Acute In-patient UnitsStandard Operating Procedure (SOP)

Document SummaryTo outline the role and function of Acute Inpatient Unit’s operating within Cumbria Partnership Trust.

To provide guidance to this multidisciplinary team to deliver high quality care to adults, young people, and relatives / carers.

DOCUMENT NUMBER AI 01DATE RATIFIED September 2016

RATIFIED BY Jill Archibald

DATE IMPLEMENTED September 2016

NEXT REVIEW DATE September 2017

ACCOUNTABLE MANAGER Acute and Urgent Care Manager

AUTHOR Jill Archibald

VERSION CONTROL V1.0

Important Note:The Intranet version of this document is the only version that is maintained.

Any printed copies should therefore be viewed as “uncontrolled” and, as such, may not necessarily contain the latest updates and amendment

1. INTRODUCTION

1.1 Purpose of this document

To outline the role and function of all the Acute In-patient Units operating within Cumbria Partnership Trust.

To provide guidance to the multidisciplinary team to deliver high quality care to adults, young people, relatives / carers.

1.2 Principles and Values

1.2.1 The underlying philosophy of the Units concentrates on social inclusion and recovery.

Staff on all in-patient wards will work together with service users who experience problems with their mental health. Using evidence based practice approach, the care given will be a stepping-stone for ensuring a commitment to enable recovery and promote social inclusion. A learning environment for both staff and service users will be promoted.

- The in-patient unit’s are an integral part of the service provision to service users within the Cumbria population and as such should be viewed as a major stakeholder in the provision of hospital and community based services, such as the Access and liaison Service, Home Treatment Teams, and the community mental health teams.

- The in-patient units are committed to implementing a brief solution model of care delivery. This will be undertaken by utilising the skills of the in-patient nurses, formal training and co-opting of specialist trainers where necessary.

- The in-patient units are committed to providing its staff with the skills necessary to undertake the care of service users in the most acute phase of illness.

- The in-patient units are committed to MDT collaboration and will actively engage with other services in order to provide quality care and a seamless approach to service user care delivery, to enable recovery and promote social inclusion.

1.3 Equality and Diversity

1.3.1 The acute in-patient service accepts that, to accommodate the needs of the community that it serves, it must ensure the highest levels of awareness and understanding of equality and diversity amongst its staff. This service aims to deliver acute healthcare services that are equitable and are appropriate to each person’s needs regardless of age, disability, race, gender, religion/ belief, sexual orientation or domestic circumstances, as per the Equality Act 2010.

1.3.2 All of the in-patient units will make reasonable adjustments to support people who require additional needs.

1.3.3 Guidance on national legislation, training and support can be accessed through the Human Resources Team or via email: equality@cumbria.nhs.uk

2. Scope This Operational Procedure applies to all staff, secondees, students and volunteers engaged in delivering services on the Unit or on behalf of CPFT.

3. THE SERVICE

3.1 Service Location and Operational Hours

There are 4 acute in-patient units through Cumbria. They are all registered CQC registered.

Hadrian Unit Dova Unit Carleton Clinic Dane Garth Cumwhinton Drive BarrowCarlisleTel: 01228 602000

Yewdale Ward Kentmere WardWest Cumberland Hosp Westmorland Hosp

Regulated Activities: Assessment of medical treatment for persons detained under the Mental Health Act 1983;

Treatment of Disease, Disorder or Injury

3.1.2. The Units operate 24 hours per day, 7 days per week. Certain therapies, interventions and activities will only be available during set times, or on specific days.

3.1.3 Visiting hours on the Unit are: Monday to Friday: 6pm – 8pm Saturday and Sunday: 2pm – 4pm, and 6pm – 8pm

3.1.4 There are designated areas for visiting children who under 18 years old.

3.2 Service Description

3.2.1 All 4 units are mixed sex needs-led acute ward for adults. Each Unit are designated places of safety under 136 of the Mental Health Act. The Units work with service users who have a primary presentation of acute functional mental illness who require an inpatient episode because they are:

At risk of immediate and significant self harm/suicide/self-neglect An immediate and significant risk to others due to their mental health

In circumstances where there is immediate risk of the breakdown in normal life or support network

At significant risk of personal vulnerability and exploitation

3.3 Staffing and Shift Patterns

Each ward works with safe staffing levels. There are qualified RMNs working each shift along with HCA’. Each ward has individualised rota systems. There is a minimum staffing level required for each ward, with systems in place to increase staffing based on dependency of patients at that time.

3.3.3 Throughout the early and into part of the late shifts, there will also be various input on the Unit from other members of medical, rehabilitation, therapeutic and support staff.

3.4 Meal times

3.4.1 Meals will always be served and supervised by members of staff, during the designated, protected meal times.

Breakfast: 08.00 Lunch: 12.00 – 12.30 Dinner: 17.00 – 17.30 Supper: 21.00 – 21.30

3.4.2 Patients should be encouraged to eat their meals in the communal dining area, unless this would not be appropriate based on the patients clinical presentation.

3.4.3 Hot and cold drinks are available to patients 24 hours a day.

3.5 Referral Criteria

3.5.1 Who we work with

Each of the units work with adults who have a primary presentation of acute functional mental illness who require an inpatient episode, as it is not viable to provide or continue home treatment as they are:

At risk of immediate and significant self harm/ suicide or self neglect due to their mental health and/or

At immediate and significant risk to others due to their mental health. In circumstances where there is immediate risk of the breakdown in normal

life or support network. In circumstances where existing community service user is already receiving a higher

level of input due to the level of deterioration of their mental state, or the increased level of risk.

A significant risk of personal vulnerability and exploitation. A significant risk of mental health deterioration without mental health

intervention. All service users are aged 18 and above

How people access our service

3.5.2 The ALIS will be the ‘gatekeepers’ for all the referrals to the in-patient service. The ALIS/HTT will be contacted by professionals in the case of all individuals they refer for in-patient admission, either through emergency or planned routes via their GP; Out-Patients, Community Mental Health Teams (CMHTs), First steps, (PCT) Accident & Emergency Acute ward within general hospitals (MAU) and Mental Health Act 1983 assessments, Section 136 assessments via the Police.

For further details please see Operational Policy for ALIS/HTT.

3.5.3 Assessments under section 136 of the Mental heath Act (1983)This Section refers to the police power to remove to a place of safety a person who appears to them to be suffering from a mental illness to enable him/her to be examined by a doctor and interviewed by an Approved Mental Health Professional. A designated place of safety is identified on all 4 wards. When a 136 assessment requires an admission then it is the responsibility of the ALIS and ASW to identify the appropriate placement.

4. Entry and Exit to the Unit

4.1 Patients and their belongings are to be searched for contraband goods, prior to entry to the Unit. The list is not exhaustive, but includes alcohol, drugs (including ‘legal highs’), and anything that could be used as weapons. The Trust Policy Searching of Service Users Person, Rooms and Personal Belongings Policy, provides specific guidance on this process.

4.2. Where visitors consistently bring or attempt to bring contraband items onto the Unit, they will be asked to leave, and if it is an illegal substance or weapon, the Police are to be informed.

4.3 Food and drink items brought onto the Unit must be declared to staff, to ensure that they are appropriate, and do not contravene Health and Safety and Food Safety standards.

5 Health, Safety and Security

5.1 All staff are required to collect an alarm Blick from the designated area of each Unit, upon entry.Alarms are to be returned to at the end of each shift, where they will be charged..

5.2 All staff are required to wear their Trust ID whilst on the Unit.

5.3 All visitors and contractors to the Unit are required to sign in and out at the reception of the units, and will be issued with an alarm as deemed appropriate. As applicable ID will be requested before entry onto the Unit is permitted.

5.4 The Shift Lead is aware of the staff members who are due to be on duty, and in the event of an absence, would be responsible for attempting to contact the person.

5.5 Fire alarm tests are conducted regularly, however in the event of a Fire or emergency situation; staff are to follow the local fire evacuation procedures and plans (see associated fire plan).

5.6 Smoking is not permitted in any internal area. Smoking is only permitted in the designated areas only.

6. Acute Admissions Pathway

Each In-patient ward follows the Acute Admissions Pathway AAP. Prior to admission the purpose will be identified and agreed. The admission pathway can take 72 hours to complete. Within 72 hours the patient will be reviewed by a consultant psychiatrist within a Multi-Disciplinary Team meeting and treatment plan and estimated discharge date will be agreed.

6.1 Admission

6.2 Admissions are coordinated by the Access and Liaison Integrated Service (ALIS) team, who act as ‘gatekeepers’ to inpatient beds. If the patient is already under the care of the Community Mental Health Team (CMHT), their care co-ordinator is to be notified of their admission.

6.3 A daily (Monday to Friday) teleconference takes place at 11am, coordinated by the Trust Bed Manager, which includes all inpatient mental health units and ALIS (crisis) team managers from across the County. This provides a forum for all teams to discuss bed status, and potential admissions.

6.4. A key worker is allocated for every patient admitted. During the period of admission, the key worker role may change. The views of the patient will be sought before any change of the key worker takes place.

6.5 In the event of a section 136 to the room at the reception area, Unit staff will be notified by the ALIS (crisis) team and/or Police in the event that support is required. (Please see the associated process flowchart – S.136 suite support process).

7 Assessment Process

7.1 Upon admission , whether a patient is formally detained or admitted on an informal basis, patients must be read and given a copy of their legal rights.

7.2 Where a person does not understand their rights, re-readings must be scheduled to take place which will be entered into the Unit diary, and documented in the patient record. (Please refer to the associated flow chart for further guidance).

7.3 As capacity and consent can fluctuate, the reading and understanding of patient rights will be re-visited at regular intervals and documented in the patient record.

7.4 Within 2 hours of admission to the Unit, the patient (involving the family/carer as appropriate) will be assessed by a qualified mental health nurse (admitting nurse). The assessment will be holistic, which will enable an initial care plan to be formulated. The Mental Health Inpatient Admission Pack will be commenced.

7.5 As part of the assessment, there will be an initial physical health check completed by Unit staff, and this will also be documented within the initial care plan.

8 Clinical Risk Management

8.1 As part of the assessment process patients will have a risk assessment completed. A copy of the completed, up to date assessment should be printed and stored within the patient’s integrated record of care.

8.2 Within adult mental health care the primary assessment tool for clinical risk is the Galatean Risk Screening Tool (GRiST) which screens across various dimensions of risk including violence, suicide, self-harm and vulnerability. Where initial assessment indicates risk of suicide, violence or sexual violence further assessment should be undertaken by clinicians qualified in the use of approved tools.

8.3 Where there is a risk of harm to others identified, the Police will need to be contacted. This may necessitate a MARE referral, as per Trust Policy ‘MAPPA / Multi-Agency Risk Evaluation’.

8.4 GRIST assessments should be reviewed regularly (weekly), or more frequently as required, and upon discharge from the Unit. The findings from these are to be considered by the Dova team. Where appropriate findings should be discussed with the patient and family/carers.

8.5 Reviews will be convened at key points in the patients care episode i.e. based on level of risk identified, expected changes in risk, prior to change of members of their care team and whenever their circumstances or presentation changes or planned interventions have continued for a set period.

8.6 The CPFT Clinical Risk Policy describes a “5-step” structured professional judgement approach to risk management (Doyle & Dolan 2007) to assist in screening, assessing, formulating, communicating and managing clinical risk which is consistent with the principles of positive risk management. This approach is aimed at being preventative rather than predictive, ensuring risk assessments are closely linked to risk formulation and preventative management interventions.

8.7 The GRIST and the 5-step approach support a descriptive formulation and the preparation of a balanced and proportionate positive risk management plan relevant across a number of types of risk situation.

8.8 The 5 step approach as outlined in the Clinical Risk Policy should be followed by clinicians when completed a GRiST assessment.

9 Care Planning

9.1 Each patient will have an up to date individualised care plan formulated (on IER) following admission, which will determine the level of observations for the patient. Please refer to the associated Observations Process document and Trust Policy ‘Supported Observations Policy’.

9.2 The initial care plan will be formulated as part of the assessment process, and further developed following the completion of all admission assessments (within 72 hours) e.g. full physical health checks, screening tools.

9.3 Each care plan is collaboratively determined between the key worker, and patient. Integral to the treatment plan is a goal or set of goals to be achieved.

9.4 It is recognised that circumstances change and it may be necessary to adjust the care plan accordingly.

9.5. A copy of the up to date care plan should be printed off, signed by both the key worker and patient (if appropriate) and stored in the integrated patient notes. A copy should also be offered to the patient. Where a patient does not sign or refuses to receive a copy of their plan, this should be documented in the patient care plan.

9.6 Care plans should be reviewed and updated weekly, or more often as required to meet the current needs of the patient. Risks identified within the GRIST assessment should be reflected within the care plan, along with appropriate actions.

10 Physical Health Monitoring

10.1 Upon admission to the Unit all patients will be encouraged to have a basic physical health check, which includes: assessment of skin conditions, temperature, pulse, respirations, BP, height and weight, urine analysis, documentation of any allergies, history of any drugs, underlying medical conditions, medication history, evidence of cognitive impairment and any signs of intoxication. Please refer to the Trust procedure document ‘Physical Examination and Care of Service Users Policy and Procedures’ for more information.

10.2 On the next working day a physical health pro-forma will be completed by the Unit based Doctors, which will include a VTE assessment, blood tests and physical health examination.

10.4 Where patients are on Anti-Psychotic medications, physical monitoring records should be implemented.

10.5 If a patient is subject to rapid tranquilisation or restraint, then physical health checks should be carried out regularly, as per the Trust Rapid Tranquilisation Protocol and should be recorded on the physical health monitoring form, held within patient records.

10.6 Where a patient’s physical health condition deteriorates, or they c complain of feeling physically unwell, the Medical Early Warning System (MEWS) assessment form should be completed and action taken based on the algorithm within the Trust procedure document ‘Physical Examination and Care of Service Users Policy and Procedures’.

11 Activities

There is a dedicated Occupational Therapist for each ward, plus activity coordinators who organise weekly activities for patients.

11.1 Unit staff will ensure that patients are aware of the activities that are available on a daily basis, and will encourage engagement.

11.2 As part of the continued assessment process, following admission, the Activity Co-ordinator will meet with the patient to discuss the activities on the Unit and to complete the Activities Assessment Booklet, and pre-exercise screening tools. These are to be filed in the patient record.

11.3 Completion of the Activity Assessment booklet to be documented within the patient records, and it is to be documented if a patient does not want to take part in the activities offered.

12 Patient Review Meetings

Review Meetings:

12.1 Each individual patient will have an initial review within 3 days following admission to the Unit. Where applicable the care coordinator and / or member of the ALIS team should attend.

12.2 A further review should be arranged as and when required either with the Consultant Psychiatrist or other Senior Medical Officer. Where significant changes or decisions are to be made the care coordinator and member of the ALIS team should also attend, and the review should be arranged with Consultant Psychiatrist.

12.3 In preparation for the review the named nurse or delegated nurse should evaluate the patient care over the past 7 days identifying any areas for discussion in the MDT and ensuring a summary is written in the clinical record. They will also meet with the patient on a 1-1 basis to identify with the patient any concerns or issues or plans for discussions at the MDT

12.4 Following the weekly review, the care plan and GRIST assessment should be updated, and a further review appointment booked.

Multi Disciplinary Team (MDT) Meetings:

6. Acute Admissions Pathway

Upon admission to Hadrian Unit, the admitting nurse will begin the Admission Procedure document. This will then be later completed by the named nurse. The document needs to be filed in the patient record.

6.1 Admission to the ward

6.2 Admissions are coordinated by the Access and Liaison Integrated Service (ALIS) team, who act as ‘gatekeepers’ to inpatient beds. If the patient is already under the care of the Community Mental Health Team (CMHT), their care co-ordinator is to be notified of their admission.

6.3 A daily (Monday to Friday) teleconference takes place at 11am, coordinated by the Trust Bed Manager, which includes all inpatient mental health units and ALIS (crisis) team managers from across the County. This provides a forum for all teams to discuss bed status, and potential admissions.

6.4. A key worker is allocated for every patient admitted. During the period of admission, the key worker role may change. The views of the patient will be sought before any change of the key worker takes place.

6.5 In the event of a section 136 to the room at the reception area, Unit staff will be notified by the ALIS (crisis) team and/or Police in the event that support is required. (Please see the associated process flowchart – S.136 suite support process).

7 Assessment Process

7.1 Upon admission, whether a patient is formally detained or admitted on an informal basis, patients must be read and given a copy of their legal rights.

7.2 Where a person does not understand their rights, re-readings must be scheduled to take place which will be entered into the Unit diary, and documented in the patient record. (Please refer to the associated flow chart for further guidance).

7.3 As capacity and consent can fluctuate, the reading and understanding of patient rights will be re-visited at regular intervals and documented in the patient record.

7.4 Within 2 hours of admission to the Unit, the patient (involving the family/carer as appropriate) will be assessed by a qualified mental health nurse (admitting nurse). The assessment will be holistic, which will enable an initial care plan to be formulated. The Mental Health Inpatient Admission Pack will be commenced.

7.5 As part of the assessment, there will be an initial physical health check completed by Unit staff, and this will also be documented within the initial care plan.

8 Clinical Risk Management

8.1 As part of the assessment process patients will have a risk assessment completed. A copy of the completed, up to date assessment should be printed and

stored within the patient’s integrated record of care.

8.2 Within adult mental health care the primary assessment tool for clinical risk is the Galatean Risk Screening Tool (GRiST) which screens across various dimensions of risk including violence, suicide, self-harm and vulnerability. Where initial assessment indicates risk of suicide, violence or sexual violence further assessment should be undertaken by clinicians qualified in the use of approved tools.

8.3 Where there is a risk of harm to others identified, the Police will need to be contacted. This may necessitate a MARE referral, as per Trust Policy ‘MAPPA / Multi-Agency Risk Evaluation’.

8.4 GRIST assessments should be reviewed regularly (weekly), or more frequently as required, and upon discharge from the Unit. The findings from these are to be considered by the Dova team. Where appropriate findings should be discussed with the patient and family/carers.

8.5 Reviews will be convened at key points in the patients care episode i.e. based on level of risk identified, expected changes in risk, prior to change of members of their care team and whenever their circumstances or presentation changes or planned interventions have continued for a set period.

8.6 The CPFT Clinical Risk Policy describes a “5-step” structured professional judgement approach to risk management (Doyle & Dolan 2007) to assist in screening, assessing, formulating, communicating and managing clinical risk which is consistent with the principles of positive risk management. This approach is aimed at being preventative rather than predictive, ensuring risk assessments are closely linked to risk formulation and preventative management interventions.

8.7 The GRIST and the 5-step approach support a descriptive formulation and the preparation of a balanced and proportionate positive risk management plan relevant across a number of types of risk situation.

8.8 The 5 step approach as outlined in the Clinical Risk Policy should be followed by clinicians when completed a GRiST assessment.

9 Care Planning

9.1 Each patient will have an up to date individualised care plan formulated (on IER) following admission, which will determine the level of observations for the patient. Please refer to the associated Observations Process document and Trust Policy ‘Supported Observations Policy’.

9.2 The initial care plan will be formulated as part of the assessment process, and further developed following the completion of all admission assessments (within 5 working days) e.g. full physical health checks, screening tools.

9.3 Each care plan is collaboratively determined between the key worker, and patient. Integral to the treatment plan is a goal or set of goals to be achieved.

9.4 It is recognised that circumstances change and it may be necessary to adjust the care plan accordingly.

9.5. A copy of the up to date care plan should be printed off, signed by both the key worker and patient (if appropriate) and stored in the integrated patient notes. A copy should also be offered to the patient. Where a patient does not sign or refuses to receive a copy of their plan, this should be documented in the patient care plan.

9.6 Care plans should be reviewed and updated weekly, or more often as required to meet the current needs of the patient. Risks identified within the GRIST assessment should be reflected within the care plan, along with appropriate actions.

10 Physical Health Monitoring

10.1 Upon admission to the Units all patients will be encouraged to have a basic physical health check, which includes: assessment of skin conditions, temperature, pulse, respirations, BP, height and weight, urine analysis, documentation of any allergies, history of any drugs, underlying medical conditions, medication history, evidence of cognitive impairment and any signs of intoxication. Please refer to the Trust procedure document ‘Physical Examination and Care of Service Users Policy and Procedures’ for more information.

10.2 On the next working day a physical health pro-forma will be completed by the Unit based Doctors, which will include a VTE assessment, blood tests and physical health examination.

10.3 Within 5 working days of admission the patient will be offered the opportunity to undertake a full physical health screening which will take place at the well-being clinic, which includes Smoking Cessation and if appropriate, a Q risk 2 assessment is completed. This is all documented in the ‘My Physical Health’ booklet.

10.4 Where patients are on Anti-Psychotic medications, physical monitoring records should be implemented.

10.5 If a patient is subject to rapid tranquilisation or restraint, then physical health checks should be carried out regularly, as per the Trust Rapid Tranquilisation Protocol and should be recorded on the physical health monitoring form, held within patient records.

10.6 Where a patient’s physical health condition deteriorates, or they complain of feeling physically unwell, the Medical Early Warning System (MEWS) assessment form should be completed and action taken based on the algorithm within the Trust procedure document ‘Physical Examination and Care of Service Users Policy and Procedures’.

11 Activities

There is a dedicated Occupational Therapist on each unit, plus activity coordinators dedicated to delivering programmed activities and 1-1 sessions for patients.

11.1 Unit staff will ensure that patients are aware of the activities that are available on a daily basis, and will encourage engagement.

11.2 As part of the continued assessment process, following admission, the Activity Co-ordinator will meet with the patient to discuss the activities on the Unit and to complete the Activities Assessment Booklet, and pre-exercise screening tools. These are to be filed in the patient record.

11.3 Completion of the Activity Assessment booklet to be documented within the patient records, and it is to be documented if a patient does not want to take part in the activities offered.

12 Patient Review Meetings

Review Meetings:

12.1 Each individual patient will have an initial review within 3 days following admission to the Unit. Where applicable the care coordinator and / or member of the ALIS team should attend.

12.2 A further review should be arranged each week with either the Consultant Psychiatrist or other Senior Medical Officer. Where significant changes or decisions are to be made the care coordinator and member of the ALIS team should also attend, and the review should be arranged with Consultant Psychiatrist.

12.3 In preparation for the review the named nurse or delegated nurse should evaluate the patient care over the past 7 days identifying any areas for discussion in the MDT and ensuring a summary is written in the clinical record. They will also meet with the patient on a 1-1 basis to identify with the patient any concerns or issues or plans for discussions at the MDT

12.4 Following the weekly review, the care plan and GRIST assessment should be updated, and a further review appointment booked.

Multi Disciplinary Team (MDT) Meetings:

12.5 Every day at 9am a MDT handover takes place. All patients are discussed and considered for a full MDT review. All actions form the handover and followed up using the AAP pathway using a information.

13 Mental Health Act (MHA) – Detained Patients

13.1 For detained patients appropriate MHA paperwork will be completed as required throughout the admission period.

13.2 All paperwork for patients admitted under the MHA must be checked and sent to the Trust Mental Health Act Legislation Unit.

14 Case Reviews

14.1 Case Reviews will take place on an individual basis for patients who require a more complex review, i.e. MARE, Safeguarding or full Care Pathway Approach (CPA) review.

14.2 All persons to be involved will be identified by the meeting organiser, and will be invited accordingly.

14.3 Following the meeting the care plan and GRIST will be updated accordingly.

15 Shift Handovers

15.1 Shift handovers take place three times each day, they vary depending on the wards, but they do cover Early, Late and Night shift, and will include all qualified nurses on shift on the Unit.

15.2 All admitted patients will be discussed, with priority on clinical risk.

16 Discharge

16.1 The service will have a systematic approach to discharging of patients and should plan this with the patient and their carer / relatives (as appropriate) from the start of any individual admission as part of a systematic approach, following the AAP

16.2 The patient and family/carer will be offered the interventions that are evidence based and most appropriate to their needs. 16.3 To mitigate against any potential risks in relation to discharge of an adult or young person, the following steps must be completed prior to discharge from the service:

Review of risk and updating of GRIST Care plan to be updated. Medication (as required) - tablets to take out (TTO) - usually 7 days medication.

16.4 On discharge, the provider will communicate with the family / carer, Care Co-ordinator, GP and referrer and any other professional involved.

16.5. A formal written discharge summary will be provided to the referring agency that outlines treatment summary, progress, discharge planning and follow up, and a copy to the GP. This will be provided as soon as possible but within7 working days as a maximum.

17 Transfer of Patients

17.1 Where transfer of patients is to take place this will be done during daily working hours (e.g. 9am – 5pm), unless there is a need for an emergency transfer e.g. to the Psychiatric Intensive Care Unit (PICU).

17.2 Where transfer takes place, it will be done so to ensure that patient’s safety, respect and dignity is maintained.

18 Service User Involvement and Feedback 18.1 Each unit utilise’s the Meridian system to obtain patient feedback upon, or near to discharge from the Unit. Patients complete the feedback questionnaire on an I-Pad, that is held within the staff office.

18.2 Patient feedback information from Meridian will be reviewed regularly by the Ward Management team, and fed back to staff at team meetings. Patient Experience Team information will be displayed on the Unit.

18.3 Each unit has a family carer involvement plan that incorporates, identifying carers, involving carers and identifying their needs.

19 GOVERNANCE

19.1 Professional Governance

The service will apply the principles of sound clinical and corporate governance and undertake systematic risk assessment and risk management to deliver the requirements of the Care Quality Commission (CQC), Monitor and other relevant bodies.

20 Clinical Governance

The service will have mechanisms for:

Contribution and input into the acute and urgent care governance Audit and evaluation Emotional Health and Well Being outcomes Patient, carer and families feedback

21 Evidence Based Practice

21.1 The service will adhere to all relevant regulations, governance/NSF frameworks and NICE requirements by following agreed care pathways as these are developed or amended. The service will demonstrate that staff keep abreast of developments in the field including NICE guidance and maintain appropriate standards of clinical governance.

21.2 The service will regularly audit performance, and will ensure that audits undertaken will be completed in line with the current audit calendar. Findings from audits will be fed back to staff as applicable, and used as a baseline for improving service provision. As applicable, audits will be registered on the Trust CAPS 2 audit site.

22 Medicines & Prescribing

22.1 Prescribing practice will follow agreed local guidelines, including:

Staff to be competent in their administration, with monitoring taking place as part of staff supervision,

Medicine recording should be accurate and timely

22.2 Further guidance on the management of medications can be found in the Trust Medicines Policy.

23 Incident reporting, Risk Assessment and Escalation of Issues

23.1 When reporting an incident, all staff are required to follow the duties and responsibilities as detailed in the Trust’s ‘Incident and SIRI and Near Miss Reporting Policy’.

All staff will adhere to the policy described above, in particular they will:-

Report incidents and near misses. Raise any concerns about situations that led to, or could lead to, an

incident or a near miss with their line manager, risk management department or appropriate Trust specialist adviser.

Not file copies of completed incident forms in clinical records. Attend court as a witness in an inquest if called to do so. Provide details and share information in relation to learning lessons from

incidents.

23.2 Risk assessments that are completed in the department will be shared with staff and regularly reviewed and updated by the Service or Ward Manager.

23.3 All identified hazards and incidents should be reported to the nurse in charge, or Service / Ward manager immediately, and where there is a significant issue that arises out of usual daytime operational hours, then this would need to be escalated within the Trust to the Bronze on Call manager, via the Carleton Clinic, Carlisle on 01228 602000, or the Police as appropriate.

24 Safeguarding

24.2 All Unit staff are expected to attend safe safeguarding training appropriate to their role and as indicated in Trust guidance on mandatory training requirements in relation to safeguarding.

24.1 If there is a safeguarding concern, both Health and the local authority should ensure that lines of communication are opened and remain open during the process of referral, assessment, care planning and reviews. Staff must follow the CPFT ‘Safeguarding Policy’.

25 Information Sharing

25.1 The Trust will only share information with other agencies on a need to know basis or when required to do so under the law or for the purpose of the protection of the public or the best interests of the patient. Information will only be shared when it is in the best interest of the individual. Informed consent to share information will be obtained from the individuals.

25.2 For further information please refer to the Trust’s ‘Confidentiality Policy’ and also the ‘Information Sharing Policy’.

26 Record Keeping Standards

26.1 Patient records will be maintained in line with Trust record keeping standards and guidelines, accurately reflecting the patients care and treatment whilst under the care of the Unit team. Please refer to the ‘Information Lifecycle and Records Management Policy’ for further guidance.

26.2 Records will be audited regularly, with findings fed back to staff, and will be reviewed as part of the individual supervision process.

27 STAFFING

27.1 Roles and Responsibilities

27.2 Each patient who is admitted will have a named nurse who also holds the role of key worker. Occasionally, the role of key worker and nurse responsible for delivering the treatment may be different. Where this occurs, the key worker roles becomes a co-ordinating and administrative role.

27.3 Each shift will have a dedicated Shift Coordinator who will delegate tasks as required, e.g. from the daily and weekly tasks lists. Tasks must be initialled / signed to indicate completion, and any issues raised to the shift lead.

27.4 Unit staff are expected to adhere to all of the Trust standards of conduct and policies.

28 Workforce Competencies

28.1 All staff working in the services are required to be competent in the core functions (Skills for Health2) including:

Effective communication and engagement Assessment Safeguarding and welfare Care coordination

Health promotion Supporting transitions Multi agency working

Sharing information Professional development

Safeguarding and promoting the welfare of children Supporting transitions Multi-agency working Sharing information

29 Clinical Placements

29.1 Recognising its commitment to clinical education and training; Hadrian Unit provides learning opportunities and clinical placements for a variety of disciplines, such as nursing, medical, Police and rehabilitation.

30 Staff Meetings

30.1 Staff meetings will be scheduled on a monthly basis, with all members of the team invited to attend.

30.2 There will be a set agenda for the meetings, covering topics that reflect the Trust and locality governance arrangements e.g. risk, lessons learned, performance, and service development. The agenda should be open to all staff to contribute items for discussion.

30.3 Meetings are to be minuted, with action points clearly documented, and then to be circulated to all members of staff.

30.4 Where staff cannot attend, for example those who are on a night shift; specific information from the meeting needs to be cascaded from the Ward Manager / Clinical Lead.

31 REVIEW

31.1. This Operational Procedure will be routinely reviewed 12 months from the date of ratification on the front page. Should there be any significant changes to service delivery within this timeframe, this Operational Procedure will be reviewed accordingly.

31.2 Appendices to this document will be reviewed and updated as required to ensure that the individual procedures described reflect current practice standards.

32 RELATED TRUST POLICIES AND GUIDELINES.

Management supervision policy Clinical supervision policy Personal development and appraisal policySafeguarding policyConfidentiality policy Information sharing policy Incident and SUI reporting policy

Policy for the maintenance of professional registration Clinical risk policySickness and absence policyPolicy on supportive observations on inpatient units.Policy for the management of service users missing or absent without leave. MHA guidelines for informal leave arrangementsProtocol for the management of informal patient’s leave from adult acute mental health in-patient wardsAge appropriate admissions policyEntry & exit policy for mental health and learning disabilities wardsSearching of service users person, rooms and personal belongings policyMAPPA / Multi-Agency Risk Evaluation.Medicines (and associated) Policies.Rapid Tranquilisation Protocol.Physical Examination and Care of Service Users Policy and ProceduresInformation Lifecycle and Records Management Policy

Some related / specific Trust Policies and guidelines are described above, however all Trust Policies can be found via the link below:

http://www.cumbriapartnership.nhs.uk/policy-documents.htm

Specifically all Clinical and Mental Health Act related Policies and documents can be found via the links below:

http://www.cumbriapartnership.nhs.uk/clinical-policies.htm

http://www.cumbriapartnership.nhs.uk/mental-health-act.htm

APPENDIX.

Supporting Documentation:

Item Name Location / LinkAssessment FlowchartObservations PathwayL1 Observations ChecklistL2 Observations ChecklistL3 Observations ChecklistMHA Paperwork Process PathwayS.136 Suite Support ProcessPhysical Health ProformaMH Inpatient Admission PackMy Physical Health BookletActivities Assessment Booklet

Pre Exercise Questionnaire

GP Letter – medications

Observation Risk Review Proforma

Admission Checklist – young personsWard Information Pack

Record of Observations

Capacity and Consent Flowchart (Informal Patients)Capacity and Consent Flowchart (Formal Patients) Fire and Emergency Procedures.

Physical Health Checklist (patients on antipsychotic medications)