Care and treatment of children under the age of 18 on adult acute mental health inpatient areas policy

Contents

1 Introduction

The legal framework governing the admission to hospital and treatment of children and young people under the age of 18 years is complex, and those responsible for their care in hospital should be familiar with the relevant legislation as outlined within the Mental Health Act 1983, Mental Health Act Code of Practice 2015, Children Act 1989 and the Mental Capacity Act 2005.

When the Mental Health Act 1983 was reviewed, the government pledged that through the introduction on 1 April 2010 of section 131(A), children and young people under the age of 18 would be treated in an environment in hospital which had suitable regard to their age, and, that the inappropriate admission of children and young people to adult acute mental health wards would be avoided.

2 Purpose

Whilst it is accepted that the admission of a child or young person to an adult acute mental health ward should not occur, there may be exceptional circumstances in which this may happen, urgent necessity and the absence of satisfactory immediate alternatives.

An adult acute mental health ward will only be used if:

• no specialist child and adolescent bed can be secured
• it is an emergency situation with admission to an adult acute mental health ward being the only safe option

The purpose of this policy is to set out the arrangements within the Rotherham, Doncaster and South Humber (RDaSH) (the trust) for the provision of inpatient care to patients admitted to the adult acute mental health wards who are under the age of 18 years, to provide guidance to staff on how to manage such an admission, how to appropriately care for a child or young person, and how to appropriately facilitate their discharge or transfer.

3 Scope

This policy is relevant to the child, adolescent mental health service (CAMHS) staff and staff on the adult mental health wards.

This policy covers anyone under the age of 18 years who is admitted to an adult acute mental health ward and the following definitions apply:

3.1 Who is classed as a child?

A child, is someone who is under the age of 18 years. The Mental Health Act Code of Practice also refers to someone who is under the age of 18, as a child. Within this policy the term child has been applied to anyone under the age of 18 years.

4 Responsibilities, accountabilities and duties

4.1 The trust

The trust is responsible for making suitable organisational arrangements to support the effective implementation of this policy.

4.2 The Locality Care Group Management team

The Locality Care Group Management team is responsible for:

• clinical staff on the adult acute mental health wards receiving induction and training to equip them with the knowledge and skills to effectively implement this policy
• monitoring compliance with the requirements of this policy
• the review of this policy

4.3 Modern matron or service managers

The modern matrons or service managers are responsible for:

• bringing any issues which may affect the implementation of this policy to the attention of the care group director for adult inpatient Services
• notifying the appropriate care group directors, of any admissions under this policy
• all staff they manage being aware of and implementing the contents of this policy
• liaising with the community or workers from the children and young person’s services about the transfer of any child or young person admitted to a more appropriate care facility. This is to be done as soon as possible after admission, but no later than within 48 hours
• ensuring that the admissions are monitored and delays in transfer are escalated to the appropriate care group directors
• monitoring that all clinical inpatient staff have an enhanced disclosure and barring service (DBS) check completed prior to them undertaking any nursing responsibilities for children or young people under the age of 18 years
• informing any bank staff employed within the adult mental health inpatient services at their induction that they are not to undertake any direct nursing care for children and young people under the age of 18 years, unless this has been risk assessed and deemed appropriate by the ward manager

4.4 Ward managers

The ward managers are responsible for:

• notifying the modern matron or service manager, named nurse or professional for safeguarding, Mental Health Act manager and the relevant commissioner of any admissions under this policy
• providing updates on any admissions to the relevant Commissioners
• arranging for the transportation for the transfer of any child or young person to the most appropriate care facility

4.5 Inpatient clinical staff

All inpatient staff are responsible for:

• implementing this policy in accordance with the principles and supporting legislation as identified within section 1 of this policy
• notifying the appropriate modern matron or service manager immediately of any admissions under this policy
• attending any training which is provided to them in respect of this policy
• reporting through the appropriate channels any safeguarding children issues which may come to light during the assessment or admission of the child or young person

4.6 Referring agency or workers

Prior to an admission under this policy taking place, any workers or agencies that refer a child or young person to the adult acute mental health wards are responsible for evidencing that they have:

• explored all alternatives to admission and established that there is no immediate alternative to the admission
• assessed and documented the competence and, or consent of the child or young person
• made the inpatient staff aware of the grounds for admission identified in section 5.5 below
• to ensure liaison with the local children’s services has taken place (Working Together to Safeguard Children 2018; section 17 Children Act 1989, Child in Need (Mental Health) and may require 47 Children Act 1989 investigation, duty to investigate; section 11 Children Act 2004)
• care, education and treatment reviews (CETR), does the patient have an existing label or diagnosis of an autistic spectrum disorder (ASD) or an assessed intellectual disability (learning disability)? A CETR may be held for anyone with learning disabilities, autism or both who may be at risk of admission to, or who is already in, a specialist learning disability or mental health hospital. The review is led by the responsible commissioner with support from two independent expert advisers whose role is to bring an additional challenge and an alternative perspective. The review team makes recommendations to improve the individual’s care with follow-up checks to ensure this is happening. Therefore, it is important to inform the responsible commissioner

4.7 Community children and adolescent mental health services (CAMHS) workers

The staff working in these services are responsible for:

• securing a more age appropriate placement for any child who is admitted within the required 48-hour time frame and completing the form 1 gatekeeping referral as soon as alerted to the need for an admission
• securing a more age-appropriate placement for any young person who lacks the capacity or competence to consent to an admission to an adult acute mental health ward and requires an inpatient stay and competing the form 1 gatekeeping referral
• ensuring that the gatekeeping referral and assessment is monitored and delays in transfer are escalated to the appropriate service managers or care group directors
• providing support and advice to inpatient staff when the admission of a child or young person occurs
• liaising with the service manager or modern matron about the admission and transfer and discharge details

4.8 Trust safeguarding children named nurse or professionals

The safeguarding children named nurse or professionals are responsible for supporting clinical staff in relation to all safeguarding children matters.

5 Procedure or implementation

Prior to the admission of a child or young person, all appropriate avenues to provide suitable care without the need to admit them to an adult acute mental health ward should be explored and documented in the clinical records.

In accordance with all admissions to the adult acute mental health wards across the trust, the admission of all children and young people will be gate-kept by the adult Access team.

5.1 Admission assessment pathway (please refer to appendix A for full details)

5.1.1 During normal working hours

During the normal working hours of 9am to 5pm, Monday to Friday any referral of a young person under the age of 18 years to the Access team will be passed onto the local CAMHS service and they will be responsible for completing the assessment.

5.1.2 Out of hours

Out of hours (5pm to 9am) any referral of a young person under the age of 18 to the Access team will be assessed in the following way:

• under 16 years of age and anyone in the care of the local authority, will be jointly assessed with the on-call CAMHS worker
• 16 and 17-year-olds, will be assessed by the Access team worker in consultation with the CAMHS out of hours’ worker

5.1.3 Assessment of a young person under the age of 18 years who is brought to the section 136 Suite

The section 136 assessment is to be processed in the same way as for an adult but a practitioner from the CAMHS service is to be involved in the assessment.

5.2 Establishing who has parental responsibility

Those with parental responsibility have a central role in relation to decisions about the admission and treatment of their child. It is therefore essential that those proposing the admission and, or treatment identify who has parental responsibility and that this is recorded in the child or young person’s clinical records.

Those with parental responsibility will usually, but not always, be the parents of the child or young person. A mother automatically has parental responsibility for her child from birth. A father usually has parental responsibility if he’s either: married to the child’s mother (they both keep parental responsibility if they later divorce) or listed on the birth certificate (from 1 December 2003). Other people may acquire parental responsibility. Practitioners should always check with those caring for the child or young person whether any child arrangements orders, parental responsibility agreements or orders, or special guardianship orders have been obtained.

Where children or young people are looked after by the Local Authority it will be important to establish whether they are subject to a care order (or interim care order) or are being voluntarily accommodated by the local authority.

5.3 Consent in relation to children and young people

The valid consent of a child or young person will be sufficient authority for their admission to hospital and, or treatment for mental disorder, additional consent by a person with parental responsibility will not be required. It is good practice to involve the child or young person’s parents and, or others involved in their care in the decision-making process, if the child or young person consents to information about their care and treatment being shared.

To be able to give valid consent a child must have competence and a young person must have the capacity to make the particular decision to agree to their admission to hospital. They must have sufficient information to make that decision and not be subject to any undue influence when doing so. Unlike adults, the refusal by a competent child or young person with capacity may, in certain circumstances, be overridden by a court.

5.3.1 Assessing a child’s competence and a young person’s capacity

Before relying on the consent of a child or young person it is necessary to ascertain whether they can give valid consent. The test for assessing whether a child under 16 years can give valid consent differs from that of a young person aged 16 or 17 years.

The test for children under 16 is determined by considering whether they are “Gillick competent” (see appendix B).

The test for capacity of a young person aged 16 or 17 years is assessed in accordance with the Mental Capacity Act 2005.

5.3.2 Informal admission of a child under 16 who is “Gillick competent”

An assessment should be carried out by the referring team or clinician to ascertain and document whether the child is “Gillick competent” (MHA Code of Practice 2015, 19.24 to 19.43 and appendix B).

“Gillick competent”: If the child is “Gillick competent” and consents to the admission, they may be admitted as an informal patient.

If a “Gillick competent” child does not consent to admission the situation is more complex. Previously, a person with parental responsibility has been able to give consent on their behalf; however, it is now advised that consideration should be given to assessing for detention under the Mental Health Act 1983. If this is not appropriate then authorisation from the Court should be considered (MHA Code of Practice 2015, 19.39).

5.3.3 Informal admission of a child under 16 who is not Gillick competent

Not Gillick Competent, where a child is not Gillick competent then it may be possible for a person with parental responsibility to consent, on their behalf, to their informal admission to hospital for treatment for mental disorder.

If it is not considered appropriate to rely on parental consent or the proposed admission is outside the scope of parental responsibility (MHA Code of Practice 2015, 19.38 to 19.43) the child cannot be admitted informally. In such cases, consideration should be given to whether admission under the MHA 1983 is necessary and whether the criteria are met.

If the MHA 1983 is not applicable, legal advice should be sought on the need to seek authorisation from the court before further action is taken.

For further information and clarification see the MHA Code of Practice 2015.

5.3.4 Informal admission of a young person aged 16 or 17 with capacity to consent

The effect of Section 131 MHA 1983 is that where a young person aged 16 or 17 years old has capacity (as defined in the MCA 2005) to consent to being admitted to hospital for treatment for mental disorder, they may either consent, or refuse to consent, to the proposed informal admission.

If a young person has the capacity to consent to informal admission and gives such consent, they can be admitted, irrespective of the views of a person with parental responsibility (who cannot prevent the admission).

If the young person with capacity does not consent to their informal admission to hospital, then a person with parental responsibility cannot consent on their behalf. Consideration should be given to whether the criteria for admission under the MHA 1983 are met. If the MHA 1983 is not applicable, legal advice should be sought on the need to seek authorisation from the court before further action is taken.

5.3.4.1 Review

Where children and young people are admitted, the question of whether the care regime amounts to a deprivation of liberty must be kept under regular review.

5.3.5 Admission of a young person aged 16 and 17 who lacks the capacity to consent

Where a young person lacks capacity to consent to admission it may be possible for them to be admitted in accordance with the MCA 2005, unless the admission and treatment amounts to a deprivation of liberty. If the MCA cannot authorise informal admission, but admission is thought to be necessary, consideration should be given whether the criteria for admission under the MHA 1983 are met. If the MHA 1983 is not applicable, legal advice should be sought on the need to seek authorisation from the court before further action is taken.

For further information and clarification see the Department of Health The Mental Health Act Code of Practice (2015).

Staff should ensure that the assessment of capacity is recorded on the MCA1 questionnaire on the patient electronic record and the evidence of the best interests decision make recorded on MCA2.

For further information and guidance see the trusts MCA mental Capacity Act 2005 policy.

5.4 Deprivation of liberty

5.4.1 Determining deprivation of liberty

On the 19 March 2014 the Supreme Court handed down its judgment in the case of P v Cheshire West and Chester Council and P and Q v Surrey County Council (2014) UKSC 19.

The judgment is significant in the determination of whether arrangements for the care and treatment of an individual lacking capacity to consent to those arrangements amount to a deprivation of liberty.

To be deprived on one’s liberty, you must be 16 years plus. Below the age of 16 Gillick Competence is to be used.

The acid test, the key point arising from the Supreme Court judgment was the introduction of a revised test to determine whether a deprivation of liberty is occurring known as the “acid test”.

The two questions which now must be applied are:

• is the person subject to continuous supervision and control continuous supervision and control refers to oversight even when the patient is not in the line of sight, it must amount to supervision and have a clear element of control
• is the person free to leave? free to leave, the person may not be asking to go or showing this in their actions, but the important factor is how staff would react if that person did try to leave or if a relative or friend asked to remove them

For a person to be deprived of their liberty all three elements must apply.

For further guidance see the trust MCA deprivation of liberty (DoL) policy.

Decisions whether the child or young person’s admission and, or treatment amounts to a deprivation of liberty must be considered on a case by case basis.

Of a significant factor for children under 16 when considering this is the role of parental control and supervision for example, where it is usual for a child of under 12 not to be allowed out unaccompanied without their parent’s permission, this would not usually be an acceptable restriction on a 17-year-old.

In determining whether a person with parental responsibility can consent to the arrangements which would, without their consent, amount to a deprivation of liberty, practitioners will need to consider and apply developments in case law following “Cheshire West”. Decision makers may need to seek legal advice in respect of certain cases.

5.4.2 Children under 16

If a child under 16 is not under a formal care order, his or her parents can authorise a deprivation of liberty in the exercise of parental responsibility regardless of the child’s mental capacity for example, in hospital.

If a child under 16 is under a formal care order for example, looked after child under an interim or final care order who are deprived of their liberty the deprivation will need to be authorised by the family court.

5.4.3 16 and 17-year-olds

The courts have now confirmed that for 16 and 17-year-olds who are deprived of their liberty and lack capacity to consent to the arrangements (or do have capacity and refuse) that those with parental responsibility cannot give valid consent. The deprivation will therefore have to be authorised by either:

• Mental Health Act 1983 (MHA)
• Court of Protection

Where the MHA is not applicable urgent advice should be sought from the Mental Capacity Act lead with regard to seeking an urgent order from the courts.

5.5 Admission to an adult acute mental health ward

An adult acute mental health ward will only be used if:

• no specialist child and adolescent bed can be secured

and either:

• it is an emergency situation with admission to an adult acute mental health ward being the only safe option
• during the assessment of any child or young person to decide whether admission to an adult acute mental health ward is appropriate, the following must be considered:
  • under what grounds they will be admitted
  • what, if any, treatment plan is appropriate
  • how any particular needs the child or young person has will be met during the admission
  • but staff must also consider that “at least one of the people involved in the assessment of a person who is under 18 years of age for example, one of the two medical practitioners or the approved mental health professional (AMHP), should be a clinician specialising in CAMHS. Where there is not possible, an AMHP should have access to an AMHP with experience of working CAMHS and the medical practitioner should consult a CAMHS clinician as soon as possible.” Mental Health Act Code of Practice 2015 (19.73)

The assessing service will contact the adult acute mental health inpatient bed manager; and enquire as to the availability of a bed. When making this call, the assessing service will provide the following details to the nurse in charge of the ward:

• name of the patient
• age of patient
• reason for admission
• child or young person’s ability to consent or not to the admission
• details of any safeguarding children concerns
• any identified risks
• child protection status
• reason that alternatives to admission to an adult acute mental health ward are not available or suitable

5.6 Safety considerations prior to accepting a young person or child for admission to an adult acute mental health ward

Whilst it is accepted that the admission of a child or young person to an adult acute mental health ward will only ever take place if no other suitable alternative is available, the safety of the child or young person is paramount. Therefore, before accepting the admission the nurse in charge of the ward must give consideration to the risk profile of the other inpatients on the ward.

In the event that any patient on the ward is considered to pose a risk to the child or young person, arrangements are to be made for the admission to take place to another ward.

In the event that there is an identified risk on the other ward, arrangements are to be made for the transfer of the adult patient(s) onto one ward to enable the safe admission of the child or young person to go ahead.

5.7 Transport arrangements

It is the responsibility of the assessing service to make arrangements for the transportation and escort of the patient to the inpatient ward. The method of transport will be assessed on a case-by-case basis, and also take account of identified risk issues. Details of specialist transport providers. Refer to safe transportation of patients (mental health and learning disability services) policy.

5.8 Admission to the ward

5.8.1 Children under 18 years

Staff should refer to this policy

In relation to the medical admission, the arrangements are as follows:

• Monday to Friday, 9am to 5pm, The medical assessment will be completed by the Medical staff from the relevant locality
• outside normal working hours, The on-call doctor will complete the medical admission assessment

On admission, inpatient staff must ascertain from the referring agency or worker and document in the clinical records:

• who has parental responsibility in respect of the child or young person
• whether the child’s competence or young person’s capacity to consent to the admission, has been assessed and documented; and
• the legal grounds for the admission (as described in section 5.4) and the admission assessment
• the use of Oxehealth system on the ward will be discussed with the person with parental responsibility and the child or young person as applicable, advising of the information available to support the decision to consent or decline to it’s us in the bedroom. Refer to the Oxehealth, standard operating procedures

For a child:

• during the child’s admission process, all attempts should be made to have a person with parental responsibility present. If the child is admitted outside normal working hours, staff must notify the relevant CAMHS service of the admission as soon as possible

For a young person:

• if the young person is in agreement, a person with parental responsibility should be present

5.9 Notification requirements on admission

5.9.1 Tier 4 Gatekeeping assessment

Doncaster and Rotherham, the CAMHS member of staff (following assessment for admission) will complete a referral for a tier 4 gatekeeping assessment to secure a bed within a specialist child and adolescent unit and will send this to The Becton Centre (The Becton Centre for Children and Young People is a state-of-the-art centre for children and young adults aged up to 18 years with serious and complex mental health issues. The centre offers intensive outreach treatment, day and inpatient services) (see appendix A).

North Lincolnshire (Hull, East Riding and North-East Lincolnshire), Inspire (CAMHS), the service has 13 beds in total. Nine beds are for general adolescent admissions and four are PICU (psychiatric intensive care unit) beds. The inpatient unit is equipped and staffed to treat young people struggling with a wide range of mental health issues such as depression, severe anxiety, psychosis and eating disorders.

Inspire CAMHS inpatient unit
70 Walker Street
Hull
HU3 2HE

5.9.2 Notification to the clinical commissioning group (CCG)

The ward manager will notify the relevant commissioner (CCG) of the admission details for any under 18’s who are admitted to the ward pending transfer to an age appropriate placement. This will be done by email with the following people being copied in:

• care group directors for adult services and CAMHS
• modern matron or service manager
• safeguarding children’s named nurse or professional

5.9.3 Additional reporting requirements in respect of a child admitted under the age of 16

As the admission of anyone under the age of 16 years to an adult ward is reportable to the CCG as a serious incident, during normal working hours the appropriate modern matron or service manager should be informed at once, of any decision to admit a child under the age of 16 years. At all other times, the senior manager on-call should be contacted.

5.9.4 Notification to the care quality commission (CQC)

The ward manager will notify the relevant MHA office of the admission details for any under 18s who are admitted to an adult acute mental health ward, as this is a registration requirement for the CQC. The MHA office will ensure that the CQC notification form is completed and forwarded, copying in the following people:

• director of nursing
• chief operating officer
• nurse consultant safeguarding

5.10 Staffing levels

When a decision is made to admit a child or young person, the ward staffing levels are to be immediately reviewed to maintain a safe and appropriate level of staff and skill mix, as the child or young person is to be cared for on 1-to-1 nursing observations throughout their inpatient stay.

Particular regard must also be given to ensuring that the appropriate gender mix of staff is available on ward, and wherever possible the 1-to-1 nursing should be provided by a staff member of the gender that the young person identifies themselves as.

5.11 Medical responsibility

Medical responsibility for the child or young person will rest with the relevant consultant for the CAMHS services in their locality of residence. There is a joint responsibility with the CAMHS consultant leading the care and treatment and an adult responsible clinician being responsible for the application of the Mental Health Act if the child is detained.

5.12 Care and treatment whilst on the ward

The treatment of a child and young person admitted to an adult acute inpatient ward is covered within the MHA Code of Practice 2015 chapter 19 and should be read in conjunction with this policy.

CAMHS to complete care plan and update risk assessment and management. This should be done wherever possible jointly with the ward staff, the child and the person with parental responsibility

Consider safeguarding or child protection or looked after child, does the child have an allocated social worker to liaise with or does a referral to children’s social care need to be completed.

Children and young people admitted to hospital for the treatment of mental disorder should be accommodated in an environment that it is suitable for their age. The main points that should be considered are outlined below:

• when taking decisions under the act about children and young people, the following should always be borne in mind:
  • the best interests of the child or young person must always be paramount
  • children and young people should always be kept as fully informed as possible
  • the child or young person’s views, wishes and feelings should always be considered
  • any intervention in the life of a child or young person that is considered necessary by reason of their mental disorder should be the option that is least restrictive and least likely to expose them to the risk of any stigmatisation
  • children and young people have as much right to expect their dignity to be respected as anyone else
  • children and young people have as much right to privacy and confidentiality as anyone else
• due to the age of the child or young person, discussion groups held on either the ward or in the occupational therapy (OT) department may not be suitable. However, it may be beneficial for the child or young person to receive an individual OT or therapy programme designed to meet their specific needs
• any community involvement will continue during the child or young person’s stay on the ward, with regard being given to increasing input during this time
• staff must pay attention to age-related social activities, for example, age certificate films; ensuring that all treatment and activities are age-appropriate to the child or young person
• arrangements will be made for the consultant psychiatrist from CAMHS services to assess at regularly agreed intervals during the child’s or young person’s stay. There should be at very least daily contact between CAMHS and Ward staff
• at weekends or during bank holidays, the nurse in charge of the ward will notify the on-call doctors that a child or young person is an inpatient on the ward
• if staff encounter management problems due to the child’s behaviour, advice should be sought from the relevant Adolescent Unit how best to provide nursing care

Any admission to an adult acute mental health ward is to be for the shortest length of time possible. A control panel meeting consisting of representation form the adult in-patient services, local CAMHS and Safeguarding team.

Control panel meeting to be convened for 9am the day after admission and each day until transfer and it is to include:

• identify named person to co-ordinate care delivery and transfer to tier 4 arrangements
• ensure allocation of adequate staff resources
• provide leadership and monitoring of the direct care delivery from CAMHS and the adult mental health ward.
• review quality and care delivery every 24 hours
• challenge and escalate
• ensure the voice of the child or young person is heard
• clarify who will feed back to parents, carers or corporate parent for a looked after child (LAC).
• consider a care, education and treatment reviews (CETR) meeting led by the responsible commissioner. A CETR may be held for anyone with learning disabilities, autism or both.

5.13 Prescribing of medication

Wherever possible, the prescribing of medication is to be done by the medical staff from the relevant CAMHS service. However, in the event of medication being required for an admission that comes in outside normal working hours, the admitting doctor is to refer to the prescribing protocol, which has been issued by the CAMHS service consultant.

5.13.1 For a child

The prescribing doctor will need to determine if the child is “Gillick competent” to consent to the medication:

• where a child is Gillick competent and has consented to be given treatment, they may be given treatment; however consent will be required for each aspect of their care and treatment as it arises
• where a child is Gillick competent and is not consenting to treatment it is not advisable to rely on the consent of a person with parental responsibility. Consideration should be given whether admission under the MHA 1983 is necessary and whether the criteria are met. If the Act is not applicable legal advice should be sought on the need to seek authorisation from the court before further action is taken
• in the event the child is not deemed Gillick competent permission will need to be sought from the person with parental responsibility; if consent is given on behalf of the child, but the child refuses the medication, an assessment will need to take place for detention under the Mental Health Act before medication is administered. If the act is not applicable legal advice should be sought on the need to seek authorisation from the court before further action is taken
• the person with parental responsibility should be given information by the doctor about what the medication is for, likely side effects, possible alternatives and consequences of not receiving the medication
• whether the child is Gillick competent or not, they must also be given this information in an age-appropriate format

Note, the trust patient group direction for the treatment of minor ailments on inpatient wards excludes under 16s as the nursing and midwifery council states that:

• “only nurses with relevant knowledge, competence, skills and experience in nursing children should prescribe for children”

5.13.2 For a young person

• If the young person is capable of understanding and is assessed as having the capacity to consent, then they may consent to medication for themselves.
• Whilst consent is not required from those with parental responsibility for the young person, it is good practice to include them in any medication plan (with the consent of the young person).
• Both the young person and those with parental responsibility will be given information in an appropriate format regarding any medication. This will include what it is for, possible side effects, any alternatives and the consequences of not administering it.
• If the young person does not consent to receive some or all prescribed medication, consideration should be given whether the young person meets the criteria for detention under the Mental Health Act and whether the criteria are met. If the act is not applicable legal advice should be sought on the need to seek authorisation from the court before further action is taken (MHA Code of Practice 2015, 19.59).

5.14 Leave arrangements

If a period of leave is felt to be in the child’s or young person’s best interest, leave can be agreed by the consultant in charge of their care and is to be documented in their clinical records. Refer to chapter 27 Mental Health Act Code of Practice 2015). The trust policy relating to leave should also be considered. Leave for inpatients policy and guidance including section 17.

5.15 Care reviews

All children and young persons will have their care, treatment and progress reviewed in line with the trust care programme approach (CPA) policy. During these reviews, appropriate follow-up care and alternative placements will be discussed and planned, including all discharge arrangements.

5.16 Action to take if a child or young person attempts to, or goes missing from the ward

If the child or young person attempts to go missing or is wishing to leave the ward, discussions should take place with them to negotiate any alternatives that are more appropriate. If, however, these attempts are not successful, a further risk assessment should be carried out including being assessed, as with any other adult patient, for detention under the Mental Health Act 1983.

In the rare event that a child or young person does go missing, given that they are being cared for under close observation, the procedure for if an inpatient goes missing should be referred to and followed. Additionally, the following people or services should also be immediately notified:

• child services within the local authority
• social care team (details of the specific person should be recorded within the clinical records)
• all appropriate children and young person’s services
• the police should be given specific information that it is a child who is missing
• modern matron or service manager, or out of hours, the on-call manager
• safeguarding children named nurse or professionals should also be notified at the earliest opportunity (during normal working hours)

5.17 If the child or young person is detained under the Mental Health Act 1983

If the child or young person is detained under the Mental Health Act 1983, staff should follow the guidance in the trust procedure for informing detained patients of their legal rights under section 132 of the Mental Health Act 1983, and in addition to this:

5.17.1 For a child

Their legal rights under section 132 are to be explained to them in the presence of the person who holds parental responsibility. A copy of the appropriate rights leaflet will also be given to this person, as well as to the child.

5.17.2 For a young person

Whilst the usual procedure with regard to reading a person their legal rights under section 132 of the Mental Health Act 1983 applies, consideration should be given to completing this in the presence of the person with parental responsibility, if the young person agrees. A copy of the appropriate rights leaflet will also be given to this person as well as the child.

Ward staff will also notify the local Mental Health Act Office of any admission of a child or young person under the age of 18 who has been detained under the Mental Health Act 1983.

5.18 Psychiatric intensive care (PICU)

5.18.1 For a child

Wherever possible, a child should not be cared for in an adult PICU. Should this need to be considered as part of their care, it must be discussed with the named nurse or professional, safeguarding children, modern matron or service manager, associate nurse director, deputy director of safety and quality and consultant psychiatrist caring for the child before a decision is made.

5.18.2 For a young person

Should the need arise, a young person may be cared for within PICU in accordance with existing practices in place for the transfer of care to the PICU. However, the 1-to-1 nursing is to continue.

5.19 Discharge or transfer

All admissions to the adult acute mental health wards should be for the shortest period of time possible. Planning for the child or young person’s discharge or transfer should commence either prior to or immediately following their admission and the local CAMHS services are responsible for making the appropriate discharge arrangements (control panel meeting, reviews this on a daily basis).

5.19.1 Discharge home

In the event of a child or young person being discharged to their home address, the guidance in the trust admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures.

In addition to this, the child or young person should have been referred to appropriate agencies to provide ongoing care and support, for example, early intervention services prior to their discharge from the ward. The principles of the care programme approach also apply, and all children and young people will have written information regarding ongoing support as they leave hospital.

At the point of discharge, the child or young person will be discharged into the care of a previously identified responsible person as identified in section 5.2 of this policy.

In discharge planning consideration, in consultation with the child’s parent(s) or parental responsibility holder, should be given whether local authority services pursuant to section 17 of the Children Act (1989) (Child in Need) should be requested.

5.19.2 Discharge to an adolescent unit or other care facility

If transfer to an adolescent unit is assessed as being appropriate and a place has been secured, the following points should be followed:

It will be arranged as early as possible into the admission:

• an assessment of need and risk will be made on an individual basis for the child or young person on whether they require to be accompanied by a qualified nurse from the ward and the method most appropriate to ensure a safe handover to staff on the adolescent unit
• all case notes and drug cards (if there are any paper records) will go with the child or young person, and a decision will be taken by those caring for the child or young person whether the original notes or copies will be taken. However, in all circumstances where the patient is detained under the MHA 1983 the original MHA detention papers will be taken
• a written summary of treatment and progress will be in the clinical records
• transfer will take place either by taxi or ambulance, whichever is felt to be the most appropriate, as per the trust safe transportation of patients (mental health and learning disability services) policy
• advance notice of transfer will be given to the person with parental responsibility and all services involved in the care or treatment of the child or young person
• if it is planned for the child to remain as an inpatient for 30 days or more, the local authority where the child is usually resident should be informed, pursuant to section 85 (or 86 as applicable) of the Children Act 1989

5.19.3 Delays in discharge or transfer

The control group will monitor and review all aspects of care daily.

5.20 Safeguarding children supervision for clinical staff

Inpatient clinical staff will be provided with supervision by the Children’s Safeguarding team.

6 Training implications

There are no specific training needs identified in respect of this policy, staff will be made aware of its contents in the following ways:

• review and reissue of the policy to be included in the on a monthly basis on the trust communications emails
• local induction for the following staff:
  • adult inpatients
  • early interventions
  • children and young persons mental health services (CAMHS)
  • crisis services
  • trust safeguarding named nurse or professionals

In addition, all clinical staff working on the adult mental health Inpatient wards are required to undertake safeguarding children training.

7 Monitoring arrangements

7.1 Number of admissions of children and young people to the adult acute mental health wards

• How: Reports to be made of the total number of children and young people admitted. Collation of the information on the trust electronic incident reporting system, detailing the following:
  • number
  • age
  • gender
  • ethnicity
  • distribution by unit or local authority area
  • type (for example, voluntary or compulsory)
  • length of stay on adult ward
  • outcomes
  • contact with other agencies
• Who by: Modern matrons or service managers.
• Reported to: CAMHS and adult governance group.
• Frequency: Quarterly.

7.2 Number of children and young people admitted to an adult acute mental health ward

• How: Completion of the statutory CQC notification form.
• Who by: MHA office.
• Reported to: Mental health legislation committee and sub group
• Frequency: Quarterly.

7.3 Compliance with the standards within this policy

• How: Review of any complaints or action plans that relate to the admission of children and young people.
• Who by: Modern matrons or service managers.
• Reported to: CAMHS and adult governance groups.
• Frequency: Annually.

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

There have been no additional requirements identified in regard to privacy, dignity and respect.

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) (section 1).

Please refer to section 5.12 within the policy.

9 Links to any other associated documents

• Care, Education and Treatment Reviews (CETRs) (opens in new window)
• Clinical risk assessment and management policy
• MCA Mental Capacity Act 2005 policy
• Section 132 informing detained patients of their legal rights procedure
• Care programme approach (CPA) policy
• Safe transportation of patients (mental health and learning disability services) policy
• Oxehealth, standard operating procedures
• Leave for inpatients policy and guidance including section 17
• Admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures
• MCA deprivation of liberty (DoL) policy

10 References

• Department for constitutional affairs, Mental Capacity Act 2005 Code of Practice (2007).
• Department of Health The Mental Health Act (1983).
• Department of Health Fair Access to Care Services (2003).
• Department of Health Children Act (2004).
• Department of Health The Mental Capacity Act (2005).
• Department of Health The Mental Health Act Code of Practice (2015).
• Family Law Reform Act 1969.

11 Appendices

11.1 Appendix A Pathway for child requiring admission to general children’s ward of adult mental health ward while awaiting a tier 4 specialist inpatient bed

1. Duty mental health practitioner to assess need for tier 4 bed or community options with support:
   • requires admission in work hours-practitioner to inform the CAMHS manager, adult mental health head of service, adult mental health modern matron and Safeguarding Children team as soon as need for tier 4 bed identified
   • requires admission out of hours-practitioner to inform the CAMHS on call manager and adult mental health on call manager as soon as need for tier 4 bed identified. Please email or leave a message for the Safeguarding Children team on 01302 798198
2. Gatekeeping referral form (form 1) to be completed by assessing practitioner as soon as need for tier 4 bed identified and liaise with Becton Centre regarding bed status:
   • children’s wards acute hospitals
   • adult wards
   • detained in the section 136 suite, refer to the assessment of a child or young person detained under section 136 Mental Health Act 1983 flowchart
3. CAMHS to complete care plan and update risk assessment and management to assist ward staff.
4. Consider safeguarding or children protection or looked after child, does the child have an allocated social worker to liaise with or does a referral to children’s social care need to be completed.
5. Control panel meeting to be convened for 9am the day after admission and each day until transfer to:
   • identify named person to co-ordinate care delivery and transfer to tier 4 arrangements
   • ensure allocation of adequate staff resources
   • provide leadership and monitoring of the direct care delivery from CAMHS and the adult mental health ward
   • review quality and care delivery every 24 hours
   • challenge and escalate
   • ensure the voice of the child is heard
   • clarify who will feed back to parents, carers or corporate parent for LAC
6. CAMHS to visit the child on the placement immediately following the control panel meeting to assess the child’s mental health and physical health needs and the needs of family and staff on the placement. Detained patients must be seen by a consultant psychiatrist.

11.2 Appendix B Gillick competency

11.2.1 What is Gillick competence?

19.34, Children under 16 should be assessed to establish whether they have competence to make a particular decision at the time it needs to be made. This is because in the case of Gillick, the court held that children who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the competence to consent to that intervention. This is sometimes described as being Gillick competent. A child may be Gillick competent to consent to admission to hospital, medical treatment, research or any other activity that requires their consent.

19.35, The concept of Gillick competence is said to reflect the child’s increasing development to maturity. The understanding required for different interventions will vary considerably. A child may have the competence to consent to some interventions but not others. The child’s competence to consent should be assessed carefully in relation to each decision that needs to be made.

19.36, When considering whether a child has the competence to decide about the proposed intervention, practitioners may find it helpful to consider the following questions:

• does the child understand the information that is relevant to the decision that needs to be made?
• can the child hold the information in their mind long enough so that they can use it to make the decision?
• is the child able to weigh up that information and use it to arrive at a decision?
• is the child able to communicate their decision (by talking, using sign language or any other means)?

19.37 A child may lack the competence to make the decision in question either because they have not as yet developed the necessary intelligence and understanding to make that particular decision; or for another reason, such as because their mental disorder adversely affects their ability to make the decision. In either case, the child will be considered to lack Gillick competence.

Mental Health Act Code of Practice 2015, 19.34 to 19.37.

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Document control

• Version: 8.1.
• Unique reference number: 337.
• Approved by: Clinical policy review and approvals group.
• Date approved: 20 February 2024.
• Name of originator or author: Nurse consultant for adult inpatients.
• Name of responsible individual: Clinical policy review and approvals group or nurse consultant.
• Date issued: 23 February 2024.
• Review date: January 2025.
• Target audience: CAMHS staff and adult acute in-patient mental health area staff.

Page last reviewed: November 15, 2024
Next review due: November 15, 2025

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