Admission to adult and older persons mental health service inpatient wards procedure

1 Aim

The aim of this procedure is to set out the specific standards for when a patient is admitted to one of the adult or older person’s mental health service inpatient wards. Admission to hospital can be a difficult time for both the patient and their carers and can bring on feelings of vulnerability. For this reason it is important that we make people feel safe and secure and that they feel that they have received personal and individualised care.

2 Scope

The contents of this procedure applies to clinical colleagues working across adult and older person’s mental health inpatient services.

3 Link to overarching policy, and or procedure

This procedure is overarched by the admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures and should be read in conjunction with the following procedural documents:

4 Access or pre-admission

All referrals for a mental health assessment go to the community and, or hospital liaison, crisis, and Home-Based Treatment teams for assessment.

As part of this assessment the identified professional will consider the least restrictive option in which to provide care and treatment, taking into consideration the patient’s wishes, in line with the level of identified clinical need and risk. Crisis plans and advance statements will also be considered when arranging care.

If the outcome of a Mental Health Act (MHA) assessment is that a patient does not require an in-patient bed but may be suitable for home treatment, the admitting professional should discuss with the available gatekeeping for the patient’s locality as identified in section 5.

4.1 Patients assessed as requiring an inpatient admission

There are only 3 lawful ways in which an assessing professional can admit a patient to hospital (without the intervention of the courts):

informally (the patient gives fully informed consent)
under the Mental Health Act 1983
under the Mental Capacity Act 2005, in limited circumstances

Where a patient lacks the capacity to consent to being admitted for care and, or treatment and they do not object to this and to any treatment they will receive for mental disorder, the patient can be admitted under either the MHA or via a deprivation of liberty safeguards (DoLS) authorisation. However, consideration should be given as to the overarching need for admission, for example, care and treatment for mental disorder, and balance which regime (MHA or DoLS) is the least restrictive.

Prior to a patient being admitted, the admitting professional should ensure that where possible they understand the reason for admission and why they need to be in hospital.

For those patients who are formally admitted to an Inpatient Ward under a section of the MHA 1983, colleagues must adhere to the requirements of the MHA 1983 and the MHA Code of Practice 2015.

For those patients who lack the capacity to make the decision to be admitted to hospital, colleagues should on admission ensure that the principles of the Mental Capacity Act 2005 have been followed:

that an assessment of capacity has been undertaken and documented
that where the decision to admit the patient is made in the best interests of the person, that there is a record of this

4.2 Assessments and documentation

When an inpatient mental health admission has been identified as part of an initial assessment or by a mental health treatment team the following process should be followed.

The admitting professional will ensure the following assessments and documentation is completed and documented on SystmOne:

Patients who are new to service

mental health assessment and review (full needs assessment)
functional assessment of care environments (FACE) risk assessment
complete the mental health clustering tool
next of kin or carer details and contacts

Patients already known to a treatment team

update the FACE risk assessment to reflect any change in the patient’s clinical presentation and risk profile
ensure the mental health assessment and review (full needs assessment) is up to date
check and confirm whether there are any changes to the next of kin or carer details and contacts
re-cluster (using the mental health clustering tool) to reflect the deterioration in mental health and increased need which led to admission

If the admission is outside of normal working hours and there is a concern that the admitting professional will have to attend another assessment or attend to other duties that could result in disruption to the completion of assessments for the admission, these documents will be completed at a later time (but before the end of their shift) by the admitting professional.

4.3 Action for those patients being admitted to hospital informally

In order for the patient to make an informed choice regarding admission if they are not detained under the MHA 1983, the admitting professional should give the patient as much information as possible about the ward and provide them with a copy of the informal admission leaflet (see appendix C) and specifically discuss that the wards are smoke free and that when infection prevention and control (IPC) guidance stipulates, they may be required to isolate on admission. Please refer to the assessment and treatment provided by community services during Covid 19 (including Mental Health Act assessment) standard operating procedure for further information.

For informal patients, an assessment of capacity should be undertaken and recorded on an MCA 1 by the professional making the decision to admit to evidence the patient’s capacity to consent to the admission.

For patients who lack the capacity to consent to informal admission who are not liable to detention under the MHA, a best interest decision should be made by the professional making the decision to admit and recorded on an MCA2 and authorisation should be sought under the DoLS immediately. Please see MCA deprivation of liberty (DoL) policy.

5 Gatekeeping

Prior to any bed being sourced, the admitting professional must ensure that all the necessary steps in the gatekeeping process have been followed. Where a person has been assessed under the MHA and deemed appropriate for admission (either detained or informal), this would act as the completed gatekeeping process.

No person can be admitted informally to an inpatient bed without having first been ‘gate kept’ for admission and this decision must be clearly documented in the template on SystmOne. Documented assurance must also be provided which shows that alternatives to admission have been explored. This will be reviewed by the patient flow team prior to allocation of a bed.

Where possible a gatekeeper as identified below, would be present at any 136 assessments in order to consider alternatives to admission when someone does not require detention under the MHA.

Overall, the gatekeeping process ensures that patients are treated in the least restrictive environment possible and provides assurance that trust inpatient bed capacity is being used appropriately.

The gatekeepers will determine if the patient’s treatment pathway is an adult acute mental health ward or older person’s mental health ward due to frailty or physical ability.

5.1 Gatekeeping process of adults of working age

The identified ‘gatekeepers’ for each area are:

Doncaster, Home Treatment team
Rotherham, Crisis Team, Home Treatment team and the Hospital Liaison team
North Lincolnshire, Access team, Home Treatment team and Hospital Liaison team

5.2 Gatekeeping process for older persons

The gatekeeping process differs for older adults. In these cases, the consultant, care coordinator or duty worker in the Older Person’s Community Mental Health team will ‘gatekeep’. If outside of normal working hours or a transfer from the general hospital, this process may also involve the hospital liaison or Crisis team. The assessment prior to admission should include a review of the patient’s medical needs as it may be required for them to be admitted to the general hospital. This should be considered prior to admission to the mental health unit.

6 Sourcing of a bed

Once the gatekeeping process has been completed, a telephone call should be made by the gatekeeper to the patient flow bed manager (within working hours 8am to 8pm, 7 days a week) so that a bed can be identified following discussion around the person’s needs and requirement for admission. The patient flow bed manager will review the bed state and in the first instance will contact the ward(s) in the relevant care group to confirm bed availability. Outside of working hours (8pm to 8am, 7 days a week) a member of the hospital liaison, crisis or home-based treatment team will be responsible for sourcing a bed (when the AMHP is the admitting professional they will delegate this responsibility) and they will liaise with the identified care group bed manager regarding availability. The bed manager for each care group will be identified in the ‘RDaSH patient flow management document’ which is sent out after the mental health handover meeting every day.

At the time of requesting the bed the admitting professional will provide the following information and record on SystmOne:

patient name, NHS number and date of birth
legal status of the patient (MHA or informal)
the type of bed which is required, for example, acute, psychiatric intensive care unit (PICU), organic, functional
reason for admission and expected outcomes of admission
the expected aims of admission as agreed among the admitting professional, the patient and where appropriate their carers
expected time of patient arrival on the ward, how they will arrive and who will be accompanying them

The Patient Flow team or care group bed manager will then advise the admitting professional of the bed availability and liaise with the ward to confirm admission.

If a bed is not available within the trust and capacity cannot be created by urgently reviewing and utilising a leave bed (where safe), the out of area process must be followed (see appendix L)

7 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).

8 Admission to hospital

8.1 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.

8.2 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) policy
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.

8.3 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

8.4 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.

8.4.1 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.

8.4.2 Purposeful inpatient admission (PIPA)

In order to ensure effective, safe, and therapeutic patient-focused care our inpatient wards are implementing the components of PIPA. One of the first steps of PIPA is for there to be a clear reason for admission as agreed by the admitting professional, the clinical team, the patient and their carers where consent is given, therefore this to be documented as part of the admissions care plan.
Where other needs and risks have been identified at the point of admission, associated care plans are also to be put in place. Where possible all care plans are to be formulated in conjunction with the patient and signed by them. The patient is to be offered copies of their care plans, colleagues to ensure that the relevant template on SystmOne is completed. If the patient declines or is not well enough to be involved in the development of their care plans a record of this is to be made in the electronic patient record.

8.4.3 Restrictions

Ward colleagues and the multi-disciplinary team (MDT) will ensure that any restrictions including restrictions on access to personal possessions are necessary and proportionate in relation to the patient concerned, take into consideration the safety of the patient and others on the ward, are explained clearly to ensure the person understands, why the restrictions are in place and under what circumstances they will be changed.

8.4.4 Discharge planning

Discharge planning will commence at the point of admission in collaboration with a range of multi agencies, MDT disciplines, the patient and the patients’ relatives and carers and, or advocate (where consent is given) throughout their stay.

Within 72 hours of admission all patients will have a discharge care plan. This will detail follow up arrangements by the service or after care arrangements, including prioritising follow up within 48 hours of discharge for patients who presented with a risk of suicide during their inpatient stay.

9 Mental health assessment

On admission to hospital all patients will have a comprehensive mental health assessment and review utilising the local MDT processes. This assessment will be started within 4 hours of admission and the standard is for the initial assessment(s) to be completed within 1 week or prior to discharge.

This assessment will be undertaken by the MDT and consider the patients:

mental health and medication
psychosocial and psychological needs
strengths and areas for development

The outcomes of initial mental health assessment(s) should be shared with the patient and carer (providing patient consent has been given).

10 Physical health

All patients will have a comprehensive physical health review which will be started within 4 hours of admission or as soon as is practicable possible. The assessment is completed within 1 week or prior to discharge.

This review will include details of past medical history including any long-term conditions; current medication, including side effects and adherence; details of past family medical history; a review of physical health symptoms and a targeted systems review; lifestyle factors, for example, sleeping patterns, diet, smoking, exercise, sexual activity, drug and alcohol use; consideration of whether the patient is at risk of withdrawal from drugs or alcohol; physical observations including blood pressure, heart rate, temperature, weight, height (abdominal circumference where indicated) and respiratory rate.

Where applicable a falls risk assessment to be completed to highlight falls prevention needs and the associated strategies to be put in place immediately. Colleagues should also inform the ward physiotherapist of the admission. Note that a hospital admission is a recognised falls risk in itself; as the patient is in an unfamiliar environment with unfamiliar routines at a time when they require increased help and support. Please refer to the patient falls manual (prevention and management) for more detail.

Arrangements to be made for any special or immediate associated provision, for example, sourcing of specialist equipment or aids or wheelchairs etc.

Wherever possible, patients will be offered a colleagues of the same gender as them, and, or a chaperone of the same gender, for physical examinations. For any consultation, examination, procedure, treatment or care that is of an intimate nature, a chaperone should be offered. Obvious examples of an intimate examination include examination of the breasts, genitalia and the rectum. The patient should be given the opportunity to state their preferences in relation to the sex of the chaperone. This must be documented in their health records.

Patients will be informed of the outcome of their physical health assessment and this will be recorded in their notes. With patient consent this can also be shared with their carer.

Patients will be offered personalised healthy lifestyle interventions such as advice on healthy eating, physical activity and access to smoking cessation services. This will be documented in their care plan.

Reiterate to any patients identifying as smokers, that the trust is a smoke free site and nicotine replacement therapy (NRT) to be offered as soon as possible to help keep them comfortable and minimise the effects of nicotine withdrawal. If an in-house smoking cessation service is available, the referral should be made within 24 hours of admission. If there is no established internal smoking cessation service in place, smokers should be provided with NRT and e-cigarettes free of charge throughout of the duration of their in-patient stay and referred to the community smoking cessation services on discharge. Please see the RDaSH smoke free policy.

Where concerns about physical health are identified during their admission, patients will have follow-up investigations and treatment. These investigations will be undertaken promptly and a named individual responsible for follow-up. Advice will be sought from primary or secondary physical healthcare services as necessary.

Where the patient is found to have a physical condition which may increase their risk of collapse or injury during restraint or the delivery of other aspects of their care, this is to be:

clearly documented in their records
regularly reviewed
communicated to all MDT members;
- evaluated with them and, where appropriate, their carer or advocate
- discussed with the Reducing Restrictive Interventions team

There should be a care plan for any newly identified or pre-existing medical condition or problem where assistance or supervision from colleagues is required.

11 Risk assessment and management

11.1 FACE risk assessment

All patients will have a FACE risk assessment and management plan which is reviewed and updated regularly (in response to significant clinical or risk changes and in keeping with minimum frequency outlined in RAG tool) and shared where necessary with relevant agencies (with consideration of confidentiality). The assessment will consider risks to self, risk to others, neglect, and risk from others.

All colleagues to be aware that the risk of suicide is increased during the first 7 days after admission. Where possible the FACE risk assessment will be coproduced and include risk to carers and incorporate carers’ views on risk where necessary.

11.2 RAG rating

All new patients are to be RAG rated as red. This rating will remain in place until at least the review at 72 hours or the patient’s first MDT review (comprising MDT discussion and face to face patient review).

12 Named nurse responsibilities

All patients admitted to the ward will have an allocated named nurse who is responsible for the coordination of their care and liaising with other agencies, family, and carers during the patient’s stay. The allocated named nurse should be on duty within 24 hours of the patient’s admission and should not be imminently due to take any annual leave or other planned absence of more than two days from the ward where possible.

At the first meeting with the patient, the admitting or named nurse where appropriate will:

introduce and explain their role
inform the patient of their right to be involved in decisions about their care and treatment and explain how to achieve this, including how to engage the services of an advocate
determine what level of contact the patient wishes to have with their relatives or carers and what information they wish to be shared in relation to their care and treatment whilst an inpatient. This is to be documented in the records
if the patient refuses to give consent for any information to be shared, the named nurse will explain that such a refusal will not prevent discussion taking place to enable relatives or carers from sharing information or any concerns with colleagues
ascertain if the patient has any responsibility for the care of a child or other person. If yes, the named nurse will work with admitting professional or other agencies, friends or family to ensure that safe alternative arrangements are in place for the duration of the admission
check that the patient’s admission and related assessments (see above) are complete
review the patient’s care plans with them
provide them with a copy of the named nurse leaflet (see appendix E)

During the admission, the named nurse will:

actively engage both the patient and their relatives or carers and be the main conduit for information both to and from MDT
liaise with the allocated care coordinator or lead professional throughout the inpatient stay if already known to a community team
take on the functions of the care coordinator under CPA or equivalent for patients not previous known to community mental health teams until a care coordinator is appointed or the patient is discharged
ensure all care plans have review dates timed to suit individual needs of the patient which are the minimum timeframe for review of care plans
review care plans as a minimum at the review dates stipulated and whenever there is a significant change in clinical presentation or social circumstances and at any transition of care (for example, transfer or discharge)
provide the patient with copies of their care plan
offer to meet with the patient for named nurse 1-to-1 sessions of least one hour per week. Sessions declined should be recorded in the records
review FACE risk assessments at the minimum agreed time intervals and in the event of a significant change to risk or clinical presentation or planning of leave
monitor treatment compliance and response to medication and report any side effects

13 Positive behaviour support (PBS) and crisis plan

During admission ward colleagues will discuss with the patient any strategies for coping that they use and how they can continue to use, adapt, and develop positive coping strategies whilst on the ward.

Based on a risk assessment as well as observation of a patient for any behaviour which may indicate that there is a heightened risk of violence, aggression or abuse, individual care plans including positive behavioural support (PBS) plan if required should be developed.

The positive behaviour support (PBS) plan should include any identified or known triggers for these behaviours, actions to be taken should any of these occur, and any known physical health conditions that may be exacerbated by restrictive interventions and may impact on the post incident physical health monitoring.

The behaviour support plan must detail the responses such as de-escalation techniques, distraction, diversion and sometimes disengagement to be used by colleagues when a person starts to become anxious, aroused or distressed (secondary preventative strategies).

Any person who can reasonably be predicted to be at risk of being exposed to restrictive interventions must have an individualised behaviour support plan.

A crisis plan should also be developed as part of the care planning process and should include:

relapse indicators and plans
who to contact in a crisis
coping strategies
preferences for treatment and specific interventions
advance decision to refuse treatment (ADRT)

14 Care programme approach (CPA) and care planning

All patients admitted to adult and older person’s mental health inpatient wards will be recorded as being on CPA or equivalent. Where a decision has been made to remove CPA during an admission this must occur after an MDT review with clearly documented reasoning.

There will be a documented CPA (or equivalent) or admission review meeting within 72 hours (where practicable) of the patient’s admission. Patients are supported to attend this with advanced preparation and feedback. Any form of meeting discussing and reviewing any aspect of patient care must be documented in the records.

Every patient will have a written care plan, reflecting their individual needs. Colleagues collaborate with patients and their carers (with patient consent) when developing the care plan and they are offered a copy:

The care plan will clearly outline:

agreed intervention strategies for physical and mental health
Mental Health Act status
measurable goals and outcomes
strategies for self-management
any advance statement or ADRT the patient has made
crisis and contingency plans
review dates and discharge framework

Patients will be supported to be active participants in the planning and management of their own health and wellbeing. Each patient will have a personalised care and support plan that:

captures and records conversations, decisions and agreed
outcomes in a way that makes sense to the person
is proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs
includes a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective

The Community Mental Health Framework for Adults and Older Adults (NHS England, 2019) and related guidance is applied when planning and coordinating care with community providers.

All patients will have a documented diagnosis and a clinical formulation which is jointly constructed by the patient.

This formulation will include the presenting problem and predisposing, precipitating, perpetuating, and protective factors as appropriate. Where a complete assessment is not in place, a working diagnosis and a preliminary formulation is devised.

It is good practice for any patients who are known to have been under the care of another mental health provider for colleagues to make a request through the trust information governance department for copies of the clinical records to be forwarded to the ward so that they can be reviewed to inform decision making around future care and treatment.

15 Care planning when patients decline or lack the capacity to involved

Should a patient decide not to be involved in their care planning, or if they have been assessed as lacking the capacity to be involved in their care planning this should be documented in the patients record at the time with a clear rationale for the decision making around this.

A person’s capacity and level of engagement can change and fluctuate throughout their hospital stay, so colleagues should continue to make attempts to engage and involve the patient in the care planning process. Colleagues should document each time that attempts are made and the outcome.

See MCA Mental Capacity Act 2005 policy for further information.

16 Medicines management on admission

The admitting nurse will ask the patient if they have brought any of their prescription medications with them. If yes, they are to be removed and stored in the treatment room, so that the doctor can check the prescription as part of the medicine reconciliation process and prescribe on SystmOne.

All patients who are admitted must have their medicines reconciliation and allergy status completed and documented within 24 hours or as soon as access to the primary care record is available, in line with NICE guidance and the safe and secure handling of medicines manual. Upon completion, this should be indicated in the electronic patient record. Colleagues should understand what the patient is prescribed and what they are taking including medication which may not be prescribed. Consideration should be given to reviewing medication and any changes should be clearly documented with a clear rationale provided. See safe and secure handling of medicines manual for further information.

When medication is prescribed, assessment of capacity and consent are recorded by the consultant or clinician in charge in accordance with trust policy on the relevant system template.

For detained patients, an assessment of capacity to consent to prescribed psychiatric and physical health medication must be completed and recorded within at least 7 days following admission under the MHA (or within 7 days of detention if informal on admission).

17 Patient identification

Patient identification can be undertaken in a number of ways, and these are clearly set out in the patient identification policy.

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 the electronic patient record of both patients.

18 Communication and support for carers

The named nurse will contact family or carers within the first 48 hours of admission to discuss concerns, family history and their own needs. A face-to-face meeting can be facilitated on request where appropriate.

Colleagues should be aware, when consent has not been given for sharing information with carers or relatives, there may be situations when they can share general information about things that the carer or relative already knows; for more guidance see common sense confidentiality video (opens in new window).

If not already done the carers are to be asked if they wish to be referred for a statutory carers assessment in line with the Care Act 2014. If yes, the referral will be made by the ward colleagues. Ensure a carers assessment has been offered, or started, before the person is discharged from hospital

19 DNACPR or RESPECT or advance decisions or statements

Patients who have had previous involvement with the mental health services may have made an advance statement and an advance decision to refuse treatment (ADRT) determining their wishes in-respect of the care and treatment should they require inpatient care. These decisions can be made by the patient and, or anyone else that may have legal authority, for example, lasting power of attorney or court appointed deputy.

Colleagues should refer to the trust’s advance statements and advance decisions to refuse treatment policy for full details and check both with the patient or carers of any advanced statement or advanced decision and SystmOne for any record of an advance statement or advanced decision.

20 Planned admissions

Prior to a planned admission there should be a multi-professional discussion regarding the rationale and outcomes expected from the admission. The gatekeeping process outlined in section 5 will be followed.

For planned admissions, patients will be offered an opportunity to visit the inpatient unit before they are admitted. If this is not possible, consider using accessible online and printed information including photographs of the unit to support discussion about their admission.

If admission is being planned for a treatment episode involve:

the person who is being admitted, their family members, parents or carers, community accommodation and support providers

When planning treatment for patients being admitted, take account of the expertise and knowledge of the person’s family members, parents, or carers.

Allow more time and expert input to support people with complex, multiple or specific support needs to make transitions to and from services, if necessary.

This may include:

children and young people
people with dementia, cognitive or sensory impairment
people with neurodiverse conditions, for example, ADHD, autism, dyspraxia, dyslexia, dyscalculia, dysgraphia, and Tourette’s syndrome
people with learning disabilities and other additional needs people placed outside the area in which they live

To support the person’s transition to the ward, the admitting nurse or person responsible should make the following items available if the person needs them: a toothbrush, hygiene products and nightwear. This is particularly important for people who have been admitted in crisis.

21 Contingencies

21.1 Specific requirements for patients admitted who are subject to detention under the Mental Health Act 1983

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

21.2 Prisoners (not detained under the MHA) or those detained by the police

When a prisoner or person lawfully detained by the police, UK Border Agency or national security services is admitted to an inpatient unit, (other than forensic services) then the relevant modern matron or Service Manager, Safety team and associate nurse director are to be informed as soon as reasonably practicable, preferably within one working day.

A risk assessment is to be carried out in conjunction with the detaining authority (prison, police etc.) which includes the potential risk to others, specific risks to colleagues, the presence of detaining authority guards, the use of mechanical restraints, restricting access to areas other than the bed area or room, and to ascertain the required action if the person attempts to leave the ward or department.

For mechanically restrained persons (prisoners in chains etc.), an agreement between the detaining authority and the ward or department on the use of restraints, including when they are used, is to be documented in the care record.

Ideally the person will be accommodated in a single room rather than multiple occupancy room; this will reduce anxiety of other patients, improve privacy for the person and make security management easier. Seclusion is not to be used for this purpose unless the clinical presentation indicates that seclusion would be a viable clinical intervention.

The detaining authority (if necessary, their medical department) are to be included in all discharge planning prior to discharge to ensure suitable arrangements are made.

21.3 Patients requiring admission to or consideration for a PICU environment

The MDT on receipt of the referral form will make decisions regarding the suitability of the patient admission or transfer. The MDT may decline to accept patients if they anticipate that the patient mix will comprise safety and, or therapeutic activity. This decision to accept or decline patients will be based on a clear clinical rationale based on risk assessment and alternative care options will be identified if the referral is declined. The decision will be recorded on the referral form and on SystmOne. RDaSH PICU referral form and RDaSH PICU referral flow chart.

21.4 Request from another trust to utilise an RDaSH adult and older person’s mental health inpatient bed

If another trust is asking to use one of our in-patient beds, this must be approved by the Patient Flow team (within working hours) and the bronze on-call manager outside of these times.

21.5 Patients who are homeless or at risk of being homeless

Patients, who have recently been homeless, or who are at risk of being made homeless, should be identified as soon as possible on or before admission, so that the appropriate agencies in both health and social care can be involved at an early stage. This will ensure that appropriate and timely needs assessments have been actioned to develop a discharge plan proportionate to individual need. If for any reason it has not been possible to secure appropriate accommodation and the patient is no longer requiring an inpatient bed, the patient is to be directed to either the:

Citizen’s advice Bureau
Local Authority Housing Department Crisis Accommodation team

For any homeless patient subject to CPA there must be explicit plans in place to maintain contact and enable the 72-hour follow up to take place before they leave the ward.

22 Appendices

Please see admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures webpage for appendices attached to this procedure.

Appendix D Nursing admission checklist
Appendix E Named nurse leaflet
Appendix F Evidence of legal authority to admit an Informal patient checklist
Appendix L Out of area placement flowchart

Document control

Version: 4.
Unique reference number: 349.
Approved by: Clinical policies review and approval group.
Date approved: 20 December 2023.
Name of originator or author: Head of patient flow.
Name of responsible individual: Chief operating officer.
Date issued: 20 December 2023.
Review date: 31 December 2026.
Target audience: Clinical colleagues working in the adult mental health and older person’s mental health Inpatient services, community, hospital liaison, crisis, and home-based treatment teams and AMHP’s for reference.
Description of change: Amendment to update appendix D and E (in line with patient flow procedure).

Page last reviewed: April 23, 2024
Next review due: April 23, 2025

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