Acceptable behaviour policy

Thank you to Birmingham and Solihull Mental Health NHS Foundation Trust policy for the management of unacceptable behaviour policy and Greater Glasgow and Clyde NHS, standards of behaviour protocol and guidance for patients and visitors for sharing their policies which have been used to construct this Rotherham, Doncaster and South Humber Foundation Trust (RDaSH) policy.

Contents

1 Introduction

1.1 Rationale

The purpose of this policy is to provide standards for the management of unacceptable behaviours of all types that are of a discriminatory or abusive nature. Its aims are to establish the principles and procedures for the recognition of, response to and treatment of discrimination and abuse that could arise in connection with the services and activities provided by Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH). It provides a framework and guidance for all employees and others within the organisation who could be exposed to aggressive, threatening discriminatory behaviours so that they are better supported and equipped to avoid and minimise the risks of such behaviours.

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH), hereinafter referred to as the trust has a duty to:

• provide a safe and secure environment
• establish basic principles for the recognition of, response to and appropriate management of aggressive, abusive, and discriminatory behaviour within the trust in order that its staff may be better equipped to deal with a potential or actual situation

Managing such incidents in a structured and cohesive manner underpins the ability of staff to work in a safe and secure environment. Abusive, discriminatory, or antisocial behaviour by any person is not acceptable. However, given the broad range of services provided by the trust and the diverse nature of the individuals we engage with, each and every situation would need to be assessed on an individual basis to ensure the effective management and prevention of such behaviours towards trust staff members.

Abusive, discriminatory, or antisocial behaviour towards trust staff may also constitute a criminal offence, so in addition to the processes outlined within this policy, it may also be necessary to report such incidents to the police for consideration of criminal investigation and prosecution where appropriate.

Where such conduct is by a staff member, such behaviours would be managed wholly within the trusts’ disciplinary procedures, although where such conduct constitutes a criminal or civil offence, this would also be reportable to the police and, or the relevant professional body where applicable.

1.2 Scope

This policy is intended to cover all activities of the trust and the areas where trust activities are carried out, including home visits by community staff, and staff working in premises that are not owned or managed by the trust.

The aim of this policy is to address abusive, discriminatory, and aggressive and nuisance behaviours towards trust staff and those undertaking official duties on behalf of the trust and to mitigate the associated risks of such behaviour from:

• members of the public
• patients or service users
• carers or relatives and associates of patients or service users
• visitors
• contractors and third parties on trust premises

The policy supports the delivery of high quality clinical and backbone services through the provision of a safe, supported, and secure environment.

The policy considers relevant legislation, such as the Equality Act (2010), Health and Safety at Work Act (1974) and the Management of Health and Safety at Work Regulations (1999).

In addition to the general and statutory duty and specific acts and regulations, employers have a duty to take responsibility for the care and safety of their employees.

Equally, employees have a corresponding obligation to take reasonable care of their own safety and that of others whilst at work. They have a duty to cooperate with their employer to enable compliance with statutory obligations. An example of this would be working in accordance with training and instructions that have been provided and to report hazardous situations or concerns in a timely manner. This would include incidents of abuse, discrimination, harassment, and antisocial behaviour whilst in the workplace, be this on Trust premises, or undertaking official duties on behalf of the organisation elsewhere, for example a community setting.

1.3 Principles

The principles of this policy are to promote and support effective working practices and the provision of services that are fair, accessible and that meet the needs and requirements of all individuals, and to support and enable its staff to do so in a safe and secure environment, without fear of abuse, discrimination, threats and antisocial behaviours directed towards them.

2 Policy

This policy has been developed to support staff undertaking their duties as an employee of the trust when they are confronted with abusive, discriminatory, threatening, antisocial and nuisance behaviours. Every member of staff must be aware of their responsibilities in the context of this policy and take appropriate measures for the safety of themselves and others.

This policy aims to achieve this by providing a process that enables such behaviours to be recognised together with a structured response that enables the described behaviours towards trust staff to be managed appropriately. Several informal and formal sanctions are available up to and including the withdrawal of clinical care and, or criminal prosecution where deemed appropriate. These procedures are set out at appendix A of this policy.

Individual members of staff when confronted with the behaviours described in this policy will report such incidents using the trust incident reporting system. Staff with managerial responsibilities will ensure that all necessary steps are taken to support staff reporting abuse, discrimination, threats and antisocial behaviours risks when these are notified, and that all reports are assessed, documented and communicated to ensure that all possible actions are taken to mitigate such risks and that the safety of those to whom such behaviours have been directed is maintained. Whilst every situation will differ, some examples of unacceptable behaviours are set out in section 7 (glossary), of this policy. However, these examples are not exhaustive.

Staff who experience or encounter unacceptable behaviours, in addition to reporting the incident to their line manager, can also contact the staff network groups, Human Resources or People and Organisational Development teams, Freedom to Speak Up (FTSU) Guardian or Champions, their staff side representatives, the trust Health and Safety team and occupational health service, should they wish to seek additional support or discuss any concerns they may have.

All actions taken should be updated on the appropriate clinical records together with any identified risks to personal safety where appropriate and the trusts incident report system. It is also important that all risk information be shared with other agencies as necessary in accordance with the information sharing protocols.

3 Procedure

The procedures for the implementation of this policy are set out at appendix A, but examples of the various sanctions that can be applied in response to abusive, discriminatory, threatening, and antisocial behaviours are as follows:

• consultation or discussion with the patient, service user, carer, relative, or visitor to highlight unacceptable behaviours and minimise or dispel potential incident
• escalation to manager for intervention
• manager to liaise with relevant safety team (in the Nursing and Facilities Directorate), to identify appropriate response and support with reported incident.
• use of a verbal warning by service manager
• issue of an unacceptable behaviour letter (where appropriate)
• issue of a warning letter (for example, yellow card)
• expulsion or exclusion from trust premises and, or withdrawal of clinical services (permanent basis via red card)
• report to South Yorkshire or Humberside Police for criminal investigation and consideration of prosecution where appropriate

The above is not an exhaustive list, and all situations and responses should be assessed on an individual basis.

There will be situations where such interventions could be inappropriate. For example, a clinician may assess an individual as not having any understanding of the impact of their behaviour. In such situations, the responsible manager will need to undertake a risk assessment and implement all possible measures to minimise risks to staff and others to enable the continuation of their care.

However, in such situations, the appropriate control measures should be developed with the support of a multidisciplinary team, trust Legal, Complaints team, and safeguarding teams as required.

4 Responsibilities

4.1 Chief executive

The chief executive has overall responsibility for the policy.

If there is a dispute concerning the issuing of red cards raised by the executive clinical directors or chief operating officer, the chief executive will make the final decision.

4.2 Executive clinical directors

These are the chief medical officer (CMO), chief nursing officer (CNO) and director for psychological professionals and therapies.

These executive directors are responsible for considering requests to issue red cards and then have authority to issue red cards.

4.3 Director for corporate governance

Is responsible for keeping and overseeing the register of red and yellow cards considered and issued. This director is also responsible for ensuring an annual audit concerning these.

4.4 Care group quad teams

These are the care group director, care group medical director, care group nurse director and care group director for psychological professionals (or in the physical health care group the director for allied health professionals)

Are responsible for the oversight and management of the directorate leadership teams.

The consideration and issuing of yellow cards is the responsibility of the care group quad teams. Where there is a dispute they can escalate this to the chief operating officer.

4.5 Directorate leadership teams

These report to the Carer Group Quadrumvirate. They comprise clinical and managerial leads.

Are responsible for ensuring that all appropriate risk assessments are completed for their areas of responsibility and that immediate action is instigated for the reporting and response to incidents.

Where appropriate, in the first instance they are to attempt to control such incidents sufficiently that the risk is reduced to enable the continued provision of care. They are also to be the liaison point for the police or other agencies if they are requested to attend. Line managers are responsible for ensuring that staff are supported following incidents.

The consideration and issuing of unacceptable behaviour warning letter is the responsibility of the directorate lead teams. Where there is a dispute they can escalate this to the Care Group Quad team.

4.6 All staff

All staff have a responsibility to behave in an acceptable and professional manner, in both their professional and personal undertakings whilst on trust premises and when representing the trust. Where an incident occurs, all staff have a responsibility to document and follow the incident reporting process, in accordance with trust policies and procedures.

4.7 Complaints handlers in the Nursing and Facilities team

Will be notified of all reported incidents and support team managers and Health and Safety teams in decisions as to the appropriate level of response to reported incidents.

4.8 Complaints and Patient Experience team

To retain a copy of all warnings issued because of implementing the guidance within this policy.

4.9 Trust quality and safety sub-clinical leadership group

The trust quality and safety sub-clinical leadership group will provide a reporting structure and will review submitted reports that incorporate actions taken under this policy, providing oversight and assurance that appropriate actions are being taken. This means the executive director lead is the chief nurse.

5 Development and consultation process

The following groups have been consulted as part of the development process for this policy:

• clinical leadership executive
• trust executive
• GP partners, via the chief executive
• Health and Safety team, via the executive chief nurse
• board of directors

6 Reference documents

• Health and Safety at Work Act.
• Equality Act (2010)
• Criminal Justice and Immigration (CJIA) Act (2008).
• Risk management policies.
• Trust policies associated with patient safety incident response framework.
• Health and safety policies.

7 Glossary

8 Audit and assurance

8.1 Number of verbal threats or abuses reported

• Lead: Service managers.
• Tool: Trust risk management system.
• Frequency: Monthly.
• Reporting group: Care Group monthly meetings.

8.2 Number of verbal warnings, yellow cards and red cards issued

• Lead: Director of corporate governance.
• Tool: Total letters issued.
• Frequency: 6 monthly.
• Reporting group: Quality and safety sub-clinical leadership groups.

8.3 Audit of incident and correspondence totals

• Lead: Director of corporate governance.
• Tool: Multi-professional team including expert by experience.
• Frequency: Annual.
• Reporting group: Clinical leadership executive and trust board.

9 Appendices

9.1 Appendix A Procedure for the management of unacceptable behaviours

Following any incident, staff involved must report this to their line management. This will allow for the incident to be fully assessed and, decisions made in relation to the next steps as to how the individual responsible will continue to receive any care from the trust.

Such incidents must be fully recorded on the trust incident reporting system and any associated risks fully documented on the clinical records system to ensure that all staff are made aware of any potential risks associated with that patient or service user.

The manager or staff should seek advice and support from the trust Health and Safety team at the first opportunity to ensure that all possible risks and possible resolutions are identified, discussed, and considered.

If appropriate to do so, the patient or service user can be spoken to immediately to explain that their behaviours towards trust staff are not acceptable, and the possible consequences of continuing to behave in such a manner towards trust staff. However, staff must never engage in any challenge that would put them at immediate risk of further violence or abuse and should always withdraw from any situations where behaviours displayed towards them may compromise the safety of themselves and colleagues.

When unacceptable behaviours are reported, subsequent actions are:

• report all incidents via the trust Incident reporting system
• update any risks on the patient record
• discuss with line manager
• seek support from Health and Safety team
• consider behaviours reported and appropriate level of response (informal discussion, verbal warning, a warning letter, how or if continued care will be provided and, or withdrawal of care provision temporarily or permanently)
• all responses to inappropriate behaviours should involve the team providing care, Health and Safety team, complaints team and relevant clinical and managerial leads
• any criminal offences should be reported to the police as appropriate
• appropriately share any identified risks or threats with other agencies that are currently or may be providing care and support, this should include agencies such as ambulance, police, acute and social healthcare services

Where unacceptable behaviours are demonstrated towards trust staff by carers, relatives, visitors, and members of the public, they should be asked to stop, and staff should explain the reasons for asking them to do so. If the unacceptable behaviour continues, then depending on the setting (for example, trust building or community location such as the home of a patient or service user), in addition to the above steps, the individual(s) responsible should be asked to leave immediately (trust premises), or if in the community, staff should immediately withdraw to safety and if necessary, seek immediate police assistance.

Trust staff should not put themselves at any unnecessary risk in terms of their personal safety and should call 999 if there is any refusal to leave a trust building and, or activate their lone working device if in a community setting to get immediate assistance.

The steps outlined above should be followed in the same way to highlight and address any risk and response to unacceptable behaviours from the carers, relatives, visitors, and members of the public.

9.1.1 Types of response to unacceptable behaviour

9.1.1.1 Verbal warning

A verbal warning can be issued to anyone who is acting in a rude, aggressive, or abusive manner which is offensive, or causes upset to staff or others who may be present.

Anyone who is a service user of the trust can be issued with a verbal warning.

Where given, a verbal warning should be recorded on an Incident Report that outlines the behaviour or incident that was subsequently resolved with the verbal warning, together with a note recorded within the relevant patient case notes.

9.1.1.2 Unacceptable behaviour warning letter

An unacceptable behaviour warning letter is issued following incidents that have been deemed inappropriate or unacceptable that has caused distress to staff, patients or service users or others.

This is a formally documented action but is used as an internal trust process only. However, such letters may be shared with the police or other partners as necessary under the information sharing agreements and, or for evidential purposes. Any questions in terms of sharing to be discussed with the Information Governance team.

9.1.1.3 Yellow card letter

A yellow card letter is an official warning issued for incidents of excessive aggressive, abusive, or repeated unacceptable behaviours towards trust staff. To receive a yellow card letter, the individual must have received a verbal warning about similar behaviours previously prior to escalation to a yellow card.

The yellow card process is primarily used for patients or service users, but could extend to their relatives, carers, and visitors where appropriate.

The yellow card process is issued in the form of a letter that has been formulated with the relevant service manager, Health and Safety team, and complaints team. The agreed final draft will then be considered and issued by the relevant Care Group Directorate team. An expiry date for the restricted service must be noted at this stage and recorded with an alert as to when the 12-week time period expires.

A copy of the yellow card warning letter must be uploaded to patient or service user’s clinical records together with the incident reports, that provide the supporting evidence for the issue of a warning letter. A copy of all such correspondence must be retained by the trust complaints team.

A copy of the letter issued to the person, should also be shared with partners such as GP’s and other agencies that may be involved in the provision of care for the individual concerned.

9.1.1.4 Red card letter

Red card letters are issued for acts of extreme aggression, abuse, violence, unacceptable or inappropriate behaviours. Such letters will usually be issued because of a yellow card warning having been issued, and the unacceptable behaviours have continued. However, where it is considered that an individual behaves in such an unacceptable manner, then it would be appropriate to escalate to a red card letter.

Red cards are primarily issued to patients or service users but can equally be issued to their carers and relatives where deemed necessary.

This is issued in the form of a letter and will clearly set out the reasons as to why it has been issued.

Such letters will be formulated with the relevant service manager, Health and Safety team, complaints manager and care group directorate. The agreed final draft will be reviewed for issuing by the clinical executive directors who are, the chief nursing officer, the chief medical officer and the director for psychological professionals and therapies.

A copy of the red card letter must be uploaded to clinical record together with the incident reports, that provide the supporting evidence for the issue of a warning letter. A copy of all such correspondence must be retained by the trust complaints team. An alert also must be placed on the clinical record.

A copy of the warning letter issued together with details of all possible associated risks, must be shared with partners such as GP’s, and other agencies that may be involved in the provision of care for the individual concerned in the same manner as a yellow card letter.

It may be necessary following the issue of a red warning card letter, for Rotherham, Doncaster and South Humber Foundation Trust to liaise with other healthcare providers for the transfer of an individual’s care as the trust is unable to continue as a care provider.

Where care is to continue to be provided on an urgent basis, the trust will consider all the known and potential risks of doing so, and a multidisciplinary and, or professionals meeting will be held to determine how and where this can be done safely. This may involve the provision of care at an alternative facility.

All actions and taken as part of this process should be fully documented on the relevant patient record and a copy of all supporting evidence retained by the trust complaints manager.

Where a red card warning letter is issued and results in any dispute, the recipient should be directed to the trust’s formal complaints procedure.

9.1.2 Process for appeal

As a trust, the honesty and integrity of staff is not in doubt. Therefore, where they have reported that they have been abused or targeted, then an appropriate response would be to implement the actions set out within this policy regarding the alleged incident.

To investigate the validity of a staff members report, as often the incidents occur on the phone or without witnesses, would undermine their decision to report what can often be extremely upsetting incidents.

All warning letters and red and yellow card letters will be composed with input from the relevant team, the Health and Safety team, complaints, and then issued and sent with oversight as defined above. This process will help to ensure that the therapeutic relationship between the clinical team and the recipient is not affected.

Whereby persons are not happy to have received a letter and threaten to complain or that they are to seek legal advice etc., they should be directed towards the trust process of making a complaint via the Patient Experience team.

9.1.3 Exclusion process

Where possible, discharge from service should be made as soon as it is safe to do so. Where further care is required, then guidance should be sought from the local ICB as to which healthcare provider will be able to do this.

If an admission to an inpatient facility is unavoidable, then arrangements should be made as soon as possible for a transfer to an alternative healthcare provider by the clinical care team and bed management. The individual should then be transferred out of trust services as and when a suitable placement has been identified.

The trust is committed to the provision of services and care that is fair, accessible and meets the needs of all individuals irrespective of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief (including lack of belief), sex (for example, gender), and sexual orientation.

9.1.4 Exceptional clinical circumstances

In exceptional circumstances a warning letter or verbal warning may not be appropriate, as there may be overriding clinical reasons for the cause of behaviours that would in normal circumstances be deemed inappropriate and unacceptable. In such circumstances a multidisciplinary teams or professionals meeting would need to identify the most appropriate method to address and manage the risks presented by such an individual.

Examples pertaining to exceptions may include:

• where people are detained under the Mental Health Act or have Ministry of Justice restrictions
• where people may lack capacity due to a mental health or significant cognitive impairment (for example, dementia)
• where people may lack capacity due to a physical health problem that may affect inhibition (for example, acquired brain injury, toxicity, sepsis)

There may be an emergency where an individual who is subject to warning letter or exclusion presents to psychiatric liaison or at the place of safety in crisis and requiring emergency treatment. In such circumstances the overwhelming clinical need for a therapeutic intervention would be the priority and any appropriate care and treatment should be provided. The staff providing care need to make themselves fully aware of any risks as documented in clinical records and manage these risks appropriately.

9.2 Appendix B Unacceptable behaviour warning letter

• Appendix B Unacceptable behaviour warning letter (staff access only) (opens in new window)

9.3 Appendix C Yellow card letter

• Appendix C Yellow card letter (staff access only) (opens in new window)

9.4 Appendix D Red card warning letter

• Appendix D Red card warning letter (staff access only) (opens in new window)

9.5 Appendix E Appropriate behaviour

9.5.1 Behaviour

This may not be a linear process for all patients

There are clinical situations where sanctions will not be appropriate to apply (for example, in situations where behaviour is linked to a lack of capacity), for these situations a complex clinical case meeting will be held.

This process concerns patient behaviour only. Any issues pertaining to staff have workforce polices which define the approach.

The reason why the delegated authority is provided to a small number of people to ensure appropriate oversight and consistency of approach.

9.5.1.1 Unacceptable behaviour

Unacceptable behaviour defined as:

• abusive
• discriminatory
• aggressive behaviours

Incident report to be completed.

9.5.1.2 Verbal warning

Warning to be recorded in patient record.

9.5.1.3 Unacceptable behaviour warning letter

Letter to be recorded in patient record.

9.5.1.4 Yellow card letter

• Duration 12 weeks withdrawal of services (except emergency).
• 1 year on patient record.
• Alert to be entered onto clinical record.

9.5.1.5 Red card letter

• Duration 1 year minimum withdrawal of services (except emergency).
• Remain on file indefinitely, unless appealed.
• Alert to be entered onto clinical record.

9.5.2 Decision-making

9.5.2.1 Multi-Professional team

Authority: To identify the “unacceptable behaviour” and record it. Where appropriate to issue the verbal warning and record this.

Escalation: Where there is a dispute or where an unacceptable behaviour letter, yellow or red card is considered the team have a responsibility to escalate.

9.5.2.2 Directorate Leadership team (Senior clinical specialist)

Authority: Directorate Lead team (including clinical and managerial leads) have the authority to issue an unacceptable behaviour warning letter.

Escalation: If there is dispute or a yellow or red card is considered the team have responsibility to escalate to care group quad team.

9.5.2.3 Care Group Directorate Quad team (locality responsibility)

Authority: Care Group Quadrumvirate team have the authority to issue yellow card. This includes where inappropriate behaviour with any staff in their area (for example, facilities staff and clinical staff).

Escalation: Where there is a dispute, or a red card is required the quad team have responsibility to escalate to executive.

9.5.2.4 Executive Leadership team (across trust responsibility)

Authority: Clinical executive team (comprising chief nursing officer, chief medical officer and director for psychological professionals and therapies) agree the red card.

Escalation: Where there is a difference of opinion with the chief operating officer this will be escalated to the chief executive.

9.5.2.5 Partner agencies

• GP copied into any letter of sanction.
• Police involvement with all “red” card sanctions and “yellow card sanctions where appropriate”

Governance: A register of all yellow and red cards considered will be kept by the director for corporate assurance.

Audit: The register will be audited on an annual basis by a multi-professional team including expert by experience.

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Document control

• Version: 1.
• Unique reference number: 1088.
• Approved by: Clinical leadership executive group.
• Date approved: 17 September 2024.
• Name of originator or author: Clinical leadership executive group.
• Name of responsible individual: Chief executive officer, director for people and organisational development and chief operating officer.
• Date issued: 25 September 2024.
• Review date: 30 September 2027.
• Target audience: All staff, patients and visitors.

Page last reviewed: October 29, 2024
Next review due: October 29, 2025

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