Document Title Engagement and Observation Policy… · 2020-03-05 · observation following an...

Document Title Engagement and Observation Policy

Reference Number CNTW(C)19

Lead Officer Gary O’Hare - Executive Director of Nursing and Chief

Operating Officer

Author(s) (name and designation)

Vida Morris – Locality Group Nurse Director

Ratified by Business Delivery Group

Date ratified May 2016

Implementation Date July 2016

Date of full implementation

July 2016

Review Date July 2020

Version number V04.5

Review and Amendment

Log

Version Type of change

Date Description of change

V04.4 Extension Nov 19 Extension to Review March 20

& Governance changes

V04.5 Update Mar 2020 Extension to Review to July 2020

This policy supersedes the following policy which must now be destroyed:

Document Number Title

CNTW(C)19 – V04.4 Engagement and Observation Policy

Engagement and Observation Policy

Section Contents Page No.

1 Purpose 1

2 Duties and Responsibilities 1

3 Principles 4

4

4.4

4.5

4.6

4.7

Categories of Observation:

General Observation

Intermittent Observation

Within Eyesight Observation

Within Arms-Length Observation

5

6

7

8

9

5 Who should set the Levels of Observation 10

6 When should Observation Levels be set 10

7 Involving the Patient 11

8 Record Keeping 11

9 Who should carry out Engagement/Observations 12

10 Carrying out Engagement and Observation 12

11 Reviewing Levels of Observation 14

12 Identification of Stakeholders 16

13 Equality Impact Assessment 16

14 Training 16

15 Implementation 17

16 Monitoring Compliance and Effectiveness – see appendix C

17

17 Standard/Key Performance Indicators 18

18 Fair Blame 18

19 Policy Leaflets for Engagement/Observation 18

20 Fraud, Bribery and Corruption 18

21 Associated Documentation 18

22 References 19

Standard Appendices – attached to Policy

A Equality Analysis Screening Tool 20

B Training Checklist and Training Needs Analysis 22

C Audit Monitoring Tool 23

D Policy Notification Record Sheet - click here

Appendices hyperlinked and listed separate to Policy

Appendix No: Description

1 Engagement and Observation Record

2 Leaflet – What does observation mean to me?

3 Engagement and Observation Competency Assessment

4 Engagement and Observation Decision Tree

5 Role of Allocated Nurse

Practice Guidance Notes – listed separate to Policy

Appendix No: Description

EOP-PGN-01

Children, Young People and Specialist Service, Beadnell Mother and Baby Unit

EOP-PGN-02 Nurse Call System

https://www.ntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

https://www.ntw.nhs.uk/content/uploads/2016/08/What-does-observation-mean-to-me-A5-bloom-1.pdf

CNTW(C)19

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust NTW (C)19 – Engagement and Observation Policy V04.5- Mar 2020

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1. Purpose 1.1 The purpose of this Policy is to ensure that all inpatients’ level of engagement

and observation within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust / CNTW) be allocated appropriate to their needs. The clinical risk assessment is the basis for determining levels of engagement and observation and applies to both informal and detained patients.

1.2 The Policy provides a framework for all inpatients in accordance with their

assessed level of risk and identified needs; the aim being to ensure a consistent and effective approach to patient engagement, observation and support within inpatient services across the Trust. This Policy is based upon recommendations from National Institute for Health and Clinical Excellence (NICE) Guideline 25 (2005), Guideline 10 (2015) and the Mental Health Act Code of Practice (2015) and is intended to address the mental health needs of patients who are considered to be vulnerable. This may include risk of suicide, self-harm, harm from or to others; risk associated with physical frailty or physical deterioration, increased risk of falls and sexual disinhibition. The Trust is committed to providing a safe, sound and supportive environment to all patients, carers, visitors and staff. It is recognised that patients may have changing clinical, emotional, behavioural and social needs and may require varying degrees of support, including supportive engagement and observation and a higher level of engagement.

1.3 This Policy sets out the process and procedures for guiding practitioners in

making decisions to ensure a safe and therapeutic environment, to facilitate the assessment and management of an in-patient’s level of engagement and observation, and the rationale for supporting those decisions.

1.4 Positive therapeutic and good engagement and observation can protect the

safety of patients who would be at risk of harm and should never be substituted by containment through the locking of doors in clinical environments. Therapeutic engagement and observation should always be carried out in the least restrictive environment. For more information see CNTW(C)03 – Leave, absent without leave and missing persons Policy, practice guidance note LP-PGN-02 - Entry and Exit from Wards and CNTW(C)10 - Seclusion Policy.

1.5 In addition, the Policy sets out the duties and responsibilities of all Trust and

agency staff in relation to engagement and observation. It is imperative that this policy is read in conjunction with the current safety policies and procedures.

2 Duties and Responsibilities 2.1 Chief Executive 2.1.2 The Chief Executive is responsible for ensuring that:-

An appropriate and adequate infrastructure exists to support the engagement and observation of patients

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2.2 Board of Directors

2.2.1 The Board of Directors is accountable for ensuring that:-

The engagement and observation policy is in place and current and that it is reviewed regularly including following incidents and near misses

The appropriate level of support is provided, including guidance or training for employees, patients and agency staff, in order to meet the needs of this policy and statutory legislative requirement

2.2 Executive Director of Nursing and Chief Operating Officer 2.3.1 The Executive Director of Nursing and Chief Operating Officer is responsible

for:-

The strategic and operational management of the engagement and observation of patients within the Trust. This includes ensuring that a robust policy is developed to ensure appropriate levels of engagement and observation are in place and that monitoring systems are identified to ensure the effectiveness of practice

2.3 Group Directors (North, Central and South Locality Groups) 2.4.1 Group Directors are responsible for ensuring that:-

The engagement and observation policy’s requirements are operationally appropriate

The engagement and observation policy’s requirements are implemented in practice via a robust dissemination process

There is a system in place that ensures all staff receive and have access to this policy

A record is kept that each staff member has seen and understood this policy

2.4 Managers 2.5.1 Managers have a responsibility to:

Ensure that all staff are made aware of policies and receive appropriate training in their application

Ensure that policies are implemented and evaluated appropriately

Ensure that periods of observation are viewed as opportunities for therapeutic engagement and relationship building

Identify/manage and deploy resources to meet service requirements and changing clinical needs

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2.5 Nurse in Charge 2.5.1 The nurse in charge of an inpatient area is responsible for ensuring within their

sphere of responsibility that:-

All staff attend training in relation to this policy

This policy is implemented and documentation completed

This is monitored through audit

They will take action with individual staff where necessary when the policy is not being adhered to

Their ward has appropriate resources to carry out supportive observations

All staff have been assessed against the relevant level of competency to carry out supportive engagement and observations (Appendix 3)

They will ensure that Associate Directors and Clinical Nurse Managers are briefed on any incidents occurring during working hours in relation to the implementation of this policy and in accordance with the Trust’s CNTW(O)05 – Incident Policy

They will ensure that the Point of Contact is briefed on any incidents occurring out of hours in relation to the implementation of this policy and in accordance with the Trust’s CNTW(O)05 – Incident Policy

2.6 Registered Professionals 2.6.1 Registered professionals have a responsibility to:-


Complete engagement and observation care plans for their named patients, involving the patient wherever possible, and for other patients in their care as the need arises

Inform each patient of the level of observation they have been allocated and the reasons for this using appropriate means of communication recognising that not everyone is the same

Review any patients level of observation based on clinical need/risk assessment (increasing or decreasing observations where clinically indicated) involving the patient and carers (with consent) where applicable and appropriate. Ensure that the engagement and observation care plan, wherever possible, is co-produced with the patient and is implemented and engagement and observations recorded in line with this policy

Review the engagement and observation care plan on a regular basis as specified within the review time frames in the plan

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Identify, manage and deploy resources (with guidance from other senior staff or the Point of Contact if required)

This includes being accountable for the decision to delegate engagement and observation to a non-registered member of staff or student in their third year of training, and for ensuring they are sufficiently knowledgeable and competent to undertake this role

Third year students may only undertake engagement and observation following an assessment of their competence by their mentor, co-mentor or Nurse in Charge

2.8 Non-registered staff 2.8.1 Non-registered staff have a responsibility to:-


Be familiar with and implement the engagement and observation care plan for each individual in their care

Complete documentation contemporaneously in preparation for the validation discussion with the Nurse in Charge for that span of duty

Report any relevant information to assist in the effective review of patients’ levels of observation

2.8.2 All clinical staff have a responsibility to familiarise themselves with the engagement and observation policy and act in accordance with the stated requirements.

3 Principles 3.1 Engagement with a patient, including the observation, reporting and recording

of a patient’s mental state, well being and behaviour is central to the care provided within an in-patient unit. Observation and skilled engagement enables staff to learn about patients in their care, to assess their needs, work collaboratively and facilitate the development of a therapeutic and meaningful relationship.

3.2 It is essential that when staff are involved in any level of engagement and

observation that they are fully engaged with the process. Feedback from patients through Trust surveys, questionnaires, comments and complaints show how much they value individual time with ward staff and how important it is to their progress and recovery when an inpatient.

3.3 The act of engaging with and observing patients should be more than ‘seeing’

them. Observations should be viewed as an opportunity for therapeutic engagement in which there should be some benefit for the patient. This benefit needs to outweigh the impact of observations on the patient’s privacy and

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dignity and the fact that some patients’ often see observations as intrusive, unhelpful and coercive.

3.4 Engagement should centre round the use of activity, discussion and distraction

processes, but recognition should also be made of the need for silence and as much privacy as is safely achievable. While the safety of the patient always comes first, the encouragement of communication, listening and conveying to the person that they are valued and cared for are important components of skilled nursing engagement and observation. Observing a patient who is deeply distressed is a skilled intervention and calls for empathy, engagement and readiness to act in the best interests of the patient.

4 Categories of Observation 4.1 The Trust has adopted the terminology as outlined in NICE Guideline 25 (2005):

‘the short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments’. This policy also supports compliance with the Care Quality Commission’s five domains.

General Observation

Intermittent Observation

Within Eyesight Observation

Within Arm’s Length Observation

4.1.1 For increased (enhanced) levels of observation a specific engagement and observation care plan is required

4.2 The least intrusive and restrictive level of observation that is appropriate to the

situation should always be adopted so that due sensitivity is given to a patient’s dignity and privacy whilst maintaining the safety of the patient and/or those around them.

4.3 In line with NICE Guideline 25 (2005), observation above a general level should

be considered if any of the following are present:

History of previous suicide attempts, self harm or attacks on others

Hallucinations, particularly voices suggesting harm to self or others

Paranoid ideas where the patient believes that other people pose a threat

Thoughts or ideas that the patient has about harming themselves or others

Vulnerability of harm from others

Self-control is reduced

Past or current problems with drugs or alcohol

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Recent loss

Poor adherence to medication programmes or non-compliance with medication programmes

Marked changes in behaviour, emotional state or medication

Known risk indicators including escape, absconding and going missing from the ward, risk/vulnerability, sexual behaviour

Patients on adult wards, under age of 18 must be placed within eyesight observation

This policy should also be considered if any of the following risks are indicated:-

o Deterioration or exacerbation of physical health conditions

o Cognitive impairment

o Risk of falls 4.4 General Observation

This is the minimum level for all patients. It will therefore apply to the majority of patients who are considered to be at low risk of vulnerability, suicide, self harm or harm of others

Throughout the span of duty there will be a number of opportunities for staff to be aware of the wellbeing and location of all patients on general observations and in particular during shift handovers, meal times and medication times

During night duty it is acknowledged that there are reduced natural opportunities to engage with patients. It is expected that each patient should be checked at a minimum of hourly intervals. (Any individual exceptions to hourly intervals must be underpinned by a clear clinical rationale and fully discussed and supported by the Multi-Disciplinary Team. The exception must be based on a defensible risk assessment and have a resulting risk management plan in place. The risk management plan must be subject to regular review at timeframes specified in the plan)

The member of staff undertaking the engagement and observation should be able to see clearly that the patient is breathing

The member of staff undertaking the engagement and observation should be able to see the patient’s head and ensure nothing is impeding the patient’s breathing

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If the member of staff undertaking the engagement and observation is not assured about the patient’s breathing they should enter the bedroom to ensure the patient is breathing

Consideration should be given to how an individual’s dignity could be maximised without compromising safety when individuals are in a state of undress, such as when using the toilet, bathing, showering, dressing, etc

At least once during a shift, on both day and night duty, the nurse in charge should ensure that time is set aside to review the mental and physical state of the patient and engage positively with them. The level of observation should be appropriate to meet individual needs, however, if the clinical risk escalates use of increased observation should be considered

An evaluation of the patient’s moods and behaviours should be documented following this in accordance with this policy. This will facilitate effective handover

The location of all patients on day and night duty should be known to staff but not all patients need to be kept within eyesight, however at the commencement and end of each shift the Nurse in Charge should be aware of the location of each patient and briefly engage with them. This will also inform a robust handover process.

4.5 Intermittent Observation

This level is appropriate for patients ‘potentially, but not immediately’, at risk of disturbed/violent behaviour, increased vulnerability, suicide, self harm and may include those who have previously been at higher risk and have had their observation level reviewed by the Multi-Disciplinary Team and reduced

A specific engagement and observation care plan is required that details either the exact intervals at which the observations should be carried out or a specific number of times within a specified time frame that the patient should be observed. This care plan can include individual protective factors which may influence the level or frequency of observations

An appropriately trained staff member (who has been assessed as competent by a qualified member of staff) responsible for carrying out intermittent observations over the prescribed period will have an awareness of the patients whereabouts at all times and will observe the patient either at specified intervals ranging from 15 to 30 minutes or a specified number of times and document this accordingly

For some patients in order to enhance safety intermittent observations should be carried out at varied intervals within a time frame. The varied intervals should be agreed between the Nurse in

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Charge and the members of staff completing the periods of observation during any shift

To ensure that positive engagement can take place, consideration needs to be given to the number of patients a staff member is allocated to observe at any one time. Consideration needs to be given by the Nurse in Charge to the number of staff required for the physical environment and how positively this lends itself to patient engagement and observation


Leave outside of the ward area should be considered in relation to the Trust’s CNTW(C)03 – Leave, absent without leave and missing patient policy, however responsibility for engagement and observation of the patient remains with a member of Trust staff at all times

4.6 Within Eyesight Observation 4.6.1 This level would usually be prescribed when the patient is assessed as being a

significant risk which would be reflected both in the risk assessment and individual care plan

A specific engagement and observation care plan is required. The staff member responsible for carrying out the prescribed observations over the period must document an hourly brief summary of the patient’s behaviour, mental state and general wellbeing

Issues of privacy and dignity, gender and environmental dangers should be discussed and incorporated in the care plan

The care plan must stipulate what the observing nurses are required to do to support the individual during these situations


Consideration should be given to whether the patient may only require ‘within eyesight observation’ at specific times or within specific environments, e.g. times using the bathroom and toilet within specific areas of the ward, at meal times, post visiting time or whilst in education

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This should be based on clinical risk assessment and incorporated into the patient’s individual care plan

The allocated nurse will provide one to one support throughout the whole period of prescribed ‘within eyesight observation’. On specified occasions more than one member of staff may be necessary to carry out this level of observation. The care plan will stipulate the number of nurses required

The responsibility for within eyesight observation should not be transferred to family members, carers and friends; unless in exceptional circumstances which have been agreed, risk assessed and care planned by the multi-disciplinary team.

Leave outside of the ward area should be considered in relation to the Trust’s CNTW(C)03 – Leave, absent without leave and missing patient policy, however the patient will be escorted at all times by a member of the Trust staff

If patients under 18 years of age are admitted to an adult environment they must be placed within eyesight observation or a higher level of observation on admission and for the duration of their stay (as per the Trust’s policy CNTW(C)08 - Young People requiring Emergency Admissions policy)

4.7 Within Arm’s Length Observation 4.7.1 This level will be prescribed for patients at the highest levels of risk and thus

they will need to be nursed in close proximity. Where the care plan identifies a risk in relation to potential violence and aggression consideration must be given to maintaining a safe distance in line with training.

The allocated nurse will provide one to one support throughout the whole period of prescribed ‘within arm’s length observation’. On specified occasions more than one member of staff may be necessary to carry out this level of observation. The engagement and observation care plan will stipulate the number of nurses required

Issues of privacy, dignity and the consideration of gender in allocating staff, and environmental risks need to be discussed and incorporated into the care plan. The staff member responsible for carrying out the prescribed engagement and observations over the period must document hourly, a brief summary of the patient behaviour and mental state


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Consideration should be given to whether observations can be reduced to ‘within eyesight’ once the patient has retired to bed and is asleep. This should be fully discussed within the multi-disciplinary team and reflected in the engagement and observation care plan

Leave outside of the ward area should be considered, only in exceptional circumstances in accordance with the appropriate risk assessment in place, in relation to the Trust’s CNTW(C)03 - Leave, absent without leave and missing patient policy, however the patient will be escorted by a member or the appropriate number of Trust staff at all times

5 Who should set the Levels of Observation 5.1 The prescribing of observation levels should, wherever possible, be the result

of an assessment by the Multi-Disciplinary Team. Nursing staff may need to initiate a level of observation above general level on admission or following a rapid change in the patient’s clinical presentation before discussion with the wider Multi-Disciplinary Team and/or medical staff can take place.

6 When Should Observation Levels be set? 6.1 Assessing levels of observation is an integral part of the admission process,

therefore all patients should be allocated a level of observation as soon as they arrive on the ward. All decisions about the specific level of observation should take into account:-

The patient’s current mental state as outlined in Point 3 Categories of observation

The patient’s current physical health status

Any prescribed medications and their effects and/or illicit substances and alcohol

The views of the patient and carer as far as possible

The timing of the review

Consideration should be given to periods of identified increased risk such as evenings and night; nursing handover periods, meal times, post visiting times; following a reduction in the levels of engagement and observation; improvement in mood, etc and document how specified actions can be taken.

6.2 Observation levels MUST be reviewed and documented if the patient’s risk

status changes.

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7 Involving the Patient 7.1 Every effort should be made to discuss, inform and explain to the patient about

the level of observation and any requirements to assist in implementation. With some patients it may be necessary to use a range of mechanisms to explain this. Patients should be offered the opportunity to talk to a member of the Multi-Disciplinary Team re any concerns or questions they have with regards to the level of observation. Ideally patients should co-produce the engagement and observation care plan with a member of staff. The patient should also be offered a copy of their care plan detailing observations and this should also be communicated with the patient’s consent and approval to the nearest relative/carer/friend. (Patient information regarding various levels of observation, see Appendix 2

7.2 Levels of observation should be discussed and/or negotiated with the patient

and (whilst taking into consideration patient consent, confidentiality and capacity issues) their carer/family wherever possible. Staff must clearly explain the reasons for the level of observation. This will be based on a rigorous ongoing risk assessment, which is reactive to dynamic risk factors.

8 Record Keeping 8.1 The observation levels prescribed must be recorded in such a way as to reflect

the Multi-Disciplinary Team discussion and rationale for the level of observation in the patient record. All patients must have an individualised engagement and observation care plan outlining their level of observation which, wherever possible, should be co-produced with the involvement of the patient.

8.2 The care plan should include:-

Level of observation and intervals at which the observation should be carried out; this may be at exact time intervals or irregular time intervals

The clinical rationale for observation, including identification of risk factors

Any particular requirements as outlined in this policy with regard to specific times or places

Stipulations of what clinical interventions, including engagement, are required in order to support the patient

8.2.1 Any changes to the level of observation should be amended on the care

plan/risk assessment and the patient advised accordingly 8.3 The level of observation, including the risk behaviours and factors identified,

should also be recorded and signed, as indicated on the Observation Record (Appendix 1). Records of engagement and observation should always accurately reflect prescribed levels of observation.

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8.4 Participating staff will make a brief summary of the patient’s behaviour, mental

state, physical health and level of observation record sheet in accordance with the care plan.

8.5 Patients will be offered a copy of their care plan detailing engagement and

observations, this should also be communicated with the patient’s approval to the nearest relative/carer/friend.

8.6 For all inpatients there should be, over a 24 hour period, a minimum of 3

documented summaries regarding the patient’s presentation and level of observation in the patient’s clinical record (minimum of 2 during the day and 1 at night).

9 Who should carry out Engagement and Observations? 9.1 The patient’s views and needs should be taken into account when allocating

staff to undertake engagement and observations (including factors such as ethnicity, sexual identity, age and gender) it is the responsibility of the nurse in charge to ensure that engagement and observations are carried out according to the agreed level. The staff member responsible for carrying out within eyesight and within arm’s length observation will usually:-

Be a Registered Nurse, Non Registered Nurse, Allied Health Professional or third year student who has been assessed and deemed competent by a registered nurse, to carry out observations in accordance with this policy. The Competency Assessment Form (Appendix 3) must be completed for all staff (including bank/agency/student in all cases). Competency should be reassessed on an annual basis.

10 Carrying out Engagement and Observation 10.1 Engagement and observation usually involves a number of nurses, with care

being handed over at intervals determined by the nurse in charge, wherever possible staff should not undertake continuous periods of observation above the general level for longer than 2 hours unless this is specifically identified within the care plan of the individual patient. Excellent communication amongst staff must be maintained.

At the beginning of each shift, the nurse in charge will allocate and record the engagement and observation for that span of duty taking into account each individual patient’s characteristics and circumstances (including factors such as ethnicity, sexual identity, age and gender). The nurse in charge shall ensure that all members of the ward team, who are involved in engagement and observations with a patient, understand the individualised engagement and observation care plans for each patient, in terms of who is being observed at what level, and why. During the handover each patient’s

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mental and physical state will also be reviewed, identifying potential risks and patients views towards the prescribed level of observation

Before taking over the patient’s engagement and observation, each nurse will have familiarised themselves with the patient’s individualised engagement and observation care plan, the type of engagement required, current risks and individual needs

At the point of handover between members of staff carrying out engagement and observation the patient should be involved, wherever possible, so that they are aware of who is continuing to work with and support them

10.2 The member of staff undertaking observation:

Should have been assessed and deemed by a registered nurse as being competent in carrying out engagement and observation in line with this policy

Should take an active role throughout the period of observation in engaging positively with the patient in line with their current care plan

Should maintain the patient’s privacy and dignity in line with the current care plan, acknowledging professional boundaries and the appropriate use of therapeutic touch. Consideration should be given to how an individual’s dignity could be maximised without compromising safety when individuals are in a state of undress, such as when using the toilet, bathing, showering, dressing, etc

Should be appropriately briefed about the patient’s history, background, specific risk factors and particular needs

Should be briefed about any specific risks, interventions and contingency plans should this patient require to be escorted outside of the ward environment in line with their current care plan

Should be familiar with the ward, the ward policy for emergency procedures and potential risk in the environment

Should be familiar with the Trust’s policy CNTW(C)03 – Leave, absent without leave and missing patient policy;

Should be approachable, listen to the patient, know when self-disclosure and the therapeutic use of silence are appropriate and be able to convey to the patient that they are valued

10.3 If the nominated staff member cannot continue the engagement and

observation for any reason, he/she will be responsible for notifying the nurse in charge, whilst maintaining the patient’s safety, who will ensure that another member of staff carries out the engagement and observation.

http://nww1.ntw.nhs.uk/services/?id=6537&p=5539&sp=5540

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10.4 When engaging/observing with patients staff should be assessing specific issues noted within the care plan, other changes may include the following:-

General behaviour

Movement

Posture

Speech

Expression of ideas

Appearance

Orientation

Mental Health

Physical Health

Mood and attitude

Interaction with others

Reaction to medication

Level of consciousness

Cognitions

Immediate environment

10.5 These observations should be viewed as an excellent opportunity to undertake

therapeutic engagement and intervention in which there should be some benefit for the patient.

10.6 Staff should also aim to actively engage with the patient and enable them to be

as independent as possible. 10.7 Staff should also be aware of the other team members’ current duties/locations

and how to gain rapid access for assistance if required. 10.8 Wherever possible staff should not undertake continuous periods of observation

above the general level for longer than 2 hours unless this is specifically identified within the care plan of the individual patient.

11 Reviewing Levels of Observation 11.1 Throughout a patient’s stay, the level of risk will be determined, and the

appropriate observation levels prescribed accordingly. Any member of the Multi-Disciplinary Team can raise the need for further consideration of a patient’s observation level and ask for a review of the necessary level of observation of a patient at any time.

11.2 Observation levels should be reviewed at the Multi-Disciplinary Team Meeting

in conjunction with the Designated Responsible Clinician. In exceptional circumstances this can delegated to another doctor who knows the patient.

11.3 Where a patient is on a level of observation above general, the continued need

for this should be reviewed at a minimum of every 24 hours, or more frequently if required by the nurse in charge and designated responsible clinician or nominated deputy and documented in the clinical record. For services where medical staff are not readily available at weekends, a review can be undertaken by the nurse in charge. Under such circumstances this will be agreed in advance by the Multi-Disciplinary Team and recorded in the care plan.

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11.4 Changes to a patient’s observation status must be informed by team members

who have knowledge of the patient in line with a previously agreed care plan, which is clearly documented and agreed by the patient’s designated responsible clinician and Multi-Disciplinary Team. A new risk assessment must be undertaken and documented with clear risk management plans in place within the care plan.

11.5 Any decision to increase levels of observation should be made by the Multi-

Disciplinary Team and wherever possible include the patient, however, where necessary qualified nursing staff have the authority to increase the level of observation in response to urgent changes in need. The increase in the level of observation should be communicated to the patient and to the Multi-Disciplinary Team at the earliest opportunity.

11.6 Any decision to decrease the level of observation should be made by the Multi-

Disciplinary Team and wherever possible include the patient. However, where necessary the following will have the authority to decrease the level of observations according to changes in presentation as agreed in the care plan:-

Either a minimum of 2 members of qualified nursing staff, 1 of which will be a Band 6 Nurse or above, who are familiar with the patient

Or a registered nurse and the doctor who are familiar with the patient

11.6.1 At the time of any decrease, as soon as practicable thereafter, the other

members of the Multi- Disciplinary Team should be informed. 11.7 Whenever the level of observation has been reviewed a rationale should be

provided to the patient wherever possible, recorded in the patient’s notes by a member of the Multi-Disciplinary Team involved in the decision to review and the patient’s individualised care plan by the nurse in charge; whenever the level of observation changes, a new Engagement and Observation Record is created. The nurse in charge should ensure the rest of the care team are informed of the change in the level of observation.

11.8 For any level of observation where there is significant clinical disagreement,

particularly concerning a reduction of the level of engagement and observation, the level of engagement and observation must be left unchanged until this can be reviewed by the Multi-Disciplinary Team. A consensus of agreement must be reached explaining rationale and the outcome of the discussion must be documented in the patient record.

11.9 Whenever there is a change in a patient’s level of observation the rationale

underpinning the change must be carefully and comprehensively documented in relation to defensible decision making.

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12. IDENTIFICATON OF STAKEHOLDERS 12.1 In line with CNTW(O)01 – Development and Management of Procedural

Documents, this policy was circulated for Trust wide consultation to the following:

Corporate Decision Team

Business Delivery Group

North Locality Care Group

Central Locality Care Group

South Locality Care Group

North Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

13. EQUALITY IMPACT ASSESSMENT 13.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

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

14. TRAINING 14.1 Observing patients at risk is a highly skilled activity. The Trust will ensure that

all staff (qualified, unqualified, other clinical staff, bank and agency staff) have access to appropriate levels of training. It is the responsibility of each Care Group Director to ensure staff attend. Levels of training are identified in the training needs analysis (see Appendix B) and are included within the Essential Training Guide which forms part of CNTW(HR)09 - Staff Appraisal Policy and Practice Guidance Notes. Essential components of adequate training include:

Risk assessment

Developmental Issues and their influence on risk assessment

Management and engagement of patients at risk of harming self and others

Service specific issues;

Factors associated with self-harm/harm to others

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Indications for observation

Levels of observation

Attitudes to engagement and observation

Therapeutic opportunities in observation

Roles and responsibilities of the multi-disciplinary team in relation to observation

Making the environment safe

Recording engagement and observation

The use of reviews and audit (SNMAC, 1999)

14.2 Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link

http://nww1.CNTW.nhs.uk/services/index.php?id=3796&p=2780

15. IMPLEMENTATION 15.1 This will be monitored by the North, Central and South Care Groups. 16. MONITORING COMPLIANCE AND EFFECTIVENESS – See Appendix C 16.1 Audit of engagement and observation should be facilitated at ward level. A

minimum data set would include:

Reason for observation

Specific level, or levels of observation

Length of time observed

Any untoward incidents

16.2 Random samples of engagement and observation records should be examined

by managers and monitored for compliance to the policy. 17. STANDARD/KEY PERFORMANCE INDICATORS 17.1 The Care Quality Commission require assurance and information relating to the

observation and engagement policy within the Trust. Information may also be considered by the NHS litigation authority. Key performance indicators within service specifications maybe outlined relating to the observation and engagement policy, it is therefore required that records/procedures are maintained as specified within this policy.

http://nww1.ntw.nhs.uk/services/index.php?id=3796&p=2780

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18. FAIR BLAME 18.1 The Trust is committed to developing an open learning culture. It has endorsed

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

19. POLICY LEAFLETS FOR OBSERVATON 19.1 Any information given to patients needs to be in an accessible format, accurate and ‘branded’ correctly. The Trust follows the process around production of this information as outlined in the Trust’s policy, CNTW(O)03 Accessible Information for Patients, Carers and Public. https://www.CNTW.nhs.uk/content/uploads/2016/08/What-does-observation-mean-to-me-A5-bloom-1.pdf

19.2 Patient Information leaflets will be reviewed every 3 years with the exception to those documents which are reviewed on an annual basis. However, should there be any changes in legislation or practice; all documents will be reviewed immediately irrespective of review date. 20. FRAUD, BRIBERY AND CORRUPTION 20.1 In accordance with the Trust’s policy, CNTW(O)23, Fraud, Bribery and

Corruption, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

21. ASSOCIATED DOCUMENTATION

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

CNTW(O)05 Incident Policy and practice guidance notes

CNTW(C)03 Leave, absent without leave and missing patient Policy

CNTW(C)08 Young people requiring admission to hospital policy

CNTW(C)10 Seclusion Policy

CNTW(C)11 Search Policy

CNTW(C)16 Positive and Safe, Physical Management of Violence and Aggression Policy

CNTW(C)48 Care Coordination/Care Programme Approach for Children and Young People Specialist Service Policy

CNTW(HR)09 Staff Appraisal Policy and Practice Guidance Notes



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22. REFERENCES

HMSO 1999 Mental Health Act, Code of Practice

NICE May 2015 Violence and Aggression: The Short Term Management in Mental Health, health and community settings.

NIMHE National Institute for Mental Health in England

Preventing Suicide: A toolkit for mental health services

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Christopher Rowlands May 16 May 19 Trust wide

Policy to be analysed Is this policy new or existing?

CNTW(C)19 – Engagement and Observation Policy- V04

Existing

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

The aim of this policy is to ensure a consistent and effective approach to patient observation, engagement and support within inpatient services across the Trust. This policy is based upon recommendations from National Institute for Health and Clinical Excellence (NICE) Guideline 25 (2005) and is intended to address the mental health needs of patients who are considered to be vulnerable or at risk of suicide, self harm or harm to others. The Trust is committed to providing a safe, sound and supportive environment to all patients, visitors and staff. It is recognised that patients may have changing clinical, behavioural and social needs and may require varying degrees of support (including observation) to be offered during these phases

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

Clinical Staff, service users in inpatient environments, relatives and carers

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

Disability Dignity, privacy and respect issues for patients being observed within eyesight and arms length. For patients with a learning disability easy-read material explaining the reasons for the level of observation should be prepared. Advocates will need to be available. Material will need to be prepared in a variety of accessible formats for people who have visual impairments. Deaf people will need an interpreter present throughout the observation period for the clinician to effectively observe and engage therapeutically.

Sex Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Race Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Will be a need for presence of translated material and or interpreter, need for advocacy to negotiate level of observation

Age Dignity, privacy and respect issues for patients being observed within eyesight and arms length.

The suitability of presence on an adult ward for children and young people.

Accessible information will need to be produced to meet the needs of those with dementia.

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There may be a need for advocacy.

Gender reassignment

(including transgender)

Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Sexual orientation. Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Religion or belief Dignity, privacy and respect issues for patients being observed within eyesight and arms length – especially an issue at prayer time. What will be a suitable observation time for patient during Ramadan? – clearly not meal time

Marriage and Civil Partnership

N/A

Pregnancy and maternity

Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Carers N/A

Other identified groups N/A

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

Through standard policy process

Pilot to be undertaken in order to gather evidence and test the new policy

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

Full Trustwide consultation undertaken

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

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

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

Eliminate discrimination, harassment and victimisation

Advance equality of opportunity

Promote good relations between groups

What is the overall impact?

Addressing the impact on equalities

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

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

Manager’s signature: Chris Rowlands Date: May 16

Appendix B

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Communication and Training Check List

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

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

Change to existing policy.

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

Staff required to carry out patient engagement and observation should be aware of CNTW(C)19 Engagement and Observation policy including levels of observation issues relating to patient engagement and written records required.

Training will incorporate the changes as outlined in the policy version 4.

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

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

Please identify the risks if training does not occur

Local standards and NICE Guidelines recommendations.

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

All ward based clinical staff who are required to carry out patient engagement and observation, including staff (e.g. medical) involved in making decisions around observation levels. This is also relevant to bank staff, agency staff, and students in training who have been assessed as competent to carry out observations.

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

Staff will be trained to safely carry out patient observation and complete relevant documentation

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

Local Ward/Unit Induction

Newly Qualified Orientation Programme

Cascade

Raising staff awareness of the amended policy will also be carried out via the Chief Executives Bulletin and internal CAS alert/safety message as appropriate.

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

Executive Director of Nursing and Chief Operating Officer

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Appendix C

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

CNTW(C)19 – Engagement and Observation Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1. Documentation relating to patient observation and engagement will adhere to the Trustwide Engagement and Observation Policy

Weekly review of documentation by Ward Manager

Findings to be taken to Supervision with Clinical Nurse Manager and Associate Director

Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Locality Care Group Quality and Performance

2. At Ward level competency records will be completed for all new staff – 3rd year nurisng students, and bank and agency staff working on the wards



Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Group Quality and Performance

3. Training records will be maintained of all staff who have attended Engagement and Observation policy awareness and training

Reviewed within JDR process by Ward Manager via the Dashboard

Locality Care Group Quality and Performance

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Continued …..

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where Results and Any Associate Action Plan Will Be Reported To, Implemented and Monitored; (this will usually be via the relevant Governance Group).

4. Patient observation records demonstrate clearly the level of observation prescribed, an individual care plan has been drawn up in line with record keeping standards and the observation has been completed as per policy



Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Locality Care Group Quality and Performance

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

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