Contents
1 Policy summary
This policy sets out the roles and responsibilities for colleagues, patients and visitors in line with the Mental Health Act (MHA) Code of Practice 2015, Chapter 8 and the Mental Capacity Act (MCA) 2005 for the use of controlled access and egress to the hospital wards.
2 Introduction
The trust believes the safety of patients, colleagues and visitors is its utmost priority, and recognises its responsibilities and duty of care to ensure provision of safe and secure environments.
The trust operates controlled access or egress across all wards and expects all colleagues to ensure patients are aware of their rights, the reasons for the controlled access and egress and that the options for access and egress are made clear to both patients and visitors.
This policy provides a systematic and consistent approach to the management of access and egress procedures across the trust. The trust recognises its duty to ensure clear communication and offer appropriate routes of escalation to those patients and visitors who experience difficulties with the access and egress policy.
The trust recognises that those patients admitted to mental health and physical health wards may have complex, specific and individual needs. The controlled access or egress to wards is intended to protect patients. This extends to protecting patients, colleagues and from others gaining access to the wards.
This approach is compliant with the Mental Health Act, Code of Practice (chapter 8).
3 Purpose
This guidance sets out the requirements for the use of controlled access and egress to the hospital wards based on the guidance given in the Mental Health Act Code of Practice 2015, chapter 8 and the Mental Capacity Act 2005.
4 Scope
This policy applies to the trust’s inpatient areas where controlled access and egress procedures are in place as set out below and applies to both informal patients and patients who are subject to lawful detention.
For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.
5 Procedure and implementation
5.1 Quick guide
5.1.1 Minimum standards
- All ward areas will ensure they have clear information displayed by the ward doors to inform patients and visitors how they can leave the ward.
- Where colleagues have concerns about the risks posed by a patient should they leave the ward, then they must discuss this with the patient.
- For both informal and detained patients their ability to understand the processes relating to the access or egress to wards should be continuously reviewed.
5.1.2 Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards
- If it is not felt to be safe for a patient to leave and the patient cannot be persuaded to stay on the ward, a doctor must be contacted to carry out an assessment under section 5(2) MHA 1983. If there is a delay in the doctor coming to do the assessment, the nurse should consider the use of section 5(4) MHA 1983.
- In the case of patients asking to leave who lack capacity to understand the reasons they are being held on the ward under the Deprivation of Liberty Safeguards (DoLS) or are awaiting a DoLS assessment. The ward manager must make a decision under the Mental Capacity Act in their best interests based on the risks of leaving the ward unescorted or with an escort.
5.1.3 Patients’ rights
- All patients, regardless of their legal status, will be provided with verbal and written information on how to access or egress the ward. Where possible this should be done both prior to and on admission. Please see appendices D, E and F.
5.2 Definition of airlock
There are a number of units across the trust which operate with airlocks as part of their entrances:
The airlock comprises the front entrance area to the ward or unit, the external entrance door lock which is controlled by a magnetic device and a set of internal doors which are also controlled by magnetic locks. Each set of doors operates separately and independently of the other set, however both sets of doors are interlocked such that one set of doors has to be closed before the other will open, for example, the internal doors cannot be opened until the external doors have been closed and vice versa. The airlock is the area between these two sets of doors.
5.3 Definition of controlled access and egress
All other wards or units within the trust operate with controlled access and egress systems into the unit and individual wards. The doors to the wards or units are fitted with an electromagnetic lock and to allow access or egress a switch is provided into the ward or unit to allow staff to give access and egress to patients, visitors and other colleagues.
5.4 Minimum standards to be applied by ward colleagues
All ward areas will ensure they have clear information displayed by the ward doors to inform patients and visitors how they can leave the ward (appendix C).
As part of local induction processes; all colleagues will be clear on the reasons and purpose for employing controlled access and egress on the ward.
All patients, regardless of their legal status, will be provided with verbal and written information on how to access or egress the ward. Where possible this should be done both prior to and on admission.
For those patients who are detained under the MHA or subject to DoLS, this will include information on their legal status and the implications for them accessing and egressing the ward.
Information should also be provided to the patient’s family and carers on admission to ensure they are clear in the ward’s approach to access and egress.
In the case of informal patients, all colleagues working with the patient should ensure they are supportive of the patient’s right to leave the ward where it is safe for them to do so.
Colleagues must explain the patient’s legal rights where necessary and ensure any difficulties experienced by the patient are raised as a concern.
Where colleagues have concerns about the risks posed by a patient should they leave the ward, then they must discuss this with the patient. The information discussed should include details of how they could request discharge themselves from the hospital and their compliance with the agreed care plan and how to request a review of this.
For both informal and detained patients their ability to understand the processes relating to the access and egress to wards should be continuously reviewed. The Mental Capacity Act is the governing framework for assessments of capacity and this should be adhered to support improvement of their understanding.
The ward manager must ensure all colleagues being inducted onto the ward are provided with information on the approach, philosophy and aims of this guidance.
5.5 Informal patients with capacity to consent to admission
Informal patients should be made aware of their legal position and rights, failure to do so could lead to a patient mistakenly believing that they are not allowed freedom of movement, which could result in an unlawful deprivation of their liberty. Colleagues should ensure:
- there are signs up informing informal patients of their rights to leave the ward
- a copy of the informal rights leaflet should be provided to the patient
- where a patients legal status changes from being detained under the MHA to informal, they should be informed of their rights as an informal patient and this should be documented in the electronic patient record
Informal patients have the right to leave at any time however prior to admission and on admission they will be advised that we would like them to remain on the ward for 72 hours in order that we can undertake an assessment of their care and treatment needs.
Informal patients cannot be required to ask permission to leave the ward but may be asked to inform colleagues when they wish to leave the ward. This is so that staff are aware of who is on the ward at any one time, thereby ensuring the health and safety of all.
5.6 Patients who lack capacity to consent to admission
The trust has a duty of care towards the patient, if a patient expresses a wish to leave, the nurse must make a decision based on the latest risk assessment and the patient’s current presentation whether it is safe for them to leave. If it is not felt to be safe and the patient cannot be persuaded to stay on the ward, a doctor must be contacted to carry out an assessment under section 5(2) MHA 1983. If there is a delay in the doctor coming to do the assessment, the nurse should consider the use of section 5(4) MHA 1983.
In the case of patients asking to leave who lack capacity to understand the reasons they are being held on the ward under the DoLS or are awaiting a DoLS assessment. The ward manager must make a decision under the MCA in their best interests based on the risks of leaving the ward unescorted or with an escort.
Patients detained under the DoLS are able to leave the ward if escorted by colleagues or family members and it is safe to do so, as detailed in their care plan.
Information should also be provided to the patient’s family and carers on admission to ensure that they are clear in the ward’s approach to access and egress.
6 Training implications
There are no specific training needs in relation to this procedure, but clinical colleagues working on any of the inpatient wards which have controlled access will need to be familiar with its contents.
As a trust procedure, all colleagues need to be aware of the key points that the procedure covers. Staff can be made aware through a variety of means such as:
- team meetings
- local induction
- one to one meetings or supervision
7 Equality impact assessment screening
To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.
7.1 Privacy, dignity and respect
The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.
Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).
7.1.1 Indicate how this will be met
No issues have been identified in relation to this policy.
7.2 Mental capacity act
Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.
Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.
7.2.1 Indicate how this will be achieved
This policy will be implemented in accordance with the guiding principles of the Mental Capacity Act 2005 (section 1).
8 Associated documents
- Clinical risk assessment and management policy
- Patients missing or absent without leave (AWOL) policy
- Incident management policy
9 References
- Mental Health Act 1983 as amended by the 2007 Act.
- Mental Health Act Code of Practice 2015.
- Mental Capacity Act 2005.
10 Appendices
10.1 Appendix A Responsibilities, accountabilities and duties
10.1.1 Trust board and chief executive
The trust has a responsibility to have effective risk management procedures in place, which maintain the rights and dignity of patients, and for the monitoring of these processes.
10.1.2 Service manager (inpatients)
The service managers are responsible for:
- the implementation of the policy and clinical colleague’s compliance with its contents
- reviewing the frequency of the implementation of this policy
- any colleagues they manage being aware of this policy and its contents
- keeping this policy under review so that its contents are reflective of current practice
10.1.3 Clinical colleagues who work within the inpatient wards
The clinical staff are responsible for:
- implementing the requirements of this policy
- reporting any non-compliance with this policy
10.2 Appendix B Monitoring arrangements
10.2.1 Compliance with the standards as set out in this policy
- How and who by: Audit of the access and egress policy by service manager (inpatients).
- Reported to: Care group quality meeting.
- Frequency: Quarterly.
10.3 Appendix C Ward door notice
10.3.1 Notice
It is necessary to lock this door for the safety and security of patients, staff and visitors.
If you wish to leave, please speak to any member of staff who will be happy to help you.
10.4 Appendix D Legal rights for informal patient’s leaflet (Rotherham)
10.5 Appendix E Legal rights for informal patient’s leaflet (Doncaster)
10.6 Appendix F Legal rights for informal patient’s leaflet (North Lincolnshire)
Document control
- Version: 2.
- Unique reference number: 563.
- Ratified by: Clinical policies review and approval group.
- Date ratified: 12 November 2024.
- Name of originator or author: Head of quality, compliance and assurance.
- Name of responsible individual: Chief nurse.
- Date issued: 10 December 2024.
- Review date: 31 December 2027.
- Target audience: Clinical colleagues working on the trust’s inpatient wards.
- Description of change: Addition of section 1 and 5.1 and change of order in line with updated policy template. Minor amendments such as change of title to reflect restructures and addition of appendices 4,5, and 6.
Page last reviewed: December 10, 2024
Next review due: December 10, 2025
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