Blanket restrictions policy

1 Introduction

Whist the trust is committed to delivering care to patients in the least restrictive way it is recognised that there are occasions when in the interest of patient safety, a decision has to be made which will have a direct impact on patients’ freedom of movement or ability to undertake certain activities.

Such decisions are considered to be blanket restrictions which refer ‘to rules or polices that restrict a patients liberty and other rights, which are routinely applied to all patients, or to classes of patients, or within a service, without individual risk assessments to justify their application.” (Mental Health Act 1983: Code of Practice, section 8.5 page 64).

As a blanket restriction can potentially be in violation of Article 8 of the European Convention on Human Rights (ECHR) which requires public authorities to respect a person’s right to private life the use of them should be avoided unless they can be clinically justified as a necessary and proportionate response to manage risk.

Within the trust there are two distinct types of blanket restrictions:

those in place across the whole trust to meet national guidance or legislation
those implemented by individual wards or services on a short-term basis to maintain patient safety

At no time should a blanket restriction be put in place to punish or humiliate an individual or group of patients.

2 Purpose

The purpose of this policy is to evidence how the trust is complying with its regulated activities as monitored by the Care Quality Commission (CQC) by setting out the arrangements in place within the trust to authorise, monitor and review restrictive practise with the overall aim of reducing their use to a minimum.

3 Scope

This policy will apply to all staff working on the inpatient and day care areas in the Rotherham Doncaster and South Humber NHS Foundation trust.

4 Responsibilities, accountabilities and duties

4.1 Chief executive and board of directors

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

4.2 Executive Management team (EMT)

The Executive Management team are responsible for authorising the implementation of a blanket restriction which is likely to have a long-term impact subject to the required local accountability and governance arrangements being in place as set out in section 5.11 of this policy (Mental Health Act Code of Practice (1983), chapter 8).

4.3 Director of nursing and allied health professionals

The director of nursing and allied health professionals is the accountable director with responsibility for ensuring implementation of this policy.

4.4 Care group directors, modern matrons and service managers

Care group directors, modern matrons and service managers are responsible for:

raising clinical staff awareness of this policy and maintaining effective communication of the policy to all staff
overseeing implementation and compliance with this policy
ensuring that any locally authorised blanket restrictions are:
- the only option available to the clinical team
- reviewed in line with this policy
- implemented for the shortest time required
addressing, noting and taking relevant action regarding concerns raised by staff that individual requirements or circumstances are not being met in relation to this policy
taking appropriate action where staff fail to comply with this policy

4.5 Clinical staff working on the ward and day care areas

It is the responsibility of all clinical staff working on the ward and day care areas to:

comply with the requirements of this policy
the nurse in charge at the time of a local blanket restriction being put in place should, where practicable discuss this with the modern matron and complete an IR1 to log the blanket restriction
report any incidents in relation to any breaches in relation of this policy to their line manager and via the trust IR1 safeguard reporting system

4.6 Trust Adult Safeguarding team

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

4.7 Compliance and assurance officer

The trust compliance and assurance officer is responsible for:

maintaining the trust data base of blanket restrictions.
monitor that all reviews of blanket restrictions are undertaken
liaising with the CQC in relation to any blanket restrictions that are considered to be reportable
providing a monthly report on the use of blanket restrictions to the environmental risk in clinical areas group (ERICAG); as part of the patient safety report to the quality committee and quarterly report to the mental health legislation committee

5 Procedure or implementation

5.1 The need for blanket restrictions

As far as possible blanket restrictions should be avoided unless they can be justified as a necessary and proportionate response to an identified risk The risk would normally apply to a particular patient and been identified through their individual risk assessment and a risk management plan put in place. Where the management of the risk for an individual patient impacts on the wider patient group it is classed as a blanket restriction and the implication of this restriction needs to be assessed for each patient it impacts on and documented in their clinical records.

When determining if the restriction they need to apply is a blanket restriction as defined within the policy they need to consider the following.

5.1.1 Does this rule, procedure or decision restrict a patient’s freedom or other rights, and will it be applied to all patients in the area?

5.1.1.1 Yes

This is a blanket restriction.

Check section 5.3 to determine if it is an approved trust wide restriction. If working in the trust forensic units check that it isn’t already covered in the following Amber Lodge SOPs:

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

If not covered by either of the above refer to section 5.4 onward of this policy

5.1.1.2 No just an individual patient

This is not a blanket restriction.

Explain to the patient and record in their clinical records why the action that has been taken is necessary and under what legal framework, for example, Mental Capacity Act (MCA) or with informed consent

If in doubt contact your line manager or manager on call for advice.

5.2 What will not form part of any blanket restriction

The Code of Practice MHA (1983) is clear that on the basis it could constitute a breach of a patient’s human rights the following should not ordinarily be the subject of a blanket restriction (possible exceptions may apply in the trust low secure unit):

access to, or a ban on, mobile phones and their chargers
access to the internet
any in or outgoing patient mail
visiting hours
patient access to their money or the ability to make personal purchases
preventing patients from taking part in preferred activities

Code of Practice MHA (1983), chapter 8.

5.3 Authorised trust-wide restrictions

Whilst it is important that patients’ human rights are not infringed there are times when a balance needs to be made on the basis of safety for service users and staff. With this in mind, the Executive Management team have authorised the following restrictions as being appropriate and proportionate to the provision of safe care within the trust inpatient or day service facilities. The restriction of these items is supported by the CQC who have advised in their brief guide for inspectors that the banning of these ‘prohibited’ or ‘contraband’ items within inpatient services should not be challenged as blanket restrictions.

Authorised trust-wide restrictions
Restriction	Rationale
No smoking on any trust premises	This is in line with the trust commitment to improve people’s physical health and the full rationale can be found in the RDaSH smoke free policy
Patients are not permitted to smoke when on staff escorted leave	The RDaSH smoke free policy does not permit patients to smoke whilst on staff escorted leave as it would expose staff to the inhalation of second-hand smoke
Patients are not permitted to have Ignition sources such as lighters and matches on their person	As patients are not permitted to smoke cigarettes, cigars or pipes whilst on trust premises there is no need for them to have ignition sources on their person. Additionally, there is an increased risk of either accidental or intentional fire related incidents when patients have access to ignition sources
Alcohol and new psychoactive substances (NPS or legal highs) are not permitted on trust premises	Alcohol and legal highs are not allowed on the inpatient or day service areas as: they can have an adverse effect on a patient’s ability to engage in their treatment program they may adversely interact with the patients prescribed medication they can be a destabilizer for a patient’s mental health and therefore have a negative impact on their recovery there may be patients on then unit recovering from alcohol or drug misuse and being in the proximity of these will negatively impact on their recovery for some people they can be a trigger for aggressive, violent or sexually disinhibited behaviour which could place them and, or others at risk
Illicit drugs are not permitted on trust premises	No illicit drugs are allowed on trust premises as the possession and distribution of these can constitute a criminal offence. Additionally, the potential adverse effects on a patient can be as described in the section above relating to use of alcohol
No illegal pornographic materials are allowed on trust premises	This is not permitted on the basis that it is illegal due to the extreme nature of it and will be considered offensive to most people. Please note that this only applies to illegal pornographic material and not mainstream pornography
Items which can be used as weapons are not permitted on trust premises	The trust would be negligent in its duty to protect the people under its care or employ if it knowingly allowed weapons onto its premises. However, as it is recognised that knives may be carried for reasons other than as a weapon, for example religious practices and staff are to refer to appendix A of this policy for further guidance on the management of sharp implements
Material that incites violence or racial or cultural or religious or gender hatred is not permitted on the wards	This is not permitted on the basis that the use and, or distribution of such material could constitute a criminal offence. Additionally, such materials can be considered offensive in nature
Clingfilm, foil, chewing gum, blue tack, plastic bags, rope, metal clothes hangers, laser pens, spiral bound notepads or books	Being potentially compromising to safety of patients and staff or the security of the ward
Animals (except service or assistance dogs)	Being potentially compromising to health and safety of patients and staff
Controlled access and egress to all inpatient wards	This is to ensure that a safe protective environment is provided to patients, staff and visitors by controlling who has access to the ward areas at any given time
The locking of access to outdoor space at night	This is to maintain the safety of patients, staff and visitors during the night when visibility in these areas will be limited. However, ward staff can permit the use of these outdoor areas at night on an individual or group patient basis as long as the circumstances and assessment of risk indicate it is safe to do so
Set meal times	Due to the catering arrangements there are set delivery times to the wards that have pre-prepared meals delivered
Plastic bags on the acute adult mental health wards, psychiatric intensive care unit (PICU), forensic series and rehabilitation and recovery wards	On the acute and forensic wards this is due to the suffocation risk should an acutely unwell patient place one over their head. On the rehabilitation and recovery wards a decision has been made to ban them in line with the government policy to reduce their usage due to the environmental impact when they are discarded. The patients on the rehabilitation and recovery wards are encouraged to utilize reusable bags
Agreed visiting times for the inpatient wards	Open access to visitors can be disruptive to patients’ treatment programs and also cause distress to other patients. The trust arrangements for visiting inpatients are set out in the visiting patients on inpatient areas policy. This policy includes what arrangements will be made for visitors who can’t attend at the agreed times
All clinical areas which have medication cupboards and medical equipment stored in them will be kept locked when not in use	This is on the grounds of patient safety due to the potential consequences of a patient gaining unsupervised access to the medication and equipment held in these clinic rooms

All wards and day service areas have been issued with posters for display in patient areas advising that the above are prohibited and that patients are to speak with staff if they require more detail. A copy of this poster is included in appendix B.

5.4 Amber Lodge low secure

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

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

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

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

There may be times when in the interest of patient, public and, or staff safety a decision is made to prohibit or restrict access to items that would not normally be prohibited or restricted. Examples of this may be:

when an environmental risk occurs which cannot be individually managed
the need to restrict certain food items on the ward area, such as nut-based products due to the admission of a patient with a known allergy

Wherever possible in these cases the restrictions should be implemented following a multi-disciplinary team (MDT) review which has considered and ruled out all other alternatives to the blanket restriction for managing the situation. However, it is accepted that in some urgent situation the decision will have to be made by the nurse in charge and reviewed by the MDT as soon as possible.

Where no alternative to the blanket restriction can be identified the following action is to be taken:

all patients affected by the blanket restriction are to be notified of what the restriction is, why it has been applied, when it will be reviewed and who they can talk to if they have any concerns about the restriction
any impact of the restriction on each individual patient is to be documented in their clinical record and included in their care plan
an IR1 is to be submitted categorised as a non-patient safety incident with full detail of:
- the nature of the blanket restriction, including the impact on the individual effected.
- the reason for its application
- who was involved in making the decision
- the number of patients affected by the blanket decision
- the anticipated duration of the restriction
- date the decision will be reviewed
in addition to completing the IR1 if the modern matron or service manager were not involved in the original decision to impose the blanket decision the nurse in charge is to notify them. Out of hours this notification will be to the on-call manage
the modern matron, service manager or on call manager will make a judgment whether the implementation of the blanket restriction needs to be escalated to the care group director
the MDT will review the need for the blanket restriction to remain in place at the earliest opportunity
the outcome of these reviews will be monitored by the trust compliance officer so that the central data base can be updated
all blanket restrictions should be recorded into every patient’s electronic patient record on SystmOne via the process at appendix D and when the restriction is removed this must also be closed on SystmOne

It is important that locally implemented blanket restrictions are regularly reviewed and in place for as short a period as possible.

5.6 Implementing a blanket restriction at the request of a patient group

There may be occasions when a patient group makes a request for a blanket restriction to be imposed. Examples of this may be a request that:

a kitchen area is locked due to patients purchased food being removed from the fridge
a laundry room being locked when not in use to prevent clothes from being misplaced

In these circumstances it is important that all other possible solutions are explored before a blanket restriction is imposed and that all the patients affected by the proposed restriction:

are in agreement with its implementation
have the capacity to make an informed choice
are not affected by it to a greater extent than any of the other patients

If all the above points are met staff should follow section 5.5 above.

In the event that one or more of the patient affected by the restriction either don’t agree to it or do not meet the above bullet points staff will either have to consider what alternative ways there are of managing the situation or through an MDT discussion agree if the blanket restriction will need to be applied on a local level and if yes follow the guidance as set out in section 5.5 of this policy.

5.7 Action when a blanket restriction needs to be implemented which will have a longer-term impact on patients

Where it is immediately evident that a locally imposed blanket restriction will have a longer-term impact on patients this is to be escalated via the care group triumvirate to operational management meeting (OMM).

In these cases, OMM will:

determine the review time frame
agree if any further action is required to mitigate the need for the blanket restriction
consider if it needs to become a trust endorsed blanket restriction and as such added to section 5.3 of this policy, via approval at EMT

5.8 Process for CQC notification

In any instance where a blanket restriction has been assessed as having a long term impact on patients the trust compliance officer will notify the CQC and agree with them as to the frequency of their required updates.

Once the blanket restriction is lifted the compliance officer will inform the CQC.

5.9 Information to patients and carers

Relatives or friends of the patient are to be informed by clinical staff as to what items are restricted and the reasons why and asked that they check with staff before handing such items to the patient during a visit.

In addition to staff verbally telling them, each ward and day service will also display the trust approved poster (see appendix B) and include relevant detail in their ward or service information booklets.

5.10 Action if a blanket restriction is identified during a CQC inspection (including a MHA inspection)

Whilst it is hoped that through their awareness of this policy staff will be able to recognise when a particular practise constitutes a blanket restriction it is accepted that there may be occasions when this is not the case. In the event of the CQC raising a blanket restriction which the trust is not aware of this policy will be retrospectively applied and the action taken reported back to the CQC via the required action plan or provider statement.

5.11 Governance arrangements

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

relevant modern matron or service manager
relevant associate nurse director
relevant care group director
chief operating officer
director of nursing and allied health professionals
head of patient safety
compliance officer

From the IR1 the compliance officer will enter the following details onto a central data base:

ward
date blanket restriction applied
rationale for the blanket restriction
date review is due to be undertaken

The compliance officer will then on receipt of a blanket restriction IR1:

check SystmOne to ensure that the restriction has been logged on all relevant patient records within 24 hours
where this has not occurred notify the relevant ward manager who will then have 48 hours to update SystmOne
if SystmOne is not updated within 48 hours, the compliance officer will notify the relevant modern matron that SystmOne must be updated within a further 48 hours
if SystmOne is not update within 48 hours, the compliance officer will notify the relevant associate nurse director

Compliance will be monitored via the quarterly blanket restrictions report to ERICA.

The compliance officer will contact the service every month to confirm that any reviews due the previous month have been undertaken as planned. The outcome will be recorded on the central spreadsheet. The initial review will take place by the MDT no later than 7 days after its implementation. Thereafter, it should continue to be reviewed by the MDT at a minimum of every 7 days. If at this time the restriction is expected to have a longer-term impact, consideration should be given by the care group to escalate to ERICA (see section 5.7) who will determine the frequency of the review.

The ERICA group, will review all locally imposed blanket restrictions, and as part of this review consider if any locally imposed blanket restrictions are regularly being applied and if so whether it requires a review of policy or processes or environment to mitigate the need for the blanket restriction.

The compliance officer will provide a quarterly report to the ERICA, but items for escalation will be reported by exception as required.

6 Training implications

There are no specific training needs in relation to this policy. Training is included within the PMVA training. However, staff will need to be aware of its contents. Staff can be made aware through:

line manager
trust weekly bulletin
team brief
performance review
trust intranet
local trust induction

7 Monitoring arrangements

7.1 Blanket restriction reviews

How: Report.
Who by: Compliance officer.
Reported to: ERICA.
Frequency: Quarterly and by exception

Compliance with is this policy will be monitored through the appropriate processes which will be implemented in the event of a breach being reported.

8 Equality impact assessment screening

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

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

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

8.2 Mental Capacity Act (2005)

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

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

8.2.1 How this will be met

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

9 Links to any other associated documents

The following standard operating procedures for Amber Lodge:

prohibited and restricted items management (forensic service)
pornographic and sensitive material management

10 References

Care Quality Commission brief guide, the use of ‘blanket restrictions in mental health wards (opens in new window).
Mental Capacity Act 2005.
Mental Capacity Act 2015, Code of Practice.
Mental Health Act 1983 Code of Practice (2015)

11 Appendices

11.1 Appendix A Guidance to staff on the safe management of sharp implements on inpatient and day services areas

11.1.1 Items which may need to be controlled

Whilst it is accepted that there are many items which can be used by a patient to harm either themselves or others there are some which pose an obvious risk, such as:

knives
razors
pencil sharpener blades
scissors
tools

These items in particular need to be taken into account when undertaking each patient’s clinical risk assessment. However, for any patient identified as presenting a high risk to themselves or others staff may need to have arrangements in place for the safe control of any number of additional items.

11.1. Risk Assessments or care planning

Due to the nature of their presentation and potential risk to self and, or others all patients will have a full risk assessment completed at the time of their admission to the ward or episode of treatment in a day service. This will be done using the relevant trust approved clinical risk assessment format which within the trust is FACE.

As the risk assessment will inform care planning and decisions around care delivery it must be current, and reflective of the patient’s presentation taking into account both past and present risks. Particular attention must be paid to any risk of self-harm, harm to others and previous use of weapons.

Throughout a patient’s stay on the ward the risk assessment will be kept under review and amended to reflect the changes in the level of risk posed. With each review of the clinical risk assessment the patients care plan will also be updated.

Consideration should also be given to the overall risk any item presents to the general population of the ward, including if it is taken by another patient. Staff should consider what items are appropriate for the environment and the need for urgent access to any particular item; for example, items such as pencil sharpeners and scissors are unlikely to be needed urgently and could be accessed on request when needed.

11.1.3 At admission

On admission to the ward all patients will be asked if they have brought any of the following items with them:

knives
razors
pencil sharpeners
scissors
tools

Please note that this list is not definitive, and staff should consider items that can be broken or manipulated to create a sharp object.

If the patient has brought any of these items onto the ward staff are to ask that they hand them in for safe keeping until a full clinical risk assessment has been completed following which a decision will be made whether to return the items to the patient.

In the event that a patient denies having brought in any of these items, but staff have evidence to the contrary a search is to be undertaken and staff are to refer to the trust policy and procedure for the searching of a person (patient and visitor) or their property for full guidance.

11.1.4 Information to patients

On admission patients are to be asked if they have brought any of the items listed in section 4.1 with them, and the admitting nurse is to provide them and their relative or carer with an explanation as to why the use of such items may be restricted whilst they are on the ward.

In the event that a patient denies having any of the restricted items with them, if they are accompanied by a friend or relative the admitting nurse should where possible see the accompanying friend or relative in private and ask them to confirm that this is correct.

Each ward has a ward information booklet a copy of which is given to the patient following their admission and this booklet also details which items may be restricted on the ward and the reason why.

Wherever possible patients should be asked to make arrangements to access an electric razor for them to use on the ward.

It is also important that patients are reminded of the above when they have a period of leave from the ward, and the fact that should they return from leave with a potentially restricted item they are to inform the nurse in charge who will then make a decision whether the item(s) need to be kept in safe storage.

11.1.5 Information to relatives or friends

11.1.6 Action if a relative or friend refuses to comply with the requirements of this guidance

In the event that a patient’s relative or friend does not comply with the request to check with staff before handing any restricted items to the patient, staffs are in the first instance to remind them of this requirement and the reason why. However, if they consistently fail to check with staff before handing restricted items to the patient consideration needs to be given to the need to either supervise their visits or bar them from the ward. In these circumstances staffs are to consult with their modern matron, or manager on call (outside normal working hours) before any decision is made.

11.1.7 Safe storage of items by staff

Any items removed from a patient for safe keeping are to be placed in a plastic belongings box which is to be clearly labelled with the patient’s name. There will be an inventory sheet kept in the box (see appendix C) which is to be dated, timed and signed each time an item is removed or returned to the box.

The only item that will not be stored in patient’s plastic belongings box or returned to a patient is a knife, as there is no reason why a patient would need access to it during their stay.

These boxes will be kept in the ward storeroom.

Each patient is to have their own box, and under no circumstances are these boxes to be shared by patients.

All items kept in safe storage will be returned to the patient when they are discharged from the ward.

11.1.8 Safe storage, management and disposal of knives and bladed objects

In the event that a knife is removed from a patient consideration should be given to the knife’s type, purpose and rational for its possession. This should be documented in a patient note and recorded in the risk assessment where appropriate. Staff are to remove the knife from the patient and contact the police, who should arrange to collect and dispose of it if they believe this to be an appropriate action.

Without police involvement staff do not have the right to dispose of items without approval of the owner.

In the event that the police are unable or unwilling to support the disposal of a knife or bladed object, but the patient does agree to disposal then the majority of such items can be placed in the larger sharps’ bins. If the implement is too large for a sharps bin, then the item should be dealt with on a case-by-case basis with advice or assistance from the Health Safety and Security team and the Waste Disposal team.

If the patient does not agree to disposal then the item should be placed in safe keeping (that is, in a locked area with no patient access) until the patient is discharged.

As discharge approaches, if staff continue to have concerns about the patient holding or carrying a knife or other bladed item then this concern should be discussed with the police and their advice sought. All conversation with the police should be documented in the patient record.

Staff should ensure that a robust and detailed risk assessment is completed to reflect any decision-making processes including the involvement of the MDT, senior management, and the trust Health Safety and Security team were appropriate.

Staff may also wish to follow this process for any item they consider having been carried by the patient with the intent of using as a weapon.

11.1.9 Action if patient is to retain the items themselves for safekeeping

If the outcome of the risk assessment is that the patient can retain the items, staff are to inform the patient that as the items could be used by another patient to harm themselves or others they must:

keep the items locked in their individual locker when not in use
only use them in their bedroom
not allow any other patients access to the items
immediately report to staff any loss of the items

11.1.10 Action if a patient does not keep items retained by them safe

In the event that a patient does not comply with the requirements detailed in section 8 staff are in the first instance to remind them of the requirements, but if they consistently fail to comply staff are to remove the items into safekeeping.

11.1.11 Supervision of patients whose items have been retained by staff for safekeeping

The level of supervision required by a patient when using a sharp implement will be determined and kept under review as part of their individual clinical risk assessment.

11.1.12 Patients not felt to need 1-to-1 supervision whilst using sharp implements

A member of the clinical team will return the item to the patient noting the date and time on the inventory sheet. It will be agreed with the patient roughly how long they need to use the item. This staff member is then responsible for ensuring the return of the item within the agreed time frame.

If the member of the clinical team is going off duty, they must hand over this responsibility to another staff member before they leave the ward.

The responsible staff member will return the item into safe storage noting the date and time it is returned on the inventory sheet.

11.1.13 Patients who have been identified as requiring 1-to-1 observation when using sharp implements

If the patient has been identified as posing a high risk to themselves or others a member of the clinical team is to remove the item from storage noting the date and time on the inventory sheet and take it to the patient. They will then remain with the patient whilst they use the item, returning it to safe storage noting the date and time it is returned on the inventory sheet once the patient has finished with it.

Note, under no circumstances are staff to give any patient two disposable razors to use at the same time.

11.1.14 Action if a patient refuses to return the item

If a patient refuses to return an item to safe storage the patient is to be nursed on 1-to-1 observation and a decision made by the clinical team as to how the item can be safely removed.

Once the item has been removed from the patient it must be returned to safe storage with the date and time noted on the inventory sheet.

A clinical review will then be undertaken to decide if the patient can safely be allowed further access to the item. If it is decided that access cannot be safely allowed their risk assessment and care plan are to be updated to reflect this, and a note made on the inventory sheet that the item is not to be handed to the patient. The clinical team will agree a time frame for reviewing this decision.

The nurse in charge of the ward will inform the patient as to the reason why they are not being allowed access to the item, and the time frame within which the decision will be reviewed.

11.1.15 Patients returning from a period of leave

Whenever a patient returns to the ward from a period of leave, they are to be asked if they have brought any sharp implements back to the ward with them and if the answer is yes, staff are to take the required action in line with this guidance as identified through the patients clinical risk assessment.

11.1.16 Guidance to staff for when a male Sikh is admitted to the ward or attends day services

Devout Sikh men who have undergone the amrit ceremony (which is akin to a baptism) wear a small ceremonial dagger called the kirpan as part of their religious faith. The kirpan is one of five symbols of Sikhism which they are meant to wear at all times following the amrit ceremony. It is symbolic rather than functional and worn as a reminder to Sikhs of their duty to fight injustice and maintain independence of spirit. It is usually around 8 inches long, blunt and worn sheathed attached to a cloth belt, called the Gatra. This type of kirpan presents no more risk than a dinner knife and its use in an act of violence is practically unknown. However, there may be rare occasions where a patient is wearing a potentially unsafe kirpan, such as one with sharp edges, is pointed, or is much longer. Consideration also needs to be given to any potential risk should another patient gain access to it.

If a patient is admitted to the ward wearing a kirpan staff should in the first instance examine it to determine the level of risk, it poses. If there are any concerns about safety, these should be discussed openly and sensitively with the patient and (if appropriate) their carers, explaining that the concerns are about safety. The wearing of the kirpan by a patient must also be considered as part of the patient’s clinical risk assessment.

In the event that the kirpan being worn by the patient at the point of admission is not safe staff should ask if it can be replaced with a smaller one which is considered to be safe.

Document control

Version: 2.6.
Unique reference number: 491.
Approved by: Clinical policies review and approval group.
Date approved: 3 October 2023.
Name of originator or author: MHA manager.
Name of responsible individual: Executive medical director.
Date issued: 24 October 2023.
Review date: March 2024.
Target audience: Amendment to monitoring arrangements following and action from 360 internal audit clinical policies.

Page last reviewed: November 18, 2024
Next review due: November 18, 2025

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