Blanket restrictions policy – Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

1 Policy summary

This policy will apply to all colleagues working on the mental health (adult and older peoples) and learning disabilities inpatient and day care areas in the Rotherham Doncaster and South Humber NHS foundation trust.

The policy ensures that colleagues understand their responsibilities in adhering to the Mental Health Act Code of Practice section 8 in relation to blanket restrictions. This will ensure that patients’ freedoms and liberties are not unnecessarily and unjustifiably restricted and that the trust is able to monitor where appropriate restrictions are required.

2 Introduction

The Mental Health Act Code of Practice defines blanket restrictions as “rules or policies that restrict a patient’s liberty and other rights, which are routinely applied to all patients, or to classes of patients, or within a service, without individual risk assessments to justify their application”. The Code’s default position is that “blanket restrictions should be avoided unless they can be justified as necessary and proportionate responses to risks identified for particular individuals”. The code does allow that secure services will impose blanket restrictions on their patients.

3 Purpose

Where blanket restrictions are identified as necessary and proportionate there should be a system in place which ensures these are reviewed within a regular time frame, with an overall aim at the reduction of restrictive practices. This policy defines the process by which blanket restrictions are managed.

4 Scope

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure

5.1 Quick guide

5.1.1 Consent

Consent is not required, but all relevant patients must be informed of the application of a blanket restriction.
Ensure that all relevant patients understand the restriction in place, how long it will be in place and what alternatives, if any, are available, for example alternative outdoor spaces.

5.1.2 Blanket restriction Information

The application of a blanket restriction must be recorded on the blanket restriction template on the electronic patient record (EPR) system and copied to all current inpatient records for that ward.

5.1.3 Minimum content

Date restriction applied.
The rationale for the restriction including the assessment of risk and alternative measures attempted prior to applying restriction.
Timescale for review.
Expected length of restriction.
Date restriction removed.

5.1.4 Timely entries

The restriction should be reported in an incident report and recorded on the electronic patient record (EPR) system as soon as possible after application.
The removal of the restriction must also be recorded on the electronic patient record system.
The relevant patient care plan must be updated.

5.2 Blanket restrictions, prohibited items and restricted items

The Care Quality Commission (CQC) and the trust identify a list of prohibited items which are not allowed on mental health and learning disability wards at any time. These are:

5.2.1 Prohibited items

Alcohol and drugs or substances not prescribed (including illicit and legal highs).
Items used as weapons (firearms, real or replica, knives or others sharps, bats).
Fire hazard items (flammable liquids, matches, incense).
Pornographic material.
Material that incites violence racial, cultural, religious, or gender hatred.
Clingfilm, foil, chewing gum, blue tack, plastic bags, rope, metal clothes hangers and cans.
Laser pens.
Animals, except for service assistant dogs and or therapy animals (visits from patients’ pets can be accommodated when requested and where this is seen to be beneficial and or necessary for the person’s well-being and or care. This is at the discretion of the ward manager or appropriate professional and is managed case by case in terms of risks).
Spiral bound notebooks.

The Care Quality Commission (CQC) also identify a list of restricted items where the access is controlled and may be directed according to policy and individual risk assessment. Individual patients should be risk assessed, and care planned for these. Examples of items that may fall into this category include:

5.2.2 Restricted items

Disposable cigarette lighters, for use outside the ward only.
Toiletries, aerosols, razors.
Identity documents, bank cards, items of stationery.
Cutlery, tinned materials, glassware.

No smoking on trust premises is not a blanket restriction and should not be reported as such. It is trust policy and any breach of this should be reported as a breach of trust policy. The Care Quality Commission (CQC) do not view this as a blanket restriction.

Outside these items, consideration should then be given whether the restriction is a blanket restriction:

does the restriction apply to all patients on the ward, for example closure of the garden area?
- if yes, this is a blanket restriction and must be managed as such, see sections 5.5 to 5.8
if no, does this restriction only apply to specific patients but not all?
- if only specific patients, this must be care planned for these patients and is not a blanket restriction

5.3 Normative expectations regarding blanket restrictions at different levels of security

Appendix C sets out normative expectations regarding blanket restrictions at different levels of security. It is only a guide. When making a specific judgement, inspectors must take account of factors specific to the unit or service. For example, it might be appropriate for colleagues on an acute admission ward to search all patients returning from leave, as a temporary measure, if drugs are coming onto the ward and colleagues suspect that patients are being coerced into bringing drugs in for others.

5.4 Amber lodge low secure

It is recognised within the Mental Health Act Code of Practice that for secure services due to the patients identified level of risk and need to be cared for on a ward with enhanced levels of security certain restrictions may form part of a broader package of physical, procedural and relational security measures.

Due to the restrictive nature of a secure ward Amber Lodge has admission criteria in place which patients must meet to ensure they are not being placed in an overly restrictive environment. A suite of service specific standard operating procedures that include the following subject areas are in place to provide colleagues with detail of the specific processes and governance arrangements for Amber Lodge:

prohibited and restricted Items
management of pornographic and sensitive materials
mobile phone and other devices

See section 8 for links to the relevant policies.

5.5 Action to take when a blanket restriction has to be implemented at short notice due to immediate safety concerns

Colleagues should ensure that all alternative options have been considered and attempted before implementing the restriction.

Actions:

inform and obtain agreement of the ward manager or nurse in charge if out of hours to implement the restriction
inform the matron and director nursing or senior leadership team that the restriction has been implemented
complete an incident report
record the restriction on all current patient records, it is the ward manager’s responsibility to ensure that this has been completed
log the restriction on the ward register, including dates for review
update the register when reviewed with outcome of the review and any further review dates

If the restriction is expected to be longer term, then this should be reviewed by the care group senior leadership team on a regular basis with plans in place for how the restriction will be removed.

5.6 Information to patients and carers

On admission, patients, relatives or carers should be advised of the prohibited and restricted items, this should form part of the ward’s admission pack. The patient and relative and or carer should also be informed of any current blanket restrictions on the ward.

When new restrictions are applied, all patients must be informed of this and any alternative arrangements in place.

5.7 Action if a blanket restriction is identified during a Care Quality Commission inspection (including a Mental Health Act inspection)

Whilst it is hoped that through their awareness of this policy colleagues will be able to recognise when a particular practise constitutes a blanket restriction it is accepted that there may be occasions when this is not the case. In the event of the Care Quality Commission (CQC) raising a blanket restriction which the trust is not aware of this policy will be retrospectively applied and the action taken reported back to the CQC via the required action plan or provider statement. Colleagues must immediately report the restriction as per section 5.5 above (action to take when a blanket restriction has to be implemented at short notice due to immediate safety concerns).

5.8 Governance arrangements

All locally imposed blanket restrictions will be reported on the trust incident system and recorded onto every patient record in SystmOne by the nurse in charge. The IR1 system will then generate an alert to the following:

relevant modern matron or service manager
relevant care group director of nursing
relevant care group director
chief operating officer
chief nurse
patient safety, carer and community lead (patient safety specialist)
reducing restrictive intervention lead

The ward manager should ensure that the restriction has been reported as an incident appropriately and has been logged on the ward based blanket restrictions register (see appendix D).

Each ward will hold their own blanket restrictions register and oversight of this will be at care group level. This should be discussed at the care group business meeting and out briefed to the quality and safety group. A report is also sent bi-monthly to the Mental Health Act Committee.

6 Training implications

There are no specific training needs in relation to this policy. However, colleagues can be made aware through:

line manager
team brief
performance development review
trust intranet
local trust induction

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

Any impact on a patient’s privacy, dignity and respect as a result of the implementation of a blanket restriction will be considered and risk assessed on an individual basis. Where a breach to the patient’s privacy, dignity and or respect has been identified the management of this will be included in the patient’s individual care plan.

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

8 Links to any other associated documents

The following standard operating procedures for Amber Lodge.

9 References

Care Quality Commission brief guide: Go to Care Quality Commission and search for “The use of blanket restrictions in mental health wards”.
Mental Health Act (1983) Code of Practice (2015).

10 Appendices

10.1 Appendix A responsibilities, accountability and duties

10.1.1 Chief executive and board of directors

Chief executive and board of directors are responsible for ensuring that the trust has policies and procedures in place to support best practice, the management of associated risks and compliance with all legislation which is applicable to the trust. The chief executive has overall responsibility for the health, safety and welfare arrangements of the trust and compliance with legislation.

10.1.2 Chief nurse

Chief nurse is the accountable director with responsibility for ensuring implementation of this policy.

10.1.3 Care group directors, matrons, service managers and ward managers

Care group directors, matrons, service managers and ward managers:

raising clinical colleague awareness of this policy and maintaining effective communication of the policy to all colleagues
overseeing implementation and compliance with this policy
ensuring that any locally authorised blanket restrictions are:
- justifiable and proportionate
- the only option available to the clinical team
- reviewed in line with this policy
- implemented for the shortest time required
- reported on the trust incident system and recorded in the ward based blanket restrictions register
taking appropriate action where colleagues fail to comply with this policy

10.1.4 Clinical colleagues working on the ward and day care areas

Clinical colleagues working on the ward and day care areas to:

comply with the requirements of this policy
the nurse in charge at the time of a local blanket restriction being put in place, should ensure that an incident report has been completed and advise the matron
report any incidents in relation to any breaches in relation of this policy to their line manager and via the trust incident reporting system, that is failure to report a restriction in a timely manner

10.1.5 Trust Adult Safeguarding team

Trust Adult Safeguarding team will be responsible for considering and advising on any safeguarding implications from the implementation of any blanket restrictions within the trust services.