Mental health units (use of force) policy

1 Introduction

Every individual has the right to be treated with dignity and in a caring therapeutic environment which is free from abuse. The use of force (which refers to physical, mechanical or chemical restraint, or the isolation of a patient) can sometimes be necessary to secure the safety of patients and staff. This always comes with risk and can be a traumatic and upsetting experience for patients when they are at their most vulnerable and in need of safe and compassionate care and can also be upsetting for those who witness it, such as other patients or visitors.

For too long the use of force has been accepted as the norm in many mental health services and this must change. Whilst there is good practice in many mental health units, there is still a greater focus on managing behaviour rather than working to prevent situations from escalating to the point at which the use of force is seen to be the only solution. This focus needs to shift to one which respects all patients’ rights, provides skilled, trauma-informed, person-centred care, follows the principles of least restriction, and promotes recovery.

2 Purpose

The Mental Health Units (Use of Force) Act 2018 and statutory guidance requires the trust to have a written policy to clearly set out the measures which are needed to both reduce the use of force and ensure accountability and transparency about the use of force in the mental health units in the trust.

The implementation of this Act underpins the trust’s reducing restrictive interventions (RRI) policy (formerly PMVA policy) and the work that is ongoing to reduce the number of restrictive interventions.

3 Scope

This document applies to and is relevant across the following services or departments or care groups:

acute mental health wards for adults of working age (including the s136 suites)
psychiatric intensive care units
rehabilitation mental health wards for working age adults
forensic low secure inpatient ward
older people’s mental health wards

4 Responsibilities, accountabilities and duties

4.1 Trust board

The trust board has a legal, professional and ethical obligation to minimise harm to service users, staff and others and is accountable for the use of force within the trust.

It is committed to minimising the use of force, through the promotion of positive cultures, relationships and approaches which understand the trauma history and triggers of patients which will prevent escalation and any need to use force.

It will:

understand why force is used within the trust and develop a strategy for violence reduction and the use of force
regularly review the trust’s performance in reducing the use of force
monitor the use of force on people who share protected characteristics under the Equality Act 2010 and take action on the inappropriate or disproportionate use of force where this is identified
be aware of the types of force and specific techniques which the trust uses and ensure that these are risk assessed prior to use
appoint a “responsible person” whose role it is to ensure that the trust complies with the requirements of the act

4.2 Executive director of nursing and allied health professionals

The executive director of nursing and allied health professionals is appointed as the “responsible person” whose role it is to ensure that the organisation complies with the requirements of the Mental Health Unit (Use of Force) Act:

that a “responsible person” is appointed and that the requirements of the act are carried out
publish a policy regarding the use of force by staff who work in the trust
Publish information for patients about their rights to the use of force by staff who work in the trust
ensure that staff receive appropriate training in the use of force
keep records of any use of force on a patient by staff who work in the trust, including demographic data across the protected characteristics in the Equality Act 2010
where a patient dies or suffers serious injury, have regard to any relevant guidance in relation to investigations of deaths or serious injuries
where appropriate, delegate any or all of these functions, and keep records of what and who these have been delegated to

4.3 Deputy director for safety and quality

The deputy director for safety and quality will:

act as the “deputy responsible person” to carry out the responsible person’s functions within the trust
promoting the act and supporting services to implement all its provisions
provide regular feedback to the responsible person

4.4 Head of patient safety (patient safety specialist)

The head patient safety (patient safety specialist) will:

promote awareness and support implementation of the mental health units (use of force) act within the trust
provide advice and support to managers and staff
collaborate with the PMVA team and managers to promote reducing the use of force within the trust
investigate and interrogate a sample of use of force incidents to encourage lessons learnt
collaborate with the PMVA team to provide the environmental risks in clinical areas (ERICA) group with monthly reports on the number of uses of force taking place in line with the act

4.5 Care groups

Through their deputy care group directors service managers and matrons will:

make arrangements for the effective implementation and monitoring of the policy
promote a culture which focuses on openness and transparency about the use of force
facilitate and monitor the attendance of staff on mandatory PMVA training
promote a positive reporting and learning culture to facilitate continuous improvement with regard to use of force in the trust

4.6 Deputy care group directors, service managers and matrons

Deputy care group directors service managers and matrons will:

advise and instruct staff on the policy requirements via local induction arrangements and ongoing communication mechanisms
facilitate an understanding of the legal and practice requirements which must be implemented as set out in this policy
facilitate and monitor the attendance of staff on mandatory PMVA training
maintain accurate staff training records
promote a culture which focuses on openness and transparency about the use of force
ensure all incidents are reported via the electronic incident form (IR1)
promote a positive reporting and learning culture to facilitate continuous improvement with regard to the use of force in the trust

4.7 Staff

All staff are required to:

promote a culture which focuses on prevention and management of violence and aggression by early recognition, prevention and de-escalation of potential aggression, using techniques and therapeutic approaches that support patients in line with their preferences, needs and abilities and that minimise the risk of its recurrence
operate in a trauma informed care approach
ensure that patients have a Positive behaviour support care plan in place
complying with the PMVA Policy to protect themselves and others from harm
report all incidents using the IR1 Form and participate in post-incident reviews
attend mandatory training on PMVA
seek advice and support as required in a timely manner

5 Procedure or implementation

5.1 What is use of force

The Mental Health Units (Use of force) Act defines the use of force as either:

the use of physical, mechanical or chemical restraint on a patient
the isolation of a patient

The act introduces the following definitions of use of force:

physical restraint, the use of physical contact which is intended to prevent, restrict or subdue movement of any part of the patient’s body, this would include holding a patient to give them a depot injection
mechanical restraint, the use of a device which is intended to prevent, restrict or subdue movement of any part of the patient’s body, and is for the primary purpose of behavioural control
chemical restraint, the use of medication which is intended to prevent, restrict or subdue movement of any part of the patient’s body, this includes the use of rapid tranquilisation

The act states that isolation is any seclusion or segregation that is imposed on a patient however the definitions for these are those provided in the Mental Health Act Code of Practice 2015:

seclusion, the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others. This can include seclusion where the door to a room is open, but the patient is still prevented from leaving, for example, by a staff member either in or next to the doorway
long term segregation, a situation where, in order to reduce a sustained risk of harm posed by the patient to others, which is a constant feature of their presentation, a multi-disciplinary review and representative from the responsible commissioning authority determines that a patient should not be allowed to mix freely with other patients on the ward on a long-term basis

Use of force should not be used to punish or for the sole intention of inflicting pain, suffering or humiliation. Where a person restricts a patient’s movement, or uses (or threatens to use) force then that should:

be used for no longer than necessary to prevent harm to the person or to others
be a proportionate response to that harm
be the least restrictive option

5.2 Where does it apply

A mental health unit is described as a health service hospital or independent hospital in England that provides treatment to inpatients for a mental disorder. An independent hospital will only be a ‘mental health unit’ if its purpose is “to provide treatment to inpatients for mental disorder”, and “at least some of that treatment is provided, or is intended to be provided, for the purposes of the NHS.”

The types of inpatient service which would be considered within the definition of a mental health unit which applies in the trust (this is not an exhaustive list) includes:

acute mental health wards for adults of working age and psychiatric intensive care units
long stay or rehabilitation mental health wards for working age adults
forensic inpatient or secure wards (low, medium and high)
wards for older people with mental health problems

The following services are considered to be outside of the definition of a mental health unit (this is not an exhaustive list) and therefore not covered by the requirements of the act:

accident and emergency departments of emergency departments
section 135 and 136 suites that are outside of a mental health unit
outpatient departments or clinics
mental health transport vehicles

Other types of services not applicable to this trust (this is not an exhaustive list) includes:

child and adolescent mental health wards
wards for people with autism or a learning disability
specialist mental health eating disorder services
inpatient mother and baby units
acute hospital wards where patients are “detained under the Mental Health Act 1983 for assessment and treatment of their mental disorder”

5.3 Management of risks associate with use of force

Staff should refer to the reducing restrictive interventions (RRI) policy (formerly PMVA policy) and the trust’s security policy.

5.3.1 Bespoke risk management plans

Where the behaviour of an individual indicates their level of risk cannot be managed safely using the trust standard approved techniques for that specific ward area (see appendix A) staff should refer to the Reducing Restrictive Interventions team (RRI) for a more bespoke risk management plan.

In circumstances where techniques have had to be adapted by the RRI team, these must be approved by the “responsible person” under the Mental Health Units (Use of Force) Act, and the RRI team will be responsible for gaining this approval prior to their use on the ward.

5.4 Care plans and positive behavioural support plans

Care plans and positive behavioural support plans should, with the patient’s consent take into account how patients, their families and carers are involved in care planning which should set out the preventative strategies to the use of force.

However, it is important to remember that there may be circumstances where it could be harmful to a patient to involve their family or carers (for example, survivors of domestic abuse or violence) so the patient’s wishes and preferences must be taken into account.

5.5 Recording and reporting the use of force

The use of data to inform the reducing restrictive interventions agenda is a central part of the trust’s restrictive practice reduction programme. In particular, the ability to use data to inform and promote individualised person-centred approaches to reduce the use of restrictive interventions.

However, the duty to keep a record of the use of force does not apply if the use of force is negligible and this is to ensure that the recording of the use of force remains proportionate within the aims of the act.

5.5.1 What is considered negligible use of force

Negligible does not mean irrelevant to a person’s experience of care or treatment and it is expected that negligible use of force will only apply in a very small set of circumstances.

The use of force can only be considered negligible where it involves light or gentle and proportionate pressure. Any negligible use of force must meet all of the following criteria:

is the minimum necessary to carry out therapeutic or caring activities (for example, personal care or for reassurance)
it forms part of the patient’s care plan
valid consent to the act in connection with care and treatment has been obtained from the patient, or where appropriate a member of their family or carer has been consulted, particularly a person with parental responsibility if this is in relation to a child and the child is not Gillick competent. Where the patient lacks capacity, a best interest decision would need to be made informed consent (clinical trials) SOP
and only if they are outside of the circumstances in which the use of force can never be considered (as set out below in 5.5.2)

Example: the use of a guiding hand (not gripping) by a member of staff to provide the minimum necessary redirection or support to prevent potential harm to a person. The contact would be proportionate to the task and that the person could at any time over-ride or reject the direction of the guiding hand and exercise their autonomy and the guiding hand does not cause distress to the person.

Any use of force which meets the above criteria must be included in the patient’s care plan and be recorded proportionately, for example via a weekly summary, but not as the same level of detail as required for non-negligible use of force (5.5.2 below).

5.5.2 What can never be considered negligible use of force

The use of force can never be considered negligible in any of the following circumstances:

any use of rapid tranquilisation
any form of mechanical restraint
the patient verbally or physically resists the contact of a member of staff
where the use of force involves the use of a wall, floor (or other flat surface) and the use of force is disproportionate.
someone other than RDaSH staff (who may be the patient, another patient, a visitor, or a carer) witnesses use of force, and has capacity to validly appraise and comment on the use of force, complains about the use of force that they witnessed
the use of force causes an injury to the patient or a member of staff (including any type of injury or other physical reaction including scratches, marks to the skin and bruising)
the use of force involves more members of staff than is specified in the patient’s care plan
during or after the use of force a patient is upset or distressed
the use of force has been used to remove an item of clothing or a personal possession

5.5.3 Data collection requirements

Any use of force that meets the above criteria must be recorded appropriately via the trust’s IR1 system and via SystmOne and must include the following:

the reason for the use of force
the place, date and duration of the use of force
the type or types of force used on the patient
whether the type or types of force used on the patient formed part of the patient’s care plan
name of the patient on whom force was used
description of how force was used
the patient’s consistent identifier
the name and job title of any member of staff who used force on the patient
the reason any person who was not a member of staff in the mental health unit was involved in the use of force on the patient
the patient’s mental disorder (if known)
the relevant characteristics of the patient (if known):
- the patient’s age
- whether the patient has a disability, and if so, the nature of that disability
- the status regarding marriage or civil partnership
- whether the patient is pregnant
- the patient’s race
- the patient’s religion or belief
- the patient’s sex
- the patient’s sexual orientation
- gender reassignment, whether the patient identifies with a different gender to their sex registered at birth
whether the patient has a learning disability or autistic spectrum disorder
a description of the outcome of the use of force
whether the patient died or suffered any serious injury as a result of the use of force
any efforts made to avoid the need for the use of force on the patient
whether a notification regarding the use of force was sent to the person or persons (if any) to be notified under the patient’s care plan

All the above data requirements on the use of force will either be collated from the trust’s existing IR1 system or from SystmOne, so there are no additional data collection requirements for staff.

5.6 Information about use of force

It is important that patients, and where appropriate their families and carers, are provided with information about the use of force and their rights in relation to any use of force which may be used by staff in any of our mental health units. The information will help patients and their families and carers understand what might happen to them whilst they are an inpatient in a mental health unit, what their rights are, and what help and support is available to them should they need it.

A booklet has been developed for each Ward to identify what techniques will be used within that ward environment to manage the use of force. This booklet will be discussed with all patients on admission, or as soon as is reasonably practicable after admission, so that patients understand the techniques which may be applied during their stay.

Where the patient consents, a booklet will be shared with members of their family or carer to provide the necessary information in relation to use of force within the ward environment.

If the patient initially refuses the information, staff should make further attempts at reasonable intervals to provide them with the information in an appropriate format.

Staff should record whether the information was accepted or refused by the patient.

5.7 Requests for police assistance

In circumstances where police officers have been called into mental health units to assist staff on that unit, police officers must wear and operate a body camera at all times when reasonably practicable.

This applies to English police officers, a member of the special constabulary or special constable and the British transport police.

However, it is recognised that there may be special circumstances that justify not wearing or operating a camera, it is for the police officer(s) to determine in line with current college of policing guidance on the use of body cameras whether special circumstances apply.

Images from these cameras will be the responsibility of the data controller for example, the person that takes them, the police.

5.8 Post incident reviews

Tertiary prevention recognises the need for thorough post incident review procedures in order to ensure that lessons are learned from incidents and that action is taken to prevent the risk of re-occurrence.

Following any use of force, the patient, and where appropriate family or carers will be involved in post incident reviews where the impact both physical and emotional will be reflected upon.

Debrief must:

evaluate the physical and emotional impact on all involved including witnesses
identify if there is a need, and if so, provide counselling or support for any trauma that might have resulted
help patients and staff to identify what led to the incident and what could have been done differently to ensure lessons are learnt from each incident
determine whether alternatives including less restrictive interventions were considered
determine whether service barriers or constraints make it difficult to avoid the same course of action in future
where appropriate, recommend changes to the service philosophy, policy, care environment, treatment approaches, staff education and training

Patients should not be compelled to take part in debrief, they should be offered the right to talk about the incident independently.

5.9 Raising concerns about use of force

Any concerns about the use of force can be raised with the head of learning and development and head of patient safety (patient safety specialist).

6 Training implications

All staff who may be required to use force within their job role, will be required to undergo the trust’s RRI induction training and or, RRI update training as part of their mandatory training for the specific area in which they work.

6.1 Qualified nurses and nursing assistants in inpatient MH and forensic wards, RRI comprehensive

How often should this be undertaken: Induction.
Length of training: 4 days.
Delivery method: Face to face.
Training delivered by whom: RRI team.
Where are the records of attendance held: ESR.

6.2 All nursing bank staff in inpatient MH and forensic wards, RRI comprehensive

How often should this be undertaken: Induction.
Length of training: 4 days.
Delivery method: Face to face.
Training delivered by whom: RRI team.
Where are the records of attendance held: ESR.

6.3 Inpatient medical staff in inpatient MH and forensic wards, personal safety and disengagement

How often should this be undertaken: Induction.
Length of training: Half a day.
Delivery method: Face to face.
Training delivered by whom: RRI team.
Where are the records of attendance held: ESR.

6.4 Updates or refreshers

How often should this be undertaken: Annually.
Length of training: 2 days.
Delivery method: Face to face.
Training delivered by whom: RRI team.
Where are the records of attendance held: ESR.

As a trust policy, all inpatient staff need to be aware of the key points that the policy covers. Staff can be made aware through:

all user emails
daily email
intranet
team meetings

7 Monitoring arrangements

7.1 Trust performance in reducing the use of force

How: Annual report.
Who by: Patient safety specialist or PMVA team.
Reported to: Trust board.
Frequency: Annually.

7.2 Monitoring of equality

How: Annual report.
Who by: Patient safety specialist or PMVA team.
Reported to: Trust board.
Frequency: Annually.

7.3 Monitoring of training on the use of force

How: Annual report.
Who by: Patient safety specialist or PMVA team.
Reported to: Trust board.
Frequency: Annually.

7.4 Monitoring of the recording of use of force on patients

How: Quarterly report.
Who by: Patient safety specialist or compliance lead.
Reported to: Trust board.
Frequency: Quarterly.

8 Equality impact assessment screening

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

The implementation of this act underpins the trust’s prevention and management of violence and aggression (PMVA) policy and the work that is ongoing to reduce the number of restrictive interventions.

8.1 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).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s 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.

9 Links to any other associated documents

10 References

Mental Health Units (Use of Force) Act 2018 statutory guidance (opens in new window).
Equality Act 2010.
Mental Health Act 1983.
Mental Health Act Code of Practice 2015.

11 Appendices

11.1 Appendix A Patient leaflet

11.1.1 The physical use of force, supporting holds, your rights explained

The Mental Health Units (Use of Force) Act 2018 states that we must be open and transparent with you, your family and, or your carer(s) about the physical use of force (supporting holds) that is used in the area where you are been supported.

The act states that you have a right to know:

what we do to avoid using supporting holds
why and how supporting holds maybe used to keep you or others safe
what supporting holds maybe used to keep you and other safe
what restrictions are and why they are used
how to make a complaint if you feel there has been an overuse or misuse of physical force

You can find out all of this information by asking the staff. However, if you would prefer you and, or you family or carer can ask to see the ward booklet on the physical use of force (supporting holds). This can be accessed at any time with staff support.

Document control

Version: 1.1.
Unique reference number: 624.
Approved by: Clinical policy review and approval group.
Date approved: 29 January 2024.
Name of originator or author: MHA manager or patient safety lead.
Name of responsible individual: Director of nursing and AHP.
Date issued: 6 February 2024.
Review date: March 2023.
Target audience: All mental health and forensic inpatient services.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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