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Controlled access and egress for inpatient wards policy

Contents

1 Introduction

The trust believes the safety of patients, staff and visitors is its utmost priority, and recognises its responsibilities and duty of care to ensure provision of safe and secure environments.

The trust operates controlled access or egress across all wards and expects all staff to ensure patients are aware of their rights, the reasons for the controlled access and egress and that the options for access and egress are made clear to both patients and visitors.

This policy provides a systematic and consistent approach to the management of access and egress procedures across the trust. The trust recognises its duty to ensure clear communication and offer appropriate routes of escalation to those patients and visitors who experience difficulties with the access and egress policy.

The trust recognises that those patients admitted to mental health wards have complex, specific and individual needs. The controlled access or egress to wards is intended to protect patients. This extends to protecting patients, staff and from others gaining access to the wards.

This approach is compliant with the Mental Health Act, Code of Practice (chapter 8).

2 Purpose

This guidance sets out the requirements for the use of controlled access and egress to the hospital wards based on the guidance given in the Mental Health Act Code of Practice 2015, chapter 8 and the Mental Capacity Act 2005.

3 Scope

This policy applies to the trust’s inpatient areas where controlled access and egress procedures are in place as set out below and applies to both informal patients and patients who are detained under the Mental Health Act.

4 Responsibilities, accountabilities and duties

4.1 Trust board and chief executive

The trust has a responsibility to have effective risk management procedures in place, which maintain the rights and dignity of patients, and for the monitoring of these processes.

4.2 Modern matrons for the inpatient wards

The modern matrons are responsible for:

  • the implementation of the policy and clinical staff compliance with its contents
  • reviewing the frequency of the implementation of this policy
  • any staff they manage being aware of this policy and its contents
  • keeping this policy under review so that its contents are reflective of current practice

4.3 Clinical staff who work within the inpatient wards

The clinical staff are responsible for:

  • implementing the requirements of this policy
  • reporting any non-compliance with this policy

5 Procedure and implementation

5.1 Definition of airlock

There are a number of units across the trust which operate with airlocks as part of their entrances:

  • Amber lodge
  • Jubilee lodge
  • Coral lodge
  • Doncaster adult mental health unit
  • Skelbrooke ward
  • Kingfisher ward

The airlock comprises of the front entrance area to the ward or unit, the external entrance door lock which is controlled by a magnetic device and a set of internal doors which are also controlled by magnetic locks. Each set of doors operates separately and independently from the other set, however both sets of doors are interlocked such that one set of doors has to be closed before the other will open, for example, the internal doors cannot be opened until the external doors have been closed and vice versa. The airlock is the area between these two sets of doors.

5.2 Definition of controlled access and egress

All other wards or units within the trust operate with controlled access and egress systems into the unit and individual wards. The doors to the wards or units are fitted with an electromagnetic lock and to allow access or egress a switch is provided into the ward or unit to allow staff to give access and egress to patients, visitors and staff.

5.3 Minimum standards to be applied by ward staff

All ward areas will ensure they have clear information displayed by the ward doors to inform patients and visitors how they can leave the ward (appendix A).

As part of local induction processes; all staff will be clear on the reasons and purpose for employing controlled access and egress on the ward.

All patients, regardless of their legal status, will be provided with verbal and written information on how to access or egress the ward. Where possible this should be done both prior to and on admission.

For those patients who are detained under the Mental Health Act or subject to deprivation of liberty safeguards (DoLS), this will include information on their legal status and the implications for them accessing and egressing the ward.

Information should also be provided to the patient’s family and carers on admission to ensure they are clear in the ward’s approach to access and egress.

In the case of informal patients, all staff working with the patient should ensure they are supportive of the patient’s right to leave the ward where it is safe for them to do so.

Staff must explain the patient’s legal rights where necessary and ensure any difficulties experienced by the patient are raised as a concern.

Where staff have concerns about the risks posed by a patient should they leave the ward, then they must discuss this with the patient. The information discussed should include details of how they could request discharge themselves from the hospital and their compliance with the agreed care plan and how to request a review of this.

For both informal and detained patients their ability to understand the processes relating to the access and egress to wards should be continuously reviewed. The Mental Capacity Act is the governing framework for assessments of capacity and this should be adhered to support improvement of their understanding.

The ward manager must ensure all staff being inducted onto the ward are provided with information on the approach, philosophy and aims of this guidance.

5.4 Informal patients with capacity to consent to admission

Informal patients should be made aware of their legal position and rights, failure to do so could lead to a patient mistakenly believing that they are not allowed freedom of movement, which could result in an unlawful deprivation of their liberty. Staff should ensure:

  • there are signs up informing informal patients of their rights to leave the ward
  • a copy of the informal rights leaflet should be provided to the patient
  • where a patients legal status changes from being detained under the MHA to informal, they should be informed of their rights as an informal patient and this should be documented in the electronic patient record

Informal patients have the right to leave at any time however prior to admission and on admission they will be advised that we would like them to remain on the ward for 72 hours in order that we can undertake an assessment of their care and treatment needs.

Informal patients cannot be required to ask permission to leave the ward but may be asked to inform staff when they wish to leave the ward. This is so that staff are aware of who is on the ward at any one time, thereby ensuring the health and safety of all.

The trust has a duty of care towards the patient, if a patient expresses a wish to leave, the nurse must make a decision based on the latest risk assessment and the patient’s current presentation whether it is safe for them to leave. If it is not felt to be safe and the patient cannot be persuaded to stay on the ward, a doctor must be contacted to carry out an assessment under section 5(2) MHA 1983. If there is a delay in the doctor coming to do the assessment, the nurse should consider the use of section 5(4) MHA 1983.

5.5 Patients who lack capacity to consent to admission

In the case of patients asking to leave who lack capacity to understand the reasons they are being held on the ward under the deprivation of liberty safeguards (DoLS) or are awaiting a DoLS assessment. The ward manager must make a decision under the Mental Capacity Act in their best interests based on the risks of leaving the ward unescorted or with an escort.

Patients detained under the deprivation of liberty safeguards (DoLS) are able to leave the ward if escorted by staff or family members and it is safe to do so, as detailed in their care plan.

Information should also be provided to the patient’s family and carers on admission to ensure that they are clear in the ward’s approach to access and egress.

6 Training implications

There are no specific training needs in relation to this procedure, but clinical staff working on any of the inpatient wards which have controlled access will need to be familiar with its contents.

As a trust procedure, all staff need to be aware of the key points that the procedure covers. Staff can be made aware through a variety of means such as:

  • team meetings
  • local induction
  • one to one meetings or supervision

7 Monitoring arrangements

7.1 Compliance with the standards as set out in this policy

  • How: Audit of the access and egress policy.
  • Who by: Modern matrons (inpatient service).
  • Reported to: Care group quality meeting.
  • Frequency: Quarterly.

8 Equality impact assessment screening

To download the equality impact assessment for this policy, please follow this link: Equality impact assessment.

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’. Consequently, 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 Indicate 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 colleagues 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.

8.2.1 Indicate how this will be achieved

This policy will be implemented in accordance with the guiding principles of the Mental Capacity Act 2005 (section 1).

10 References

  • Mental Health Act 1983 as amended by the 2007 Act
  • Mental Health Act Code of Practice 2015
  • Mental Capacity Act 2005

11 Appendices

11.1 Appendix A Ward door notice

11.1.1 Notice

It is necessary to lock this door for the safety and security of patients, staff and visitors.

If you wish to leave, please speak to any member of staff who will be happy to help you


Document control

  • Version: 1.
  • Unique reference number: 563.
  • Ratified by: Clinical policies review and approval group.
  • Date ratified: 3 November 2020.
  • Name of originator or author: MHA manager.
  • Name of responsible individual: Director of nursing and allied health professionals.
  • Date Issued: 2 December 2020.
  • Review date: November 2023.
  • Target audience: Clinical staff working on the trust’s inpatient wards.
  • Description of change: This is a combination of the control of access to the acute adult inpatient wards policy and the admission of a patient to one of the adult acute inpatient wards SOP and now covers all inpatient wards and provides definitions of airlock and access or egress.

Page last reviewed: March 19, 2024
Next review due: March 19, 2025

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