Admission of a patient to forensic services procedure

1 Aim

The aim of this document is to set out specific standards to follow when a patient is admitted to the forensic service. The specific standards are to be implemented in conjunction with the recognised admission checklist for all admissions to the forensic service.

2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

3 Link to overarching policy, and or procedure

This document is overarched by the forensic services manual and should be read in conjunction with the following trust documentation:

advance statements and advance decisions to refuse treatment policy
patient identification policy
Royal College of Psychiatrists CCQI (College Centre for Quality Improvement) 2023
Standards for Forensic Inpatient Mental Health Services, fifth edition

4 Procedure or implementation

4.1 Pre-admission

All referrals to the forensic service are directed to the weekly referral meeting attended by the forensic multi-disciplinary team (MDT). If the referral is considered appropriate, comprehensive access assessment is to be completed with further assessments, with input from nursing, occupational therapy, social and psychology colleagues, being completed as required if accepted for admission.

If the referral is not considered appropriate, written contact must be made with the referrer detailing the rationale for the decision and to offer guidance and support. If further details or clarification of the decision is required the referrer is to contact the responsible clinician and service manager.

4.2 Pre-admission assessment documentation

MDT members undertaking admission assessments are to complete the standardised forensic pre-admission assessment documentation in full and forward to the referral meeting for discussion at the next available meeting.

Prior to the access assessment, further information is to be requested from the referring organisation:

childhood history, developmental milestones, schooling, cause of learning disability if known, details of special educational needs such as school reports, educational reports and psychology documentation or reports
details of early psychiatric history and any professional interventions such as child and adolescent mental health service (CAMHS) involvement
learning disability assessments, Wechsler adult intelligence scale, adaptive behaviour assessment system amongst others
details of the index offence(s). Prosecution case summary, MG05, offence report, MG11, witness statement(s), MG15, record of interview(s) etc. if relevant
copies of court orders and section papers, 37/41 47/49
medical reports from two psychiatrists if recommending section 37/41
copy of the sexual harm prevention order (SHPO) if relevant
print of the police national computer (PNC) record. The Ministry of Justice (MOJ) will have sent a copy of the statement from the Secretary of State for Justice to the first-tier tribunal. The Mental Health Act office will also have a copy
annual statutory reports
tribunal reports, medical, nursing and social circumstances
copies of tribunal decisions
HCR-20
SVR-20 or RSVP if relevant
psychology reports
sex offender treatment programme, report, outcomes and recommendations if relevant
physical health conditions and treatment including the Health action plan
list of medications and T2 or T3 documentation
capacity assessments regarding medications, internet or social media, finances, contact with other
current leave status
all care plans
any safeguarding concerns, historical and current
HoNOS secure
FACE risk assessment
any other treatment programmes completed or commenced

5 Admission declined

A copy of the access assessment report will be sent to the referrer containing advice on why the admission referral has been declined. Where clinically appropriate, clinicians will offer advice and guidance for the management and treatment of the patient as part of the access report in accordance with commissioning arrangements.

6 Admission acceptance

An access report will be compiled from all of the pre-admission assessment information. Where deemed clinically appropriate a letter will be sent to the patient detailing admission plans and treatment outlines highlighting which disciplines will be involved in the care and treatment plan.

If beds are available, admission arrangements will be made as soon as practicable possible, based on the patient’s needs and their legal status.

If no beds are available, the patient will be placed on a waiting list and updates provided to the commissioners, through the Forensic weekly referral meetings, regarding anticipated bed availability

7 Patient admission the ward

A comprehensive admission checklist (appendix A) is in place for the forensic service which is to be followed for all admissions to ensure consistent and complete admissions to the units are facilitated. In conjunction with the checklist the following actions should be completed:

7.1 Prior to admission

A responsible clinician (RC) will be identified and agree responsibility for the patient.
Where clinically indicated, other disciplines; inclusive of psychology, will be allocated.
A primary nurse team will be allocated for the patient, including a named and associate nurse, special interest worker and an associate special interest worker.
The named nurse will fulfil the lead role for the patient, co-ordinating and communicating with all relevant parties in preparation for the admission and throughout the placement. Where possible the named nurse should be on shift for the admission date however if not possible the associate nurse may be utilised.
A “buddy” patient will be identified to support the patient when they arrive to the unit and for the first 4 to 8 weeks of their admission to provide peer support.

7.2 Pre-admission day

Necessary transport arrangements must be in place. The named nurse must escalate any potential costs that may be incurred as a result of the patient’s admission to the ward manager for authorisation to be sought from the service manager or nominated deputy. Where required private ambulance secure transport can be booked, if required, through details within RDaSH admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures.
The named nurse will ensure that all relevant information is available to the full team and facilitate comprehensive handover of the patient prior to admission to the service.

7.3 Patient identification

Within mental health and learning disability inpatient services, it has been agreed that as patients often have periods of leave from the ward areas as part of agreed treatment pathways, they will not be routinely asked to wear identification wrist bands. In view of this the preferred method of identification is through the use of photographs uploaded into the patient’s electronic record, SystmOne. These photos are saved to the main record and also the medication chart in the system.

In the event that a patient is admitted with the same or a similar name to an existing patient an alert to this effect is to be placed on SystmOne for both patients. Patient identification can be undertaken in a number of ways, and these are clearly set out in the trust patient identification policy.

As part of the admission process the admitting nurse or nominated deputy is responsible for gaining consent from the patient for a photograph to be taken, and recording this consent accordingly in the patient’s record on SystmOne.

7.4 Mental Health Act requirements

Due to the nature of receiving care and treatment on a low secure and locked unit all patients admitted to the forensic service will be subject to detention under the Mental Health Act 1983. Therefore specific requirements are needed to ensure admissions to the service are authorised and lawful.

The named nurse or patient’s RC should liaise with the trust Mental Health Act office prior to admission for support with receiving and receipting of patient’s section papers.

The original section papers should be received by the nurse in charge of the shift at the time of the patient’s admission. Once legality of these papers has been confirmed the nurse in charge of the shift ensure that the detention is receipted appropriately on the correct form on behalf of the hospital managers. An attempt must then be made to explain the patient’s legal rights which should be evidenced on the form 14a within SystmOne.

In the event that the patient refuses to have their legal rights explained to them or if they lack capacity at the time of admission, arrangements must be made for further attempts to be made and recorded on the form 14a in addition to documenting in the patient electronic record.

Colleagues should refer to the trust procedure for the receipt and scrutiny of detention papers policy (MHA 1983) and the procedure for section 132 informing detained patients of their legal rights procedure.

7.5 Obtaining specialist advice

There may be times where a patient is admitted who has specialist needs and in these cases, colleagues should contact the relevant trust advisor. Examples of this could be manual handling, infection control, fire safety, adult or child safeguarding issues, or police violent and sexual offender registered officer (VISOR). In cases like these colleagues should contact relevant specialist professionals within their locality to gain advice and support for the development and implementation of agreed care plans. Where possible this should be planned prior to admission however if not possible it should be undertaken at the earliest opportunity following admission to the service.

7.6 Handover process

The admitting professional will ensure a thorough handover is given to the receiving ward. In addition to the information detailed in section 6. The following admission details must be discussed and confirmed with the nurse in charge of the ward and recorded on SystmOne.
Current clinical risk profile of the patient and that the admitting professional will complete or update the patients FACE risk assessment. If the admission is due to a transfer from another inpatient ward in RDaSH the FACE risk assessment must be reviewed and updated.
Further information around risk, for example, risk to self, risk to others, falls, and any adult and, or child safeguarding concerns, multi-agency public protection arrangements (MAPPA) status where known and any bail conditions or restrictions if the patient has been seen by the Liaison and Diversion team.
Any caring responsibilities that the person being admitted to hospital may have for family, relatives including children or animals and how this is going to be managed.
The patient’s physical health care needs and requirements, including any details of recent investigations, for example, bloods, electrocardiogram (ECG), urine analysis, mobility needs.
If known, original do not attempt cardiopulmonary resuscitation (DNA CPR), recommended summary plan for emergency care and treatment (RESPECT), advanced statements (original or a copy of) that the patient has in place.
Details of current medication and any allergies.
Contact details of family or carer to be informed of the admission and any caring responsibilities highlighted.
Whether or not the patient is already known to service (this will allow the ward colleagues to gain further detail from the patient’s electronic record).
Confirmation that the admitting professional has informed the patient that we operate smoke free sites.
Any relevant historical information.
Information about who has been or still needs to be informed of the admission. Where possible the admitting professional will inform the relevant people of the plan to admit as part of their assessment and immediate care duties; This may include family members; home care agencies who may be due to visit; the care-coordinator; general practitioner etc. A good handover and communication of this information enables the ward colleagues to then take over this area of responsibility as required.
If the patient’s first language is not English and, or any specific communication needs have been identified, for example, the requirement for a British Sign Language (BSL) Interpreter, the ward colleagues should be informed of this so that arrangements can be made for an interpreter to be available at the earliest opportunity, please see interpreters policy (provision, access and use of, for patients, service users and carers).

7.7 Admission to hospital

7.7.1 What a patient should expect during their stay in hospital

During their stay in hospital patients should expect to have their privacy, dignity and confidentiality respected and to be treated in a holistic person-centred manner.

Interventions should be purposeful and carried out with the patients consent where possible or under an appropriate legal framework.

Colleagues will start to build therapeutic relationships as early as possible to:

ensure the person feels supported and is an active participant in their care
encourage the person to engage with treatment and recovery programmes
collaborative decision-making
create a safe, contained environment
reduce the risk of suicide, which is increased during the first 7 days after admission

Communication between the multi-disciplinary team should take place in a timely way to ensure care is streamlined and in most cases, recovery focussed, with the aim being towards successful discharge.

7.7.2 Orientation and information

On admission to the ward, patients will be welcomed by colleagues and shown around the ward being introduced to the various colleagues and other patients. The patient will be offered refreshments and addressed using the name and title they prefer.

Patients and carers will be asked to wait where they most feel comfortable before the admission clerking process begins (subject to risk assessment and staffing levels).

Patients will be provided with the name of the doctor under whom they have been admitted and when they are likely to see the person who will be managing their care.

At the earliest opportunity, the admitting team should provide the patient and their family, carer, or advocate with an opportunity to discuss their care. Discussions should be documented on SystmOne and cover:

place of care and reason for admission to hospital
daily routines (including the use of medicines and equipment)
mealtimes and menu choices and meaningful activities available including timetables
any visiting times or arrangements
any restrictions they may be subject to whilst on the ward including the Mental Health Units (use of force) Act 2018
any known risks including safeguarding and any additional support required
an explanation of confidentiality, its limits, and patient preferences for sharing information with third parties
advance statements or advance decisions to refuse treatment (ADRT) in place
what contingency plans may be required
end-of-life care wishes where relevant
any lasting powers of attorney for health and welfare or deputyship

On admission patients will be offered access to independent advocacy services that will take into account their language, communication, cultural, social needs and protected characteristics.

Consideration should also be given to identify whether there is a need for reasonable adjustments to be made to accommodate the patient in hospital. This is in line with the Equalities Act 2010. Examples include:

providing communication aids (this might include an interpreter)
ensuring there is enough space around the bed for wheelchair users to move from their bed to their chair
single sex accommodation
support for cognitive difficulties

Patients will be supported with their cultural and spiritual needs including meals, access to faith book or materials, a faith room and support from the RDaSH chaplaincy where appropriate.

Patients should be given accessible written information which colleagues talk through with them as soon as is practically possible.

The information includes:

their rights regarding admission and consent to treatment
rights under the MHA including right to appeal
how to access independent advocacy services
how to access a second opinion
interpreting services
how to view their records
how to raise concerns, complaints and give compliments
the identified contact or link person for each agency involved with their care
patients will know who the key people are in their team and how to contact them if they have any questions. Patients will also be informed of the colleagues who is their first point of contact for each shift

7.7.3 Other considerations

On admission the following is given consideration:

the security of the patient’s home
arrangements for dependants (children, people they are caring for)
arrangements for pets
benefits
essential maintenance of home and garden

7.7.4 Action on patient’s arrival to the ward or as soon as practicable

Please refer to appendix D, the nursing admission checklist which details all actions to be completed on and within 72 hours of admission to hospital.

The admitting nurse will contact the ward doctor if admission takes place between Monday to Friday 9am to 5pm, otherwise contact the on-call doctor to notify them of the patient’s arrival on the ward and agree who will be completing which sections of the admission assessment. It is the responsibility of the ward doctor or on-call doctor to clerk the patient in and undertake the physical health and wellbeing assessment. Please see physical health policy.
Initial admission tasks to be completed by ward colleagues using the Inpatient launchpad on SystmOne. In the event that any of these cannot be fully completed a note is to be made as to the reason why and arrangements made for their completion the next day in line with local arrangements, for example, handover documentation, diarise, and no later than 72 hours following admission.

7.7.5 Admission care plan

All patients will have a 72 hour admission care plan to meet their immediate needs and risks, taking into account the patient’s orientation to the ward and detailing their observation status. All colleagues involved in the patient’s admission need to be mindful of the fact that admission to hospital can lead to an increase in the level of stress or distress being experienced by the patient and that the provision of timely information and support can help to alleviate this. However, colleagues should take a thoughtful and sensitive approach to the patient’s presenting needs and whilst some aspects of the admission are to be completed immediately others may be completed as soon as is clinically appropriate.

7.7.7 Restrictions

Ward colleagues and the multi-disciplinary team (MDT) will ensure that any restrictions on access to personal possessions are necessary and proportionate in relation to the person concerned and are in line with the RDaSH blanket restrictions policy and the prohibited and restricted items management procedure.

7.7.8 Care planning when a patient declines or lacks capacity to be involved

There may be times during a patient’s episode of care and particularly at point of admission when the patient may either decline or lack the capacity to be involved in the planning of their care. In these circumstances colleagues are to clearly document in the patient’s electronic record why the patient has not been involved in the development of their care plan.

Patient’s engagement and capacity can change at any point during an episode of care therefore it is important that colleagues make ongoing attempts to involve the patient, recording all attempts comprehensively. Where required the use of MCA will be considered in line with MCA Mental Capacity Act 2005 policy.

Some patients may have advance decisions or statements following previous involvement with mental health and learning disability services which must be considered during any care planning pathways.

Colleagues should refer to the trust policy for advance statements and advance decisions to refuse treatment policy for full details and guidance.

8 Appendices

Please see forensic services manual webpage for appendices attached to this procedure.

Appendix A Admission to inpatient learning disability forensic services procedure
Appendix D Audit approved access to FAS form C

Document control

Version: 3.
Unique reference number: 525.
Approved by: Clinical policy review and approval group.
Date approved: 5 March 2024.
Name of originator or author: Forensic ward manager.
Name of responsible individual: Executive director of nursing and AHP’s.
Date issued: 3 April 2024.
Review date: 30 April 2027.
Target audience: All colleagues working in the forensic service.
Description of change: Full review and update the procedure.

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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