that all patients / service users within any care setting undergo a risk assessment prior to the decision to use bed rails and that documentation must support the appropriate use of bed rails for any individual (refer to Bed Rail Risk Assessment Flow Chart in Appendix 1 and the risk assessment in Appendix 2).

3.2 Reduce potential harm to patients / service users caused by falling from beds or becoming trapped in bed rails.

3.3 Support patients / service users, carers and staff to make individual decisions around the risk of using and not using bed rails.

3.4 Ensure all staff are aware of safe use of trolley rails in hospital settings (Section 9)

3.5 Ensure compliance with Medicines and Healthcare Regulatory Agency (MHRA).

4. Duties within Organisations 4.1 Leicestershire Partnership Trust (LPT):

4.1.1 The LPT Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively.

4.1.2 Trust Board sub-committees have the responsibility for ratifying policies and protocols.




4.1.3 Divisional Directors and Heads of Service are responsible for

ensuring that policy is embedded across their Division / Service.

4.1.4 Managers and Team leaders will be responsible for:

Implementation of the policy within their clinical area.

Managers and Team leaders will ensure by delegation that an individual patient risk assessment pertaining to the use of bed rails is carried out and acted upon.

To manage and /or delegate the responsibility for ensuring staff have the knowledge base for the safe use of bed rails.

Investigating incidents where patients have sustained injury following the use of bedrails.

Ensuring that action is taken to prevent recurrence of incident where bedrails are implicated in a patient sustaining an injury.

4.1.5 Responsibility of Staff:

To maintain the standard and practice described in this policy and accept accountability for their own practice.

Ensure equipment is in safe working order or in need of repair according to organisational or ICELS policy and report if no longer needed (section 8)

Report incidents and near misses relating to patient injury involving the use of bedrails.

Undertaking/cooperating with audits of practice within the clinical setting.

Complete documentation appropriate to the care setting.

4.2 University Hospital of Leicester (UHL):

4.2.1 The Chief Nurse has overall responsibility for the quality of medical and nursing intervention to support the policy.

4.2.2 It is the responsibility of the Consultant to ensure that a medical management plan is in place to treat and prevent causes of falling.

4.2.3 The Heads of Nursing and Matrons are responsible for ensuring

compliance with this policy, supporting training, audit, reviewing results and implementing change where appropriate.

4.2.4 The Ward Sister/Charge Nurse has responsibility for ensuring




adherence to policy are maintained and that staff report any examples of non-adherence to the policy through the hospital adverse events reporting system.

4.2.5 It is the responsibility of all members of the multi-disciplinary team to ensure they comply with the policy and to consult and update with the

service user their families and carers regularly.

4.2.6 The Specialist Nurse for Discharge has responsibility for e n s u r i n g discharge teams working within UHL receive training to ensure compliance with policy when ordering hospital beds/bed rails for patients/service users for discharge, who are assessed as at risk of slipping, sliding or rolling out of bed.

4.2.7 The Discharge Team (discharge specialist sisters, discharge coordinators, acute care nurses, primary care coordinators) have responsibility for complying with policy when ordering equipment for patients/service users who are assessed as being at risk of slipping, sliding or rolling out of bed. The team will ensure that service users, their families and carers, are consulted regarding the assessment and care plan; and that a formal handover is provided to community health or social care services that are responsible for the patient / service user following transfer.

4. 3 Local Authority Social Care Teams:

4.3.1 Heads of Service and Operational Managers will be responsible for:

Implementation of this policy within their service area.

Managers and Team Leaders will ensure by delegation that a

mental capacity assessment is undertaken where it appears the individual concerned may lack capacity to consent to the use of bed rails. Where the person concerned lacks capacity then local authority staff will seek alternative solutions. In all cases where bed rails are prescribed a risk assessment pertaining to the use of bed rails will be carried out and acted upon.

Review the use of bedrails where these are prescribed by local authority staff.

To manage and/or delegate the responsibility for ensuring that staff employed by the local authorities are trained in the safe use of bed rails. Where local authority staff prescribe bed rails for use by independent sector providers they will ensure that the provider is instructed in their safe use. In other cases independent sector providers are accountable through their contractual arrangements with local authorities for the safe use of equipment.

Investigating incidents where patients have sustained injury




following the use of bed rails prescribed by social care staff.

Ensuring that any necessary action is taken to prevent recurrence of any incident where bedrails have been implicated in a patient sustaining an injury.

Maintain the standards in this policy and accept accountability for their own practice.

Report incidents and near misses relating to patient injury involving the use of bed rails.

Undertaking/co-operating with audits of practice within the clinical

setting.

Complete documentation appropriate to care setting.

4.4 Integrated Community Equipment Loan Service (ICELS) Equipment Provider:

4.4.1 The ICELS Equipment Provider will:

Ensure that their staff are trained to install bed rails correctly and are complying with manufacturer’s instructions.

Provide manufacturer’s instructions with delivery of all bed rails – for both new and recycled bed rails.

Ensure recycled bed rails are inspected, stored and maintained in line with manufacturer’s instructions and their own operating procedures.

Ensure bed rails are supplied in good, clean working condition.

Ensure that bed rails and bed rail bumpers meet product standards determined by up to date International, European and British health and safety requirements. Only supply bed rails when requested by an authorised prescriber.

5. Responsibility for Decision Making

5.1 Decisions about bed rails need to be made in the same way as decisions about other aspects of treatment and care, as outlined in the consent policies of the organisations signed up to this policy.

5.2 This means:




The patient must consent to whether or not to have bed rails if they have capacity to make this decision. Consent must be voluntary and informed and can be given orally and/ or in writing. Someone could also give non- verbal consent as long as they understand where appropriate, capacity should be determined by an assessment under the MCA (2005). (Capacity is the ability to understand, weigh up, retain and communicate the risks and benefits of bedrails once these have been explained to them and this will be recorded in the patient/service user care plan/records.)

Every effort must be made to ensure that the patient is given the opportunity to be involved in the decision-making process. This may involve consideration for optimising communication patients/service users (e.g. communication aids, time/place of assessment, interpreter).

Staff can learn about the patient’s likes, dislikes and normal behaviour from relatives and carers, and must discuss the benefits and risks with relatives or carers. However, relatives or carers cannot make decisions for adult patients (except in exceptional circumstances where they hold a Lasting Power of Attorney extending to healthcare decisions under the Mental Capacity Act 2005).

If the patient lacks capacity, staff have a duty of care to decide if bed rails are in the patient’s best interests and this must be in consultation with the patients representatives and documented in the patient / service user records.

6. Individual Patient / Service User Assessment

6.1 Most decisions about bed rails are a balance between competing risks. The risks for individual patients can be complex and relate to: their physical, sensory and mental health needs; the environment; their treatment; their personality; their lifestyle; and the equipment available, inclusive of type of bed, bed rail and bed rail accessories. Staff must use their professional judgment to consider the risks and benefits for individual patients / service users. Bed rails must be used only if the benefits outweigh the risks and this must be documented in the patient / service user records. The Bed Rail Risk Assessment Flowchart (appendix 1) is available to aid decision making.

6.2 A comprehensive individual assessment must be carried out prior to the bed rail being used in the patient / service user’s care setting that the bed rail is intended for use. The assessment must be clearly documented.

6.2.1 Within a hospital setting the continued use of bed rails must be reviewed by a health care professional each time there is a change in circumstances involving the patient or at a minimum of weekly. If the service is unable to achieve this it should be logged on the organisations risk register




6.2.2 In the community setting the continued use of bed rails must be reviewed when there is a known change in the circumstances involving the patient or a minimum of 6 monthly until the patient is discharged. When the patient is discharged from the community service staff should follow the transfer process in section 11

6.2.3 All staff must ensure that the patients / service users and carers (formal or informal) are aware of the their responsibility to;

Ensure correct use of bed rails and bed rail accessories.

Alert health care professional to a change in the circumstances that would affect the safe use of bed rails. (See appendix 5)

6.3 When the patient / service user has been assessed as requiring bed rails but then refuses them an alternative outcome of preventing injury from sliding, slipping and rolling out of bed must be considered. All decisions and information provided to the patient / service user must be documented and related to the Mental Capacity assessment and patients best interests

6.4 Bed rails must not be used if:

The patient is agile enough or confused enough to climb over them, unless

the service is providing one to one care to mitigate risk.

The patient would be independent if the bedrails were not in place.

(See Bed Rail risk assessment flowchart, Appendix 1)

6.5 When a patient / service user requests bed rails without having determined the risk of rolling, sliding or slipping out of bed, staff should ensure that the appropriate strategies are in place to allow the patient / service user to get out of bed when necessary and limit the risks associated with the use of bed rails. (Follow the process for patient request as set out in the Bed Rail Risk Assessment Flow Chart Appendix 1).

6.6 Within a hospital setting bed rails are used to transfer patients / service user between departments. Where a patient’s risk assessment has identified that bed rails are not recommended or recommended with care for the patient, then the patient should receive continuous supervision throughout time of transfer.

6.7 Bed Rail Bumpers / Cocoon systems:

For patients / service users who are assessed as requiring bed rails and may need to

consider bed rail bumpers should also consider the risks associated with the

bumpers in their assessment (refer to 7.4 and 7.4.1).

7. Risk of Entrapment

7.1 Entrapment may occur:

Between the top and end of the bed rail and the headboard / foot




board if the gap is inappropriate.

In the space between a poorly fitting mattress and side of the bed rail or if a bed rail is used that does not fit the bed base sufficiently snugly.

Between the horizontal bars of the bed rails if the physical size of the bed occupant is not considered. This applies particularly to children and small adults. (Refer to 7.3 and Appendix 6a + 6b)

In the space between the bed and the wall

If entrapment occurs this should be incident reported and would count as a ‘never event’ which the Trust has to declare

7.2 Patients / service users who have an unusual body size, such as those with amputated limbs, very emaciated, hydrocephalic or microcephaly growth restriction, may be at increased risk of entrapment. Assessment and care planning must take an individual’s risk into account; checks must be made to identify bed rail gaps which would allow head, body or neck to become entrapped.

7.3 To reduce the risk of entrapment, staff must check safe measurements of gaps are within the safe parameters when using detachable bed rails or when bed rails are fitted (appendix 6):

The gap between the top end of the bed rail and the head of the bed must be less than 6 cm or more than 25 cm.

The gap between the bottom end of the bed rail and the foot of the bed must be more than 25 cm.

The fittings must all be in place and the attached rail must feel secure when raised

(These dimensions comply with regulation BS EN 60601-2-52:2010 for beds manufactured after 2010. Beds manufactured before 2010 regulation BS EN 60601-2-38:1997 would apply)

7.4 For patients / service users who are assessed as requiring bed rails but who are at risk of striking their limbs on the bed rails, or getting their legs or arms trapped between bed rails, bed rail bumpers must be used.

7.4.1 Bed rail bumpers, are padded accessories which are primarily used

to prevent impact injuries but may in some instances reduce the potential for limb entrapment. However bumpers that can themselves be moved or compressed may introduce entrapment risks.

7.5 If a service user/patient is found in positions which could lead to bed rail entrapment, for example, feet or arms through rails, halfway off the side of their mattress or with legs through gaps between the horizontal bars of the bed rail, this must be taken as a clear indication that they are at risk of serious




injury from entrapment. Th is wo u l d be record e d as a n e a r miss a n d urgent changes must be made to the plan of care. These could include changing to a special type of bed rail, such as providing mesh bed rails, the use of ‘cocoons’, or deciding that the risks of using bed rails now outweigh the benefits.

7.6 Bariatric beds must be used with a compatible extra wide mattress and checks made for any potential entrapment gaps. If assessed for and required, compatible bed rails and bumpers must be used that are suitable for the beds and mattresses.

8. Safe Use of Bed Rails 8.1 All bed rails or beds with integral rails must have an asset identification

number and be regularly maintained and serviced.

8.2 When using bed rails, staff must ensure that:

The bed rails are not damaged, faulty or cracked. Staff should assess the risk to the patient and remove from use as appropriate and, label as fault. It is the staff responsibility to ensure patient is safe and to order replacement bed rails

Equipment identified as unsafe should be reported for repair to the relevant organisation and in accordance with organisation’s procedures.

The patient / service user, and/or their carers, know how to report a fault.

The bed rails are used in accordance with the manufacturer advice.

The bed rail(s) is suitable for the bed to which it is be fitted.

That equipment provided by ICELS is supplied with manufacturer’s instructions. If not, contact ICELS for manufacturer’s instructions to be supplied.

The patient / service user, a n d / or carers / relatives, understand the risks associated with use of bed rails and bed rail accessories.

The patient / service user, and/or carer / relatives, know that the bed rails / bed rail accessories should only be used by the patient / service user prescribed for.

The patient / service user, and/or carers / relatives, know how to alert a health care professional if the condition of the patient / service user changes.




8.3 There is a risk of entrapment under the bedrail where a mattress easily compresses at its edge and this risk should be assessed if bedrails are being considered. Dynamic mattresses normally compress at the edge when pressure is applied far more than standard foam mattresses and this risk must be reflected in the risk assessment and reassessment.

8.4 If patient / service user is found attempting to climb over their bed rail, or does climb over their bed rail, this must be taken as a clear indication that they are at risk of serious injury from falling from a greater height. The risks of using bed rails most probably outweigh the benefits and the use of bed rails must be reassessed. Such an event should be recorded as a near miss.

8.5 Beds with bed rails must be kept at the lowest possible height if left unattended to reduce the likelihood of injury in the event of a fall.

8.6 Bed rails must not be used for moving and handling purposes, unless they are

integral bed rails which are deemed by the manufacturer to be suitable for this purpose. In this case a manual handling risk assessment must be completed.

(NRS do not currently supply beds with integral bedrails)

8.7 The use of bed rails must be documented in the patient / service users records and a plan of action to review risks reflecting their individual needs must be completed and available to inform carers (refer to risk assessment action plans appendix 2).

8.8 Bed rails should be lowered when delivering person care and bumpers should be removed before lowering

9. Safe Use of Trolley Safety Rails

9.1 The bedrails risk assessment is not suitable for the assessment of trolley rails due to the differences between the equipment such as the narrowness of the trolley compared to a bed, the height of the trolley and the frequency of patient transfer.

9.2. Scope 9.2.1 This section applies to all clinical areas within hospitals that have

trolleys as their main equipment available for patients, e.g. Emergency Department, Admissions Units, Theatres, and Radiology Departments.

9.2.2 This section also applies to all staff who care for patients on trolleys whilst in UHL or LPT for admission or investigation.

9.3. Statements for the Use of Trolley rails

9.3.1 The Bedrail risk assessment will not be completed for patients who are on a trolley in UHL/LPT.




9.3.2 Due to the narrowness and height of trolleys used and the frequency of transfers between clinical areas and departments trolley rails will be used at all times for patient safety.

9.3.3 Patients being cared for on trolleys must be in line of sight of identified healthcare professional staff throughout their stay. For the Emergency Department this is in line with the existing UHL nurse led pathway for ‘Admission to Escalation Area’.

9.3.4 Clinical judgment must be used for patients where a trolley may not be suitable, e.g. those with acute onset or existing confusion or agitation, frail or older patients, those at risk of developing pressure ulcers. A bed may be more suitable for these groups of patients for which a bed rails risk assessment must be completed as per current policy.

9.3.5 For all patients who may be taken to other departments or wards on a trolley, a suitable escort maybe required (i.e. registered nurse or Healthcare Assistant) who may also have to stay with the patient whilst they are receiving treatment, investigation or clinical handover and then again to escort the patient on their return to the ward or department.

9.3.6 When a patient is transferred to a bed the bedrail risk assessment

must be completed.

10. Equipment Ordered through ICELS

10.1 Any bed rails supplied by ICELS identified as being faulty / unsafe must be reported to NRS for replacement removed immediately and arrangements made for collection. An incident form should be completed.

10.2. The ICELS Equipment Provider will carry out service and maintenance of bed rails every time they are returned for reuse and prior to re-issue. Bed rails that remain the community are part of the annual pre-planned maintenance checks carried out to profiling beds. Bed rail inspection covers:

Condition

Mounting clamps/fixings

Movement

Rail gaps

11. Alternatives to Bed Rails

11.1 Alternatives to bed rails may be the most appropriate method of managing an individual patients / service users risk of falling, slipping or sliding out of bed. The Bed Rail Risk Assessment Flow Chart (appendix 1) should be used to aid the decision process.




11.2 Alternatives to bed rails are provided below, this is not an exhaustive list and not intended to identify the only options available which may be considered suitable for individual patients / services users:

For example

Move person to a more observable area to maximise supervision.

Use of bed sensor and / or position device.

Use of high low bed.

Use of soft cushioning on the floor to break a patient / service user’s fall, such as crash mat. Crash mats may introduce patient / service user handling risks.

Ensure bed returned to lowest height after care delivery.

Ensure patient / service user needs anticipated, such as accessible drinks, regular toileting, call bell to hand.

Increased monitoring of patients / service users at high risk of falling.

Use of mesh, netting or inflatable sides.

Reducing night time sedation.

Nursing person on mattress on floor. This should be a last resort and safety checks would be required to ensure risks from hot pipes, trailing wires, and electric sockets are minimised. Moving and handling risk assessment for staff must be completed.

11.3 It is recognised that some of the safety options outlined above may not be acceptable to patients / service users, carers / relatives. Patient / service user safety must be balanced against the wishes of patients / services users, carers / relatives. These people need to be included in discussions to establish an acceptable level of risk. Any such discussions must be documented and kept

with the patients records.

12. Arrangements on Transfer / Discharge

12.1 The arrangements for continued collective responsibility for patients / service users with bed rails are set out in ‘Transfer / Discharge Arrangement Flowchart (Appendix 3)

12.2. All patients / service users considered to have a continued need for bed rails on

transfer / discharge from a health care provider will have a bed rail risk assessment completed prior to the transfer / discharge that would inform the patients’ / service user need, the bed the rails are to be used on, the type of bed rails and bed rail accessories required.

12.3 All patients / service users carers (informal or formal) with a continued need for bed rails will be involved with the decision and informed of the information detailed within the Patient / Carer Information Leaflet – Safe Use of Bedrails’ (appendix 4), any special considerations for the individual, and their need to alert a health care professional to a change in circumstances that would affect the safe use of bed rails prior to transfer, by the health / social care




professional transferring the service user / patient.

12.4 Patients / service users in residential setting. If there is a continued need for bed rails for a patient / service user in a residential setting then it is the responsibility of the residential setting to provide the bed rails and associated equipment and any equipment on loan must be returned by the health care professional to the community equipment provider.

12.5 Transfer from In-patient setting To patient’s own home:

12.5.1 Patients / service users with an on-going health need will be referred to a community health care professional, the referral must include;

Information regarding the use of bedrails;

Outcome of the bed rail risk assessment prior to transfer

Details of care plan for the safe use of bed rails

The receiving health care professional will continue to reassess the patient’s / service users’ needs for bed rails (refer to 6.2.2).

12.5.2 Patients / service users without an on-going health need will have carers (informal or formal) identified who will have been involved. The carer(s) must be provided with a Patient / Carer Information Leaflet – Safe Use of Bedrails’ (appendix 4); identifying any considerations for the individual and their need to alert a health care professional to a change in circumstances that would affect the safe use of bed rails prior to transfer, by the health / social care professional transferring the patient. If this is a transfer from an in-patient setting then this must be provided by the in-patient professional responsible for discharging the patient with this equipment.

To Residential / Non-Nursing Care Home:

12.5.3 Patients / service users with an on-going health need must be referred to a health care professional; the referral must include information regarding the use of bedrails:

Outcome of the bed rail risk assessment prior to transfer.

Details of care plan for the safe use of bed rails.

The receiving health care professional will continue to reassess the patients / service users’ needs for bed rails (refer to 6.2.2)

12.5.4 When the patient / service user is discharged from the health care professionals caseload, the health care professional must carry out an assessment to determine if bed rails are still required or not. If the bed




rails are still required then responsibility for provision of the bed rails is transferred to the residential setting and the equipment on loan must be returned by the health care professional to the community equipment provider. The loan equipment MUST NOT be left with the residential setting.

12.5.5 Patients / service users without an on-going health need transferring to a residential / non-nursing care home will NOT have bed rails or bed rail accessories provided by ICELS equipment provider. The care home provider should be involved with the decision making and must be informed of the needs of the patients / service user to enable them to provide suitable equipment. Refer to current policy for the provision of equipment.

To Nursing Care Home:

12.5.6 Bed rails and associated equipment are not provided into nursing settings.

12.6 Continued Use of Bed Rails without Health Professional contact or in between Health Care contacts:

In patient’s own home:

12.6.1 Where a patient / service user has been discharged from a health care professional caseload and where the health care professional has identified a continued need for bed rails, the health care professional must inform the patient / service user and/or carers (informal/formal) of the decision and provide them with a copy of the Patient / Carer Information Leaflet – Safe Use of Bedrail’s (appendix 5); identifying any special considerations for the individual and their need to alert a health care professional to a change in circumstances that would affect the safe use of bed rails prior to discharge by the health / social care professional transferring the patient.

12.6.2 If the patient / service user does not require continued use of bed

rails then the health care professional will arrange for the bed rails and accessories to be returned to the Equipment Provider.

To residential / non-nursing care:

12.6.3 Patients / service users without an on-going health need transferring to residential / non-nursing care home will not have bed rails or bed rail accessories provided by ICELS equipment provider. The care home provider should be involved with the decision making and must be informed of the needs of the patient / service user to enable them to provide suitable equipment. Refer to current policy for the provision of




equipment.

To Nursing Care Home:

12.6.4 Patients / service users transferring to a nursing care home will not have bed rails or bed rail accessories provided by ICELS equipment provider. The care home provider should be involved with the decision making and must be informed of the needs of the patient / service user to enable them to provide suitable equipment.

13. Education and Training

The duties of roles and responsibilities within the organisation that are party of this policy are provided in section 4.

13.1 Leicestershire Partnership Trust:

13.1.1 All clinical staff are expected to attend moving and handling mandatory training: awareness of this policy and importance of risk assessment will be iterated. Use of bedrails is also covered in the Falls awareness training.

13.2 LLR ICELS Equipment Provider staff:

13.2.1 The equipment provider will ensure that:

All driver / technicians responsible for delivery and installation of bed rails receive familiarization training, which includes how the equipment works, how it installed, how it is used;

All driver / technicians will complete a competency based product training programme that is signed off by a designated trainer.

On-site trainer will also carry out training with individual driver technicians in the community; ensuring that they are trained in how to fit rails to all types of beds and to be able to identify that they have the correct bed rails for the bed and to carry out checks to ensure safe installation.

Driver technicians will also be responsible for demonstrating and providing leaflet to the service user, their carer and/or relatives how to use the bed rails safely, e.g. lift up and down correctly.

14. Purchase and Disposal

14.1. Each organisation will adhere to their own arrangements for the




purchase and disposal of bed rails.

14.2. Bed rails supplied through the ICELS will be subject to the purchase and disposal arrangements set out in the contractual requirements between the Equipment Provider and Leicester City Council, who host the service on behalf of Partners to the Pooled Arrangement for the ICELS.

15. Cleaning and Infection Control

15.1 Each organisation will adhere to their own arrangements for cleaning and infection control and staff must comply with their own policies and procedures.

15.2 Bed rails supplied through the ICELS will be subject to the cleaning, decontamination and refurbishment arrangements set out in the contractual requirements between the Equipment Provider and Leicester City Council, who host the service on behalf of Partners to the Pooled Arrangement for the ICELS.

15.3 Staff prescribing bed rails into care settings must ensure they are aware of the important of infection control and take appropriate action and that they do not use the bed rails for any other service user.

16. Reporting Incidents

16.1. All patients / service user incidents or near misses related to the use or

condition of bed rails and / or bed rail accessories and equipment shortages associated with bed rails must be reported via each organisation’s incident reporting processes.

16.2 For equipment provided through the ICES, any incident must also be reported by H&SCP to the ICELS Partnership Manager.

16.3 The Equipment Service Provider’s staff should also report any concerns or adverse incidents that they become aware of to their own organization who will take action in accordance with their own Adverse Incident reporting policy.

17. Dissemination

17.1 Each organisation will be responsible for ensuring their own staff are made aware of this policy.

18. Monitoring Performance and Effectiveness

18.1 Appropriate use of bed rails and the completion of bed rail risk assessment tools will be monitored as part of the falls audits across




LPT/UHL on an annual basis.

Ref Minimum

Requirements

Evidence for Self-

assessment

Process for Monitoring

Responsible Individual /

Group

Frequency of

monitoring p 12 Correct

completion of bed rail risk assessment tools and use of bed rails

Section 6 Appendices 1 & 2

Monitor as part of falls audit

LPT / UHL Falls Steering Group

Annually

p 23 No injury incurred by any patient as a direct result of the use of bed rails

Section 16 Monitor incident reports

LPT/ UHL Falls Steering Group

Bi-monthly

19. Link to Standards

19.1 This Policy links to Care Quality Commission (CQC):

• Regulation 15: Premises and Equipment.

• Regulation 12: Safe Care and Treatment.

• Regulation 9: Person Centred Care.

20 Due Regard

20.1 All organisations that are party to this policy are committed to an environment

that promotes equality and embraces diversity in its performance as an

employer and service provider. They will adhere to legal and performance

requirements and will mainstream equality and diversity principles through hits

policies, procedures and processes.

20.2 The policy has been developed in context of paying due regard to the Public

Sector Equality Duty (Equality Act 2010) to eliminate unlawful discrimination,

harassment, victimization; and advance equality of opportunity and foster good

relations.

20.3 This policy sets out Leicestershire Partnership Trust’s (LPT), University

Hospitals of Leicester (UHL) and the Integrated Community Equipment

Services (ICES) and Leicester, Leicestershire & Rutland policy for ensure the

safe and appropriate use of bed rails. Every effort has been made to ensure all

equality groups (protected characteristics) are given equal access to service

provision, especially in the context of disability. This is demonstrated through




the provision of risk assessment and decision making tools to guide staff in the

identification of risks associated with the use of bed rails.

21 Associated Documentation and Useful Reference Sites

Reference Source

NPSA Safer Practice Notice: Using bed rails safely and effectively

Available at: www.nrls.npsa.nhs.uk

Health and Safety Executive, Safe Use of Bed Rails (2012)

Available at http://www.hse.gov.uk/foi/internalops/sims/p ub_serv/07-12-06/

MHRA Device Bulletin (Dec 2013) Safe use of bed rails

Available at: https://www.gov.uk/government/publications/b ed-rails-management-and-safe-use

LPT Medical Devices Policy Available at: http://www.leicspart.nhs.uk/Library/MedicalDe vicesPolicyexpJan21.pdf

http://www.nrls.npsa.nhs.uk/

http://www.hse.gov.uk/foi/internalops/sims/p

http://www.gov.uk/government/publications/b

http://www.leicspart.nhs.uk/Library/MedicalDevicesPolicyexpJan21.pdf

http://www.leicspart.nhs.uk/Library/MedicalDevicesPolicyexpJan21.pdf




Appendix 1 BED RAIL RISK ASSESSMENT FLOW CHART

Complete on initial assessment

Review if condition changes

Review in preparation for discharge







Appendix 2




Name: NHS Number: DOB: Ward:

Guidance for care planning following risk assessment and for review of risk assessment

Stage 4 Bed Rail Plan 4a (Bed Rails NOT recommended) OR 4b (Bed rails recommended or use Bed rails with care) (V1) Goal: To identify interventions required for patients who are at risk of slipping, rolling, sliding or falling out of bed who are assessed as requiring bed rails or where

alternatives need to be considered where bed rails are not recommended

EXCEPTION: Within the hospital environment bed rails are used when transporting patients between departments.

Assess each patient on an individual basis as to whether an escort is required throughout their transfer and record this on the evaluation sheet

Date/Time/Signature► Review Review

Stage 4a Plan: Risk Assessment indicates that bed rails are NOT recommended – consider alternatives Y N N/A Y N N/A Y N N/A

a. Ensure the patient/service user/carer are aware of risk assessment and how to summon help

b. If the patient/service user is unable to consent apply best interest decision through the Mental Capacity assessment process. Record decision in the evaluation section

c. Cross reference with Manual Handling Assessment and Falls Assessment and care plan to reduce risk of patient climbing out of bed without assistance (eg toileting / continence needs)

d. Ensure patient call bell is in close proximity to enable patient to call for help

e. Specify level of observation required in the evaluation section overleaf

f. Move bed to a high visibility area

g. Does patient/service user require Hi Lo Bed with crash mat in-situ? (usually for patients who are not able to stand)

h. Does patient/service user require Hi Lo Bed without crash mat in-situ? (usually when patients are likely to trip on crash mat)

i. Leave bed at low level when left unattended

j. Are Sensor mats in use?

k. Where the patient is non-concordant identify why, record action taken in the evaluation and update the care plan l. Care plan to be reviewed: Weekly; if f the patient’s condition changes; on transfer between clinical areas / wards and

following a fall. Record in the evaluation section

m. Other specific person centred care interventions:




Name: NHS Number: DOB: Ward: Date/Time/Signature►

Review

Review

Stage 4b Plan for Risk Assessment indicates that bed rails ARE recommended OR Use bed rails WITH CARE Y N N/ A

Y N N/ A

Y N N/A

a. Does the patient/service user consent to use of bed rails?

b. If patient/service user is unable to consent apply best interest decision through Mental Capacity Assessment process – record decision in the evaluation section

c. Check risks of using bed rails – risk of entrapment of arms, legs or head between bed rail and mattress. If yes consider use of bed rail bumpers

d. Are bed rail bumpers in place?

e. Cross reference with Manual Handling Assessment and Falls Assessment and care plan to reduce risk of patient climbing out of bed without assistance (eg toileting / continence needs)

f. Ensure patient call bell is in close proximity to enable patient to call for help

g. Specify level of observation required in the evaluation section below

h. Leave bed at low level if left unattended

i. Where the patient is non-concordant identify why, record action taken in the evaluation and update the care plan

j. Care plan to be reviewed: Weekly; if the patient’s condition changes; on transfer between clinical areas / wards and following a fall. Record in the evaluation section

k. Other specific person centred care interventions:

EVALUATION Date/Time/Signature ▼




Appendix 3

LEICESTER CITY COUNCIL (ONLY) BED RAIL RISK ASSESSMENT FORM

Assessing the service user:

1. Consider and evaluate the wider issues i.e. cognitive, physical, mobility,

sensory state, drug therapies, past history and environmental issues

Name: DOB:

Address: Contact details:

Name and address of GP: Name and address of next of kin:

2. Does the service user have dementia, confusion, a learning disability, micro or

hydrocephalus?

Yes consider using alternative methods

No continue assessment

3. Will the service user need to get of bed unsupervised?

Yes consider alternative methods


4. Is the service user considered at risk of falling if bed rails are not used?

Yes continue assessment

No justify and record in service user’s records




5. Could the service user climb over the top of the bed rails?

Yes use alternative methods


6. Does the service user or their next of kin insist on bed rails being used?

Yesrecord in service users records stating the use of side rails against

advice

Nocontinue assessment

7. Does the service user/next of kin refuse the use of bed rails?

Yes record in service users notes

Nocontinue assessment

8. Has informed consent been gained from the service user or next of kin?

Yes continue assessment

No refer to guidelines

9. Does the service user or their next of kin agree with the outcomes of the

assessment?

Yes record in service users notes

Norecord in service user’s records. Discuss alternative measures

10. Does the service user need an alternating pressure mattress/ specialist bed?

Yesensure side rails are compatible with

equipment Nocontinue assessment




Signature: Designation:

Date: Review date:

11. Are there any gaps between the rails and mattress, including when the

Mattress is compressed where entrapment could occur?

Yes


12. Are there any gaps between the rails and foot of the bed where the service user could

become trapped?

Yes use alternative

methods No




Appendix 4




Appendix 5

This leaflet has been produced for people who receive health and social care services and is a reminder of how to use and look after the bed safety rails you have been supplied with.

A risk assessment has been carried out by your health or Social Care professional to assess if using bed rails would be of benefit to you. The sole purpose of using bed safety rails is to prevent someone from falling out of bed and injuring themselves. They are NOT intended to stop you from getting out of bed if you wish to do so.

The person who ordered the equipment for you is responsible for ensuring that they or another professional:

Checks the bed rails provided to ensure they are safe

Demonstrates to you and your carer(s) how to safely use and check your bed rails

Ensures you and your carer(s) are aware of the risks associated with use of bed rails and bed rail accessories

Provide you with details below of how to report problems or obtain assistance

Your equipment will be provided by our community equipment provider, NRS Healthcare. On delivery you will be provided with a copy of the manufacturer’s instructions and you will be shown how to use the bed rails. Once fitted the bed rails should not be removed, if this is necessary you must seek help to re-fit them.

We advised that you carry out safety checks which should include the following:

Check all parts of the rails to ensure they are in working order

Check for defects:

o Rusting or cracks in metal frame or joints

o Flaking paintwork

o Missing locking handles and fixing clamps, loose fixings, looseness in joints

o Worn threads on clamps

o Bent or distorted features

If you discover any damage, defects or problems operating the bed rails then you must

immediately call the number detailed below in the contact section.

Some types of equipment are scheduled to have maintenance checks. You will be contacted by our equipment provider when the check is due. It is important that if your equipment needs a check that you allow the equipment provider to carry this out. A health or social care professional will also carry out a

planned review to check the bed rail is safe.

Safe Use of Bed Rails in the Community Information for Patients/Carers and Relatives

INSTRUCTIONS

MAINTENANCE AND SAFETY CHECKS




All parts of the bed safety rails can be cleaned with a mild detergent using a cloth. Avoid letting water run inside the tubes via the holes. If bumpers are used they should be wiped clean using a mild detergent solution or follow the manufacturers washing instructions.

It is important that you or your carer(s) monitor the use of the bed safety rails and you or your carers are advised to check the bed rails weekly to ensure no signs of damage or faults. You or your carers should report any of the following changes: Any changes in physical condition or mental health of user

If bed rail moves out of position and a gap appears between the bed rail and side of the mattress

If the mattress becomes ‘saggy’ at the sides and if weight is applied creating an increased gap between the bottom

of the bed rail and compressed mattress

Please report any obvious hazards to your line manager (formal carers) or to the person named below. Please look out for and report:

Changes in the lying position of the person or their behaviour which affects the way they use the bed rail

Difficulty in using or securing the bed rail

Additional adaptations which may have been made by the family

Report all accidents, incidents and hazards

CLEANING

USE OF BED RAILS

CARERS

CONTACT DETAILS




Appendix 6

SAFE USE OF BED RAILS AND DIMENSIONS




Appendix 7 Training needs Analysis

Training topic: Safe Use of Bed Rails

Type of training: (see study leave policy)

☒Mandatory (must be on mandatory training register) (Through

Moving and handling all staff and falls awareness for inpatient staff)

☒Role specific (through falls awareness for community staff)

□ Personal development

Division(s) to which the training is applicable:

☒Adult Mental Health & Learning Disability Services

☒Community Health Services

□ Enabling Services

□ Families Young People Children

□ Hosted Services

Staff groups who require the training:

All staff assessing patients / service users for the use of bed rails and working with patients / service users with bed rails

Regularity of Update requirement:

2 yearly

Who is responsible for delivery of this training?

Included in Falls Awareness training and Moving and handling training

Have resources been identified?

a/a

Has a training plan been agreed?

n/a

Where will completion of this training be recorded?

☒ULearn = Falls Awareness

☒ Other (please specify) = face to face Moving and Handling

How is this training going to be monitored?

Through mandatory training reports and audits




Appendix 8

The NHS Constitution

The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services

Shape its services around the needs and preferences of individual patients, their families and their carers

☒

Respond to different needs of different sectors of the population ☒

Work continuously to improve quality services and to minimise errors ☒

Support and value its staff ☒

Work together with others to ensure a seamless service for patients ☒

Help keep people healthy and work to reduce health inequalities ☒

Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

☒




Appendix 9

Due Regard Screening Template

Section 1 Name of activity/proposal Safe Use of Bed Rails Policy for Adults

Date Screening commenced 23/4/18

Directorate / Service carrying out the assessment

Community Health Services

Name and role of person undertaking this Due Regard (Equality Analysis)

Stephanie O’Connell

Give an overview of the aims, objectives and purpose of the proposal:

AIMS: The aim of this policy is to ensure the safety of all patients / service users using bed rails in

all care settings, whilst promoting their independence and respecting their right to make their own decisions about their care

OBJECTIVES: To ensure that bed rails are only used where assessed to be clinically appropriate, with minimum

risk and in patients best interests

To support staff in effective decision making when assessing for safe use of bed rails

To guide staff in appropriate management of bed rail equipment

Section 2 Protected Characteristic If the proposal/s have a positive or negative impact

please give brief details

Age No impact

Disability Ensures bed rails are used only in patient’s best interests

Gender reassignment No impact

Marriage & Civil Partnership No impact

Pregnancy & Maternity No impact

Race No impact

Religion and Belief No impact

Sex No impact

Sexual Orientation No impact

Other equality groups? No impact

Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below.

Yes No High risk: Complete a full EIA starting click here to proceed to Part B

Low risk: Go to Section 4. √ Section 4 If this proposal is low risk please give evidence or justification for how you reached this decision:

This is an update of an existing policy and assessed to have no significant impact on people from equality groups

Signed by reviewer/assessor Stephanie O’Connell Date 23/4/18

Sign off that this proposal is low risk and does not require a full Equality Analysis

Head of Service Signed Date

http://www.leicspart.nhs.uk/Library/MasterDueRegardTemplateOct2013.docx




Appendix 10

PRIVACY IMPACT ASSESSMENT SCREENING

Privacy impact assessment (PIAs) are a tool which can help organisations identify the most effective way to comply with their data protection obligations and meet individual’s expectations of privacy. The first step in the PIA process is identifying the need for an assessment.

The following screening questions will help decide whether a PIA is necessary. Answering ‘yes’ to any of these questions is an indication that a PIA would be a useful exercise and requires senior management support, at this stage the Head of Data Privacy must be involved.

Name of Document: Safe Use of Bed Rails Policy for Adults

Completed by: Stephanie O’Connell

Job title: CHS Lead Therapist Date 23/4/18

Yes / No

1. Will the process described in the document involve the collection of new

information about individuals? This is information in excess of what is required to carry out the process described within the document.

NO

2. Will the process described in the document compel individuals to

provide information about themselves? This is information in excess of what is required to carry out the process described within the document.

NO

3. Will information about individuals be disclosed to organisations or

people who have not previously had routine access to the information as part of the process described in this document?

NO

4. Are you using information about individuals for a purpose it is not

currently used for, or in a way it is not currently used?

NO

5. Does the process outlined in this document involve the use of new

technology which might be perceived as being privacy intrusive? For example, the use of biometrics.

NO

6. Will the process outlined in this document result in decisions being

made or action taken against individuals in ways which can have a significant impact on them?

NO

7. As part of the process outlined in this document, is the information about individuals of a kind particularly likely to raise privacy concerns or expectations? For examples, health records, criminal records or other information that people would consider to be particularly private.

NO

8. Will the process require you to contact individuals in ways which they may find intrusive?

NO

If the answer to any of these questions is ‘Yes’ please contact the Head of Data Privacy Tel: 0116 2950997 Mobile: 07825 947786 [email protected] In this case, adoption of a procedural document will not take place until approved by the Head of Data Privacy.

IG Manager approval name:

Date of approval:

Acknowledgement: Princess Alexandra Hospital NHS Trust

mailto:[email protected]


