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A Practical Workbook
Foreword Executive Summary Introduction Strategy One: Understanding the problem Strategy Two: Developing Entry and Exit policies Strategy Three: Providing meaningful engagement Strategy Four: Structuring the day Strategy Five: Engaging Stakeholders Appendix 1: The Five Strategy Self-Assessment Tool References Glossary
3 4 4 7 10 17 20 25 27 32 33
The authors wish to express their appreciation to the many people who have provided invaluable help in the creation of this practical workbook. Special thanks are due to Malcolm Rae, Yvonne Stoddart and Marion Janner for their practical advice and support, to Prof Len Bowers who remains the pioneering expert in this field, and to Greater Manchester West Mental Health NHS Foundation Trust for giving the authors the time to research and develop this document.
David Bartholomew, Senior Manager Adult Servicest Dr David Duffy, Nurse Consultant Nigel Figgins, Deputy Ward Manager All authors are employed by Greater Manchester West Mental Health NHS Foundation Trust
The national suicide prevention strategy for England highlighted people with mental health problems as a particular high risk group for suicide. We know that a significant number of suicides occur during a period of inpatient care. Managing risk effectively is therefore essential.
In December 2006, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness published its third report Avoidable Deaths. Whilst the report outlines a number of positive findings, major problems of safety still remain. This includes the number of inpatients dying by suicide whilst off the ward without permission. In mental health services it is important to balance patient autonomy with patient safety and at times this can be challenging. This workbook has been developed to help reduce the number of patients who go missing from mental health wards and who place themselves or others at risk. In addition to providing straightforward advice to staff who work in clinical settings, it also provides a range of positive practice examples from around the country. I am pleased to commend this workbook to all mental health services.
Louis Appleby National Clinical Director for Mental Health
Patients who go missing from mental health wards present a continuing challenge to mental health services. They may place themselves and others at risk, while significant amounts of health service time and resources are spent in seeking to ensure their safety.
This workbook explains the background to the challenge of missing patients and offers the following five practical strategies which can help to reduce the numbers who go missing:
• Understanding the problem • Developing entry/exit policies • Providing meaningful engagement • Structuring the day • Engaging key stakeholders
Good practice examples are provided for each strategy, together with contact details and a list of useful references. A self-assessment tool is included as an appendix so that acute services can measure their own progress and develop local action plans.
The problem of patients going missing without permission from acute wards is an important challenge for mental health care. In a study by Bowers et al (1999) 4% of people harmed themselves or others in some way following their absence from the ward, while a more recent report (Man Univ, 2006) found that no less than 27% of inpatient suicides take place off the ward, often after the person has gone missing Absence also prevents therapeutic input from staff, and is anxiety provoking for those involved. Such incidents also create time-consuming work for nurses and other professionals (eg police) (Bowers et al, 1999.c)
Research has also shown that missing patient incidents can affect carer and relative views, and faith, in mental health services. Patients present a high risk of going missing within the first 2-3 weeks of admission (Bowers et al, 1999. b). This is when they may be experiencing an acute phase of their illness and will often need a period of time to settle into the ward and familiarise themselves with the staff and the ward’s boundaries and expectations. Some patients may not believe that hospital admission is beneficial to them or in their best interests. It is therefore a key priority to ensure that staff begin to form a meaningful, therapeutic and collaborative relationship straight away (DH, 2006). One of the main reasons why patients leave the ward without permission is because they have social responsibilities to address, like paying bills or to ensure their property is secure. Staff will need to assess and recognise these issues early on in order to prevent further anxiety and worry that would then lead to the patient choosing to leave. Other reasons for going missing include symptoms of mental illness, or discontent with ward environment and care (Bowers et al,
1999.a). Interventions to prevent missing patients should target people who are newly admitted or are experiencing an acute phase of their illness. This involves assessing all new patients and identifying the most likely patients to leave, then implementing prevention strategies before this can happen. Patients who have gone missing previously are at greater risk from the same behaviours again in the future (Meehan et al, 1999). Some inpatient units are not adequately equipped with staff who are trained to manage and address these needs and therefore experience high rates of missing patients. Avoidable Deaths (Univ Man, 2006), a 5 year report of the national confidential inquiry into suicide and homicide by people with mental illness highlighted a number of key risk factors in those patients who had gone missing without staff permission, and subsequently committed suicide. They were more likely to be young, male, unemployed and homeless with high rates of schizophrenia, previous violence and alcohol and drug misuse. They were also more likely to have had over 5 previous admissions and been non-compliant regarding their medication in the last month. However, 81% of this group had been estimated as low or no immediate risk and 48% had been estimated as being low or no long term risk – with consequent lower observation levels being applied prior to them going missing. The report therefore raised concerns about the robustness of risk assessment processes and recommended a joint management review of high risk patients with other clinical teams as well as aligning CPA and risk management. It also highlighted issues re staff training, staffing levels and communications and advocated the need for closer contact with patients’ families and carers. In the past, one intervention to help reduce missing patient incidents was to simply lock the doors. However, it has been suggested that “physical security measures alone are not a sufficient answer to the problem of absconding, and nurses need to work harder to develop supportive alliances with patients” (Bowers et al,
1999.b). Around half of patients who go missing whilst already off the ward, possibly whilst on section 17 leave, are attending activities off the ward, at handover or at meal times. The remainder use alternative means such as removing glass from bedroom windows, and climbing out or leaving via fire exits (Bowers et al, 1998.e). Ensuring the safety of service users, staff and visitors, was highlighted as a key priority area for service improvement in Pathway to Recovery (HC, 2008) the Healthcare Commission’s recent review of inpatient care. It found that, although the frequency with which detained patients were absent without leave was relatively high, this was generally for brief periods and that the rate varied considerably between trusts. It recommended that commissioners and providers of mental health services need to focus on: promoting a more positive therapeutic environment and better engagement with service users to meet their diverse needs; ensuring that risk management systems are implemented in practice; and looking at ways to minimise the likelihood of patients going missing, using national guidance and best practice approaches. City University London published a self-training package for staff (City Univ, 2003) on how to reduce the numbers of patients going missing from acute wards, based upon three research studies which they had carried out. Their “antiabsconding intervention” suggested the following key actions:
• Rule clarity regarding entrance and exit policies • Identify those at high risk of going missing • Target nursing time for those at high risk • Careful breaking of bad news • Post incident debriefing • MDT review following 2 episodes of
going missing This material can be downloaded from www.citypsych.com
Seven steps to patient safety in mental health (NPSA, 2008) provides a step-by-step process to help mental health organisations, staff and teams build a culture of safety and improve the safety of service users. It acknowledges that many patient safety problems, such as patients going missing, have complex systemic causes which require actions on an individual, team, directorate and organisational level.
This workbook is intended to address this gap and assist staff in their day-to-day work.
Scope and structure of the document
The document explains the background to the challenge of missing patients and then offers five key strategies to help reduce the numbers of people who go missing. Each strategy is explained and accompanied by a practical task checklist and a range of good practice examples. Finally, a self-assessment tool is included in Appendix 1 so that wards can measure progress against each strategy and develop their own action plans.
Aims of the workbook
When patients go missing from acute mental health wards, they potentially place themselves and others at risk. The purpose of this workbook is to provide acute mental health staff with a number of practical ways in which they can effectively reduce the number of patients who go missing from acute mental health wards. It aims to:
How to use this document
Read through the document and then measure the effectiveness of your own clinical areas using the assessment tool in Appendix 1. This can also be downloaded as a user friendly Word template from www.virtualward.org.uk. By following up the references and examples of good practice, you should be able to develop and implement a practical action plan to reduce the number of missing patients on every ward.
• enable staff to view the ward as a whole system • reduce the potential for patients to go missing • improve the inpatient experience during
their stay, and
• make the ward a place which patients value
and find therapeutic.
Who should use this document?
This guide is primarily targeted to all clinical staff responsible for the care of people in acute mental health wards.
Five strategies to reduce missing patients
The available evidence indicates that strategies regarding missing patients are needed which take into account the fact that a mental health inpatient service is a whole system. This workbook outlines the following five key strategies to assist staff in reducing the chance of patients going missing: 1) Understanding the problem 2) Developing entry/exit policies 3) Providing meaningful engagement 4) Structuring the day 5) Engaging key stakeholders
Why this document is needed
Although a significant amount of research has been carried out as to why patients go missing and a number of important initiatives have been developed, there has been no brief, straightforward practical guidance readily available for staff who work in clinical settings.
Understanding the problem
When a patient goes missing, this should be recorded as a clinical incident. By seeking out this information and analysing it, we can learn lessons about who might leave, how they leave, where they go to, the reasons they leave and when this occurs. From the analysis, we can then look to develop preventative measures to help reduce missing patients incidents.
Below are suggested questions that, when answered, will help identify the areas of your service which need addressing in order to reduce the number of missing patient incidents. 3) There may be times of the day at which patients choose to leave sometimes because there are less nursing staff about. Find out at what times the incidents occur more frequently and whether they are associated with specific situations on the ward. An example of this is could be at handovers, in the evening or at the weekend. 4) Find out if the incidents are associated with the same patient. If they are, seek the patient’s view of why they are going missing – this may be related to dissatisfaction or social/equality issues. Clear management plans for such patients should be discussed and developed at a multidisciplinary team (MDT) meeting.. Check what management plans have been implemented to address the problem and whether they are evaluated for effectiveness. 5) Management of the environment will need to be considered. Patients will often use fire exits as a point of exit from the ward. Consider how the patients are leaving and by what route? Are they leaving covertly or through the main entrance? How many fire exits do you have? Are they alarmed? Do areas accessible to patients off the ward, e.g. exercise area or garden, allow unrestricted access/exit out of the hospital/unit? 6) Are patients leaving the ward without the knowledge of staff or are they not returning from agreed periods of leave? Have patients ‘run away’ following escorted leave? 7) Following the patient’s return to the ward, do the nursing staff update the risk assessment? Are triggers for the incident recorded? All relevant information including any equality issues needs to be obtained from the patient,
1) Contact your information services department and collate the information relating to missing patient incidents over the last twelve months. Ensure that any information is disaggregated by race, disability, gender, age, sexual orientation, religion or belief so that you can see whether there are any underlying equality issues which need to be addressed. 2) You can supplement this information by contacting your local police missing persons lead. You can request data on how many patients have been reported missing from your ward or unit in the last 12 months. Information can be collected from the police that demonstrate how many times they have been contacted and whether they were required to return the patient back to the ward. More detailed information can then be sought from the incident forms themselves.
so that if it does occur again then staff would have reliable information on the habits of the individual, i.e. where they go, who they see etc. 8) Are all incidents discussed within the MDT? Are clear management plans formulated? Is the patient involved in or informed of future management plans? What are the obstacles to implementing the plan? 9) Look at whether the reported incidents resulted in a review by the clinical team and whether an action plan was developed to reduce a repetition. 10) Are unsuccessful attempts at leaving the ward reported as ‘near miss’ incidents? 11) From the results obtained consider how many incidents could have been potentially prevented if one or more of the 5 strategies in this workbook were in place. Identify how many of these incidents could have been prevented by initiating section 17 leave and/or escorted leave with staff, relatives or friends.
1) Understand the problem Through analysis of the missing persons data it was possible to identify particular patterns:
• Defining those service users that had gone
missing and those that had not returned from leave.
• Understanding those service users repeatedly
going missing (20% of service users accounting for 60% of incidents).
• Establishing the time of day at which service
users were most frequently going missing. 2) Inter-agency Collaboration It was important to focus on stakeholders who have influence and are influenced by the problem of service users going missing. The Police played a major role and were involved and informed of the specific actions being taken to address the problem. Sharing the information from Stage 1 with the Police promoted a collaborative approach with good understanding of the context of the problem. 3) Action and Intervention This stage was implemented simultaneously with Stage 2 and worked around four general themes:
EXAMPLE1 The Salford Absconding Project (SAP)
Greater Manchester West Mental Health NHS Foundation Trust Issue(s) addressed re missing patients: There was a disproportionately high incidence of service users going missing from the Inpatient Unit. Approach adopted to reduce the number of missing patients: The SAP approach was to address the problem within three stages:
• Targeting the needs of those service users
who were repeatedly going missing (60% identified in Stage 1). A common characteristic of this group was that they were delayed discharges awaiting secure accommodation. It was therefore necessary to engage the PCT and Secure Commissioners to support transfers to appropriate services.
• Effective and timely use of the Psychiatric
Intensive Care Unit (PICU) to support open wards in the assessment and management of service users identified as at risk of going missing.
• Targeting the peak times that service users
were going missing through increased activity and engagement at these times.
• Introduction of “Plan Your Day” meetings with
service users in order that individuals were involved in setting out at the start of each day the specific activities and groups that they would be involved with. What worked well? • Addressing the needs of the 60% group that were repeatedly going missing led to an immediate reduction in incidents through proactive management.
missing which projected over a 12 month period would have been 268, (16% higher than the national average). In a 5 month evaluation period following this there was >80% reduction projecting under 50 such incidents over a 12 month period. Lessons learnt: • In order to plan effective interventions to reduce incidents of service users going missing, it was essential to analyse the information of previous incidents.
• Service users were positive about the Plan
Your Day meetings and the collaboration with the Ward Teams that this enabled. What did not work so well? The challenge for this initiative was the sustainability. The delayed discharge of service users awaiting specialist accommodation has re-occurred. Key benefits or outcomes: Within the initial period analysed (9 months) there were 201 incidents of service users going
• Inter-agency relationships are key. • Reducing incidents of service users
going missing is more than about locking doors. Collaboration and engagement has a major influence. For more details contact: David Bartholomew, Senior Manager Adult Services David.Bartholomew@gmw.nhs.uk
Developing entry and exit policies
Patients are admitted to adult acute inpatient units for a variety of different reasons. The function of an inpatient unit is to provide care in the least restrictive environment. The needs of the individual may range from 1:1 on a PICU to minimal observations on acute wards. It is for this reason that entrance/exit policies need to be flexible to the needs of all patients whilst acknowledging varying degrees of individual risk.
An entrance and exit policy allows staff to monitor the flow of patients in and out of the ward or mental health unit. Just as importantly, it also allows staff the opportunity to engage, assess and, if necessary, intervene with patients. (Rae, 2007) 5) Identify a workable system that allows the monitoring of patient’s movements to and from the ward. A discussion group with ward staff and or patients could achieve this. Ensure that the system chosen is benefiting the patients and not just for the convenience of staff. Challenge any custodial roles and attitudes (Rae, 2007). Examples of potential policy include ‘signing in and out policy’, ‘locked door policy’. Explore new technologies for doors, e.g. swipe cards, keypads and fobs. 6) Arrange a consultation meeting. Inform patients, advocates and Patient Advice and Liaison Services (PALS) at community meetings (or similar) about the proposed system and why it is being considered. Encourage discussion and feedback. A simple questionnaire could be handed out to staff, patients and relatives asking for their views on how to improve the safety on inpatient wards. 7) Decide when to implement a trial period. Enough time needs to be be allowed, for its implementation, review of function and an audit of missing patient incidents to occur. 8) Train all staff on how to implement and use the new system. 9) Staff will need to explain to patients the value and necessity of policies, making it clear that it is for their own safety. This could include: “Keeping inappropriate people out” (Rae, 2007). For new patients, provide policy information in both written and verbal format as part of the admission process. 10) At the end of the trial period, collect missing patients data again. Audit and evaluate the data by comparing it against the previous figures. Collect subjective feedback from all involved.
1) Collate and analyse the current missing person figures (see Strategy One above) 2) Identify from data collected if your service would benefit from an entrance/exit policy in your clinical area. 3) The ward manager will need to ensure that the absence of entrance/exit policy is recorded on the risk register or acute care forum agenda in order for senior managers to review. 4) Consider using the Missing Patients Toolkit: A resource for acute hospitals, community hospitals and mental health units for ideas in creating policy or the City University’s Anti-Absconding self-training package for ward staff (See Reference section for details).
EXAMPLE2 Use of Electronic Key Fobs on an Acute Mental Health Ward
Cheshire and Wirral Partnership NHS Foundation Trust Issue(s) addressed re missing patients: • The numbers of patients leaving the ward without prior agreement. • The time spent on managing level two observations on the ward • Daily risk assessment • Allowed the ward to be locked without preventing patients who were able to leave the ward doing so. Approach adopted to reduce the number of missing patients: • Entry and exit to Beech Ward is by the use of an electronic key fob (Salto). • Every patient on Beech Ward has their own individual room which is also operated by electronic key fob. • This initiative enabled patients, following risk assessment and discussion, to receive a personal key fob programmed to allow entry and exit to the ward. What worked well? • Communication throughout the project with patients and staff at daily community meetings. • Patients who did not receive an exit fob on admission understood why and how it linked to their intervention plan whilst on the ward. What did not work so well? On three occasions patients without a fob did leave the ward without prior agreement. This occurred when the door was open for others to leave.
Key benefits or outcomes: • 75% reduction in the numbers of patients missing from the ward. • Reduction in nursing observations solely for the purpose of patients going missing. • Increased time for nurses to engage in therapeutic activity on the ward. • Initiative extended to Juniper Ward at Bowmere Hospital. Lessons learnt: • A need to focus on a daily risk assessment • To check that patients have not been asked to change room for any reason without the fob being changed as well. For more details contact: Gill Edwards, Ward Manager, Beech Ward firstname.lastname@example.org
EXAMPLE 3 Introduction of swipe card system
Leeds Partnerships NHS Foundation Trust Issue(s) addressed re missing patients: • Reduced the number of patients on close/ intensive observations. • Reduced the number of patients leaving the ward without staff knowledge. • Use of the swipe care generated an electronic record check of who is in and out of the ward • Created short timed delay on exit from the ward giving staff further opportunity of seeing people as they leave.
Approach adopted to reduce the number of missing patients: • All Adult Acute Inpatient Wards have been electronically locked (in and out) using a monitored swipe card mechanism. • Staff from each ward are issued with electronic swipe cards that are programmed to access all areas of the unit (not just their own ward, in case of unnecessary delay in emergency). • Patients are individually assessed with a view to deciding who should not have a swipe card. • Patients subject to detention would not normally have a card. • Informal patients would normally have a swipe card to come and go. This would be their default position as legally, informal patients should be able to leave when they want to without hindrance or delay. • However all informal patients are assessed for their level of risk and should the risk action plan determine it appropriate, they would be formally asked to consent (in writing) not to have a swipe card. Should an ‘at risk’ patient refuse to accept this option (as would be their right) then the clinical team would have to reconsider their treatment plan. This would broadly have 3 options. • Accept the patient’s perception of their own risk and plan care accordingly sharing risk with the patient. • Consider the patient for discharge on the grounds that they are not willing to comply with reasonable treatment request and could be safely supported elsewhere. • Consider use of the Mental Health Act on the grounds that the patient is refusing treatment for their own safety. • This approach introduced a level of transparency that was not possible under pre-existing open door arrangements.
• The swipe card in isolation is not an attempt to reduce the number of missing persons. It is used in conjunction with having the following in place: • Having a care plan to address what action should be taken where a history of going missing is known at start of admission. • Building better partnership relations with other agencies. We have regular meetings with the local police who feedback on the number of missing persons per month and outcomes. A joint missing person’s protocol has also been generated between the two services (This is currently under further review). • Clinical team managers work with individual ward clinicians to identify from police feedback how missing person’s cases could have been managed differently. • Having clearer local guidance on what actions clinicians should take for missing persons which considers the assessment. E.g. Often patients are not actually missing, but are absent from the ward without permission e.g. section 17 authorised leave. • The above local actions would include going into the community to pick up our patients as we know where they are, rather than draining police resource unnecessarily. What worked well? • Staff have an immediate system of being able to identify who has authorisation to leave the ward. E.g. if a patient asks to be let out of the ward, then staff can immediately question why they do not have a key. This prompts them to stop and find out why before opening the door. • It reduced the necessity to have staff ‘door watching’ and promotes the use of direct engagement. • We no longer unnecessarily and unlawfully deny people the right to come and go freely without proper consideration and active thought.
• There is no evidence to support the initial view that the swipe card would be used as ‘currency’ and those patients would bribe, persuade or intimidate those who were entitled to have a card. • Patients report feeling safe as this system is also useful to make it easier to exclude unwelcome visitors, especially those with criminal intent. • Systems are in place to ensure that missing patients are reviewed clinically and managerially following an episode where a patient has left the ward without permission or agreement from staff. We have developed a missing patient action plan, for those at highest risk, and post missing episode interview process to help staff, and the service user, understand the reasons for going missing. What did not work so well? • Swipe card were initially placed on the inner ward door. However we found that the time delay was not sufficient. Swipe card system are now also in place on the outer ward door to enable an ‘airlock’ time delay. • Staff initially needed further education regarding the system to ensure that there was documented evidence that patients without keys had gone through an assessment process of showing consent not to have a key. • The entrance to the unit (building) is now also awaiting the swipe card system as there have been issues regarding people being able to leave the building. • Those without cards needing to enter the ward (this could include visitors or community clinicians) needed to ring a buzzer to be let in. The switch to open the door was behind the nurses’ station.
This was found to remove the ‘meet and greet’ of welcoming visitors. The switch has now been removed and staff now need to go to the door to swipe it open. This gives staff an opportunity to make face to face contact with those entering the ward and clarify their reason for visiting. Key benefits or outcomes: • A reduction in the number of occasions service users leave the ward without permission. • A reduction in missing persons reporting average. • Continuous development of staff assessment and risk management skills. • Clear information for service users and their families regarding how to enter and leave the ward. • Improved relationships, joint working and shared protocols with our partner agencies including West Yorkshire Police, families and carers. • Staff are better able to manage visitors by meeting and greeting them at the door (and redirect people who do not need to enter the ward). • Service users value the use of the swipe card system and are able to contribute to the decision making process regarding their own safety and wellbeing. • It is a system that our service users have been consulted on and have reported having a positive experience of. Lessons learnt: The main entrance to our unit should have been a key consideration in implementing the swipe card system. It was considered further along the process, when it became apparent that this was the key area that
patients were able to use to leave (as opposed to the initial thoughts that the ward exit doors were the main security issue). For more details contact: Linda Rose, Acute Care Pathway Clinical Governance Lead email@example.com
• At the point of each entry, service users and visitors use an intercom system to either the reception desk or ward • The entrances are all managed on a magnetic lock to both enter and leave the wards • These principles are supported by ongoing individual risk assessments, individual discussions with service users and their carers about how to enter and leave the ward areas, clear information and signage. • All service users have 1:1 meaningful engagement with a member of staff every day, and any changes in their mental health is documented and is reflected in the assessment taken prior to them leaving the ward. What worked well? • Service users and their carers supported this change. • The mechanics of putting magnetic locks on the doors did not make it appear like a secure/locked ward. What did not work so well? • Other services, community teams and visiting professionals sometimes have a lower understanding about the issues and can see the managed doors as an inconvenience. • Publicity was limited to the immediate areas and services whereas a wider programme of communication would have improved the implementation process. Key benefits or outcomes: • The wards have a ‘safer’ feel to them – service users/carers feel safer when on the unit and are not likely to go missing from the wards. • Staff have greater confidence in the ward layout and are more able to spend time engaging with service users, rather than watching and managing the doors.
EXAMPLE 4 Managing entry and exit to the acute wards in Doncaster acute inpatient wards
Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust. Issue(s) addressed re missing patients: • In December 2007 the adult acute unit for Doncaster services moved from a no longer ‘fit for purpose’ district general hospital site to a newly built and refurbished unit. • Within the new wards the layout resulted in service users being able to enter and leave the wards without the knowledge of staff. Approach adopted to reduce the number of missing patients: • Principles around service delivery were reviewed against the backdrop of maintaining and respecting a person’s autonomy and also keeping them safe during an acute mental health episode. • As a result of this brief review the unit now operates the following principles: • The entrance to the unit is via a single entrance • Each ward is also then only accessed by a single route
• People who do not have a legitimate reason to be on the unit/wards do not gain access. • There is greater staff focus and consequent skill and knowledge regarding risk assessment. • All staff are aware of the whereabouts of each service user and whether they are able to leave the ward. • There has been a reduction in the number of those who go missing from the wards. Lessons learnt: • Be brave, having managed doors does not make the wards into a ‘secure’ unit. • Publicise the change the a wide audience for greater community sign up to the changes.
even a small number of clients being reported as missing had a large impact on resources. • Staff were concerned by the fact that a tiny number of clients would repeatedly leave the ward. • Solihull had historically used its High Dependency Unit (HDU) at times to manage clients who frequently left the ward for unauthorised periods. This unit had been under review due to its level of occupancy reducing over the last couple of years. Approach adopted to reduce the number of missing patients: A new approach was adopted using a service user signing in and out whiteboard on one of the wards in order to: • Encourage engagement/assessment and interaction on leaving and returning to the ward. • Enable clearly identified times for leaving the ward to be recorded. • Give responsibility for management of leave to service users by recording when leaving the ward and also identifying their time for return.
For more details contact: Deborah Wildgoose, Nurse Consultant Deborah.firstname.lastname@example.org
EXAMPLE 5 Empowering Service Users to manage their leave by using a signing in and out board
Birmingham and Solihull Mental Health Trust – Solihull Directorate. Issue(s) addressed re missing patients: • The Solihull wards had remained unlocked and staff had historically avoided “door watching”, and focused, instead, on high levels of therapeutic engagement to actively manage risk. • Whilst the frequency of service users going missing from the wards was minimal, it was apparent from discussions with the police that
• Improve understanding of the implications of adhering to leave arrangements by encouraging greater collaboration between staff and service users. • Attempt to address the issues of boredom by reviewing the model of care and significantly increase the number of occupational therapists and activity workers on the wards. This has enabled an extended engagement and activity program to be developed. • Currently the wards doors have remained unlocked, although there has been consultation as to whether service users would prefer the ward entrance to be locked. The general feeling was that the current situation should remain with regards to leaving the ward, although access to enter the ward may be restricted due to the wards being located within a main general hospital.
• Activities offered have tried to focus on a mixture of ward based and community activities, for example striders and strollers and also Retired Greyhound Walking which have proved very popular in reducing feelings of confinement and promoting the healthy living agenda. What worked well? • The majority of admissions to Solihull have been informal admissions. This has been in part due to the fact that service users report not feeling “locked in”. • When staff have encouraged service users to take responsibility for leave this has been quite successful. • There have been good examples of discussions prior to and when returning from leave. • The number of missing service user incidents has remained low. What did not work so well? • The signing in/out board has been used on one of the wards for a number of years. At certain times it tends to revert back to Staff recording on the board which could adversely impact service users managing their leave. Key benefits or outcomes: • The wards currently remain unlocked. • The numbers of patients taking unauthorized leave have remained minimal.
• Incidents of frustration associated with leave are minimal as service users report not feeling locked in. • Feedback from service users identified that they do prefer the wards to remain unlocked as they find this comforting. • Service users do utilise the board and take responsibility for their leave. • The use of the HDU function has reduced to such an extent that the 7 beds are no longer required and this unit has been replaced with a single bedded extra care room on each ward.
Lessons learnt: • Developing a robust activity programme which focuses on exercise and community activities reduces feelings of containment. • Using a signing in and out board can prove effective when the whole team adopts an approach of encouraging service users to take responsibility for leave. • There must be adequate staffing to ensure there is engagement and discussion prior to and returning from leave. Staffing levels were reviewed using the NIMHE Acute Workload Calculator.
For more details contact: Martin Luke, Acting Deputy Director of Nursing email@example.com
Providing meaningful engagement
‘Meaningful engagement’ covers the broad spectrum of assessment, planning, implementation and evaluation of care, through the use of 1:1 contact with the patient. This should be achieved collaboratively and needs to be meaningful to both the member of staff and the service user. The 1:1’s should continue throughout the patient’s admission.
Meaningful engagement is clearly evidenced through the ‘Re-focusing’ work by Nick Bowles (2002), and ensures that all patients have the opportunity once a day to discuss, explore and ventilate their thoughts. Patient engagement involves the use of basic interpersonal skills, which should be possessed by all mental health staff, and serves a therapeutic purpose as well as encouraging effective communication between staff and service user. Engagement is more likely to be successful and meaningful for both the nurse and patient, once trust and rapport has been established. Assessment is a vital way of identifying behaviour that could lead to the patient not remaining on the ward, early on in a patient’s admission. Some risk factors to look out for include: early stages of admission, social responsibilities that need completing, patients who present a high risk to themselves or others, symptoms associated with illness and patients with a history of going missing from mental health units (Bowers, 1999). Good assessment skills are paramount in order to gather relevant information and interpret it accordingly. Many issues that might lead to the patient going missing can be resolved quickly and easily by recognising the context of their lives and understanding that individuals may have different needs depending on their age, gender, disability, race, sexual orientation, belief or religion. This needs to be understood in order to respond to them as individuals appropriately. Attention also needs to be given to the patient’s feelings about their care and their environment, since discontent with this can also lead to the patient choosing to leave over remaining in hospital (Bowers et al, 1999). Good complaints procedures need to be in place, as well as a working culture of accepting and welcoming criticism and suggestions for improvement.
1) Review risk management strategies including effectiveness of observation and engaging policies. Consider the quality of any interactions during such times, as this is likely to have an impact on the patient’s experience and choices they make. 2) Check that training and instruction on issues of risk assessment and positive meaningful engagement should “promote a sense of personal responsibility on the part of the service user” (Rae, 2007). This should be included on any trust induction package. 3) Consider replacing the term special 'observation' with special 'engagement', as it would be preferable for the patient to have short periods of time with a member of staff, who is ideally skilled to address any expressed diverse needs, (including those relating to strands of equality) rather than just someone who observes from a distance.
4) Clearly identify, through risk assessment, potential issues that might result in the patient going missing (e.g. worried about their cat, property needs securing). Negotiate with patient a solution to their concern, which benefits the patient and puts their mind at ease. If any actions are agreed staff must follow it through to the end, or risk losing the trust that was established. 5) Recognise the importance of ensuring that the patient understands the rationale for being admitted to the mental health unit. All aspects of their care and treatment needs to be explained and efforts made to ensure continuity of their care whilst an inpatient. 6) Check that patients are regularly seen by their primary, named or allocated nurse. Ensure the engagement is needs related. Try to match the skills of your staff to the needs of the patient, whilst maintaining continuity of care. 7) In order to improve the interactions and alliances between staff and patients, encourage nursing staff to develop their clinical practice in Solution Focused Therapy, Family Therapy, Cognitive Behavioural Therapy, and PsychoSocial Interventions. All of these therapies would help to increase the quality of 1:1 engagement and help to promote recovery rates. 8) Staff need to be able to demonstrate evidence of any interactions with their patients, ensuring accurate record keeping (if it hasn’t been written down, it didn’t happen!) 9) The shift co-coordinator needs to allocate individual patients to staff members at the commencement of the shift. Those patients that have leave from the ward need to be assessed that morning prior to any leave, in order to assess for changes in presenting risk.
10) Check that all patients are made aware of who their nurse is for the shift/day. This could be done verbally by staff, possibly at a patient’s ‘plan your day’ meeting, or through the use of a ward orientation board. All nursing staff need to ensure they know who their allocated patients are, and this can be done via the handover at the commencement of the shift. 11) Regularly check that nursing staff approach their allocated patients and offer 1:1 time, or arrange a time later in the shift. If a patient does not want to engage, then nursing staff will need to enquire as to the reason why and document this accordingly. 12) Develop use of ‘protected time’ to ensure that patients get undivided attention by ward staff. This period of time best occurs when there are no ward rounds and before relatives visiting hours.
EXAMPLE 6 The use of protected time
Greater Manchester West Mental Health Foundation Trust Issue(s) addressed re missing patients: • Proactively engaging service users during inpatient admission. • Improved risk assessment. • Increased ward based activity. Approach adopted to reduce the number of missing patients during protected time: • The nursing team gives all their time to the patients on the ward. • Visitors are not allowed on the ward
• No interdisciplinary work is conducted except in cases of emergency. • Telephone calls are diverted to the ward administrator. • All nursing staff are required to spend time with patients in communal areas, engaging in meaningful 1:1 or group sessions. What worked well? • This has proved to be a simple but effective method of promoting meaningful engagement. Protected time is targeted to take place at times when an increased number of service users are likely to go missing and it complements a number of approaches to address this problem. • Each protected period of time varies and is dictated by the patient’s needs and desires: Sometimes staff and patients have a general chat and everyone joins in, and on other occasions people engage in quizzes with mixed staff/patient teams. Protected time allows nursing staff the opportunity to engage with their allocated patient in a 1:1 if they have not already done so. • Documentation and other office based activity is important in the delivery of care on acute inpatient wards. Protected time has helped improve the balance between this and the opportunity for nurses to provide therapeutic engagement.
What did not work so well? • Nursing staff felt under pressure to ensure office-based tasks were completed. • It is important to continually evaluate the progress and benefits through team meetings and individual supervision. Key benefits or outcomes: • There is no empirical evidence to demonstrate that this approach has had a direct impact upon the reduction of service users going missing from hospital. It has however been recognised that during the periods of protected time there is a reduction in incidents on the ward that have previously been associated with stress leading to service users going missing. Lessons learnt: • Protected time provides an ideal opportunity for nurses to spend time with patients where by they are not distracted by other task orientated duties. • This adds to the service user experience and also supports the development of clinical skills of nurses.
For more details contact: Sheila Hulme, Deputy Ward Manager Sheila.firstname.lastname@example.org
Structuring the day
Bowers et al (1999) reported that patients often leave mental health units because they feel trapped and claustrophobic, or disinterested and bored whilst on our wards.
A structured day provides patients with the opportunity to engage in meaningful and therapeutic activity. Examples of these include recovery groups, self esteem groups, and community meetings. We can also reduce ward disturbances, and the tendency for violence by adequately structuring and resourcing our wards to enable diversional, recreational, and social activities to take place. A structured day not only occupies the patient, but helps with their symptoms by engaging them in therapeutic activity. It also encourages social interaction. Patients are more likely to feel valued, because nursing staff are putting time and effort into their recovery. “We must ensure opportunities for exercise and fresh air, or the need for observation, continuous risk assessment, communication and giving of information, responsibility, and the development of therapeutic alliances and effective personal support and care” (Rae, 2007 p15). presenting symptoms (e.g. poor self esteem, anxiety, trauma). This will enable you to identify a suitable activity or therapeutic programme. 3) Liaise with other professionals such as Occupational Therapy, Psychology or Support, Time and Recovery (STR) worker to develop a range of therapeutic activity programmes for positive engagement, which can be tailored to meet the diverse and cultural needs of the individual. You can also develop links within the local community, looking at drop-ins or volunteers to run groups, service users to identify and facilitate special interest groups. An employment worker could volunteer to attend a morning session and look at social inclusion work. 4) A patients meeting can be arranged to occur every weekday morning. This meeting can inform patients of the groups and activities for that day or the week ahead. Try to ensure attendance of as many patients as possible. 5) Staff need to maintain involvement in groups/ activities. It not only offers staff a valuable opportunity to build a therapeutic alliance with patients, but also demonstrates that nursing staff value the initiative. 6) Display information about activities and groups around the communal areas of the ward, promoting available activities for the week ahead, whilst ensuring that issues of translation and forms of communication that address the partially sighted etc are addressed. Ensure that these activities include activities both on and off the ward. Include this information in the patient’s handbook, which is given to each patient upon admission. 7) Any identified group/activity needs to be care planned, and regularly reviewed according to changing needs.
1) Positively promote activities to patients and staff. Encourage all patients and staff members to take part in therapeutic groups and activities. 2) Through meaningful engagement and assessment, identify the patient’s interests and needs. This can be achieved according to interest (e.g. music, sport, embroidery) or
8) During 1:1 time with allocated staff members, assess the suitability for the day’s activity/ group. 9) Ensure that activities also include those outside normal working hours (including evenings and weekends). Patients are more likely to go missing when there is limited activity on the ward. 10) Document attendance at such activities. This information needs to be fed into the MDT meeting. 11) Groups and activities need to be continuously reviewed, by seeking the opinions of those involved. Seek service user suggestions for alternative groups.
• The project was to provide social and recreational activities between the hours of 4.00pm and 8.0pm each weekday evening and all day on Saturday and Sunday. • Workers were employed on a sessional basis. They had a variety of skills and experience in providing social and recreational activities. • They were given a largely free hand to arrange flexible and responsive programmes with service users on the wards. What worked well? • The pilot was evaluated as successful in that it met all its objectives for providing out of hours activities to service users. • Following the pilot, funding was obtained for two permanent full time activity workers. These are now in post and continue to provide activities to service users in the identified ‘out of hours’ times. • The activity workers focus on the provision of activities that are socially inclusive and support service users maintaining contacts with their communities. Working alongside the OT and nursing staff, they facilitate out of hours activities on the wards that may then be continued within the community once a persons’ hospital stay has ended. • The Out Of Hours service is now a highly regarded embedded component of acute care within the Doncaster adult inpatient service. What did not work so well? As a result of the hours worked by the out of hours activity workers, there was a feeling of being disconnected with the ward staff. This is an ongoing issue that requires particular attention to ensure their integration within the ward teams.
EXAMPLE 7 Out of hours activities in Doncaster’s acute inpatient wards
Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust. Issue(s) addressed re missing patients: It is well documented that the underlying social and therapy needs of service users on acute wards have not been well met. Acute Problems (SCMH, 1998) suggested that 40% of service users received no social or recreational activity at all during their stay. This results in long episodes of boredom and a disconnection for service users with their own social communities. When bored and discontented service users leave the ward in search of other connection and recreation.
Approach adopted to reduce the number of missing patients: • A pilot was run for 3 months within the two Doncaster adult acute admission wards and PICU.
Key benefits or outcomes: • The numbers of those who go missing from the Doncaster wards was initially low. However as
part of the project evaluation the most commonly reported outcome for service users was reduced levels of stress, both on a personal level as well as that of the environment. • The project was described as having provided comfort, enjoyment and a sense of fun in an acute inpatient setting. Lessons learnt: • Running the project as a pilot gave the opportunity to see it work in practice and measure the outcomes prior to rolling it out. • ‘Therapy’ should be defined by patient need and as such can range from formal 1:1 work to an informal shopping trip. • A small investment can make massive changes.
inspector tasked with tackling the problem. The result of the process was a revised multiagency response to patients going missing from hospital. • Patients feeling bored in hospital. • Lack of therapeutic engagement. • Lack of support for female service users. Approach adopted to reduce the number of missing patients: • Proactive risk management plans considered the proportional response to individuals should they become missing, based on risk and past patterns of behaviour. • The policy also recognised the difference between those absent without leave (whereabouts known) and those who were truly missing (whereabouts unknown) and introduced an escalation of welfare checks to identify whereabouts before triggering the already overloaded police ability to respond to cases. The principle of this idea was that those logged with the police presented particular risk and were therefore a priority. • The introduction of the new policy and associated increased awareness of the issue led to a reduction of cases logged with the police in the subsequent year (below 300). • When the hospital was first opened in 2001 a team of diversional activity workers was developed across the acute inpatient service to offer direct engagement with patients in group or individual sessions offering a range of ‘low key’ activities particularly designed to tackle the need to occupy patients in meaningful activities (in line with ‘Acute Concerns’). This service together with a ‘central therapies’ provision has evolved into our current provision of therapeutic programmes offering a layered approach to meaningful engagement in activities and therapies.
For more details contact: Deborah Wildgoose, Nurse Consultant Deborah.email@example.com
EXAMPLE 8 Multi-agency policy development for missing patients
North Staffordshire Combined Healthcare NHS Trust Issue(s) addressed re missing patients: • In 2002-4 the Harplands Hospital, a provision of nine mental health wards located close to the acute care hospitals of the city of Stokeon-Trent, had a disproportionate amount of missing person incidents logged with the police (around 400 incidents a year). • This problem acted as the trigger for joint working between the hospital and a local police
• In 2006 a new initiative was developed (Protected Therapeutic Engagement Time) to allow inpatient teams uninterrupted time with patients on a daily basis, for one hour a day all visitors were banned from the ward area (professionals, relatives, support staff and managers alike). • Through the trusts volunteer coordinator our female ward has developed a pamper room and a pamper trolley service staffed entirely by volunteers, offering a range of treatments from facials to manicures and hand massage. What worked well? • Ward teams used more appropriate methods of locating patients whose risk was not immediate or who have a predictable pattern of behaviour rather than overloading the local police response mechanism. This was redirected towards the most urgent cases or those who posed the highest level of risk or vulnerability. • The therapeutic programme has continued to develop over the last two years to include a wider range of therapies and diversional activities including: structured therapeutic groups and individual therapies, complimentary therapies, psychological therapies, and community based therapies. What did not work so well? • Due to problems in volunteer recruitment the pamper trolley has had patchy success, but recent recruitment has improved things. The service itself is well received. • Welfare checks by the ambulance service for absent patients whose whereabouts was known have fallen by the wayside as the new contracting arrangements have developed.
Key benefits or outcomes: The number of patients missing reported to the Police dropped from over 400 to less than 300 in the year following the introduction of the multiagency policy. Lessons learnt: • It is important to allow (through policy) the flexibility of responses to patients absenting themselves from hospital. • Responses will vary depending on the immediacy of risk and predictability of behaviour. • It is also important to offer a differentiation between those missing from the ward whose whereabouts are known and those missing, whose whereabouts are unknown.
For more details contact: Rob Grant, Matron, Acute Inpatient Services, Harplands Hospital firstname.lastname@example.org
EXAMPLE 9 Star Wards
Star Wards is a project of the social justice campaigning charity Bright and works with mental health trusts to improve inpatients' daily experiences and treatment outcomes. Our vision is all patients are on wards where: • talking therapies play as substantial a role as medication • patients are supported in our management of our symptoms and treatment • there is a strong culture of patient mutual support
• patients benefit from a full programme of daily activities • patients retain and build on our community ties. Star Wards was created following the experiences of Bright’s Director, Marion Janner, as a detained inpatient. We are constantly discovering NHS hospitals which are providing an exceptionally high quality of service to inpatients, including those with the most complex and challenging needs. Over 500 wards are members, including forensic, eating disorder, learning disability, elderly and children and adolescents wards. They are providing a fabulous range of meaningful therapeutic, social and recreational opportunities for enriching inpatients’ experiences. Key benefits or outcomes: • “Better client feedback, increased staff satisfaction, less aggression and violence, more therapeutic contact” • The pioneering research on missing patients by Len Bowers and colleagues at City University identified that providing meaningful activities for patients is a key element in reducing this risk.
The heart of Star Wards’ work is inspiring a full programme of daily activities for inpatients. • While we don’t have specific data on our impact on reducing the numbers of patients going missing, our fist national members’ survey showed that 50% had experienced a reduction of violence as a result of taking part in Star Wards. • As the factors related to violence and missing patients are similar (eg quality of relationships with staff), it is likely that involvement with Star Wards has a positive effect on enabling patients to remain on the ward. • The problem-solving and creativity skills that staff deploy through their involvement can be applied with great effect to addressing the individual factors motivating potential incidents of patients leaving the ward when it’s not safe for them to do so.
For more details contact: www.starwards.org.uk or email@example.com
If initial assessment and interventions have failed, and the patient goes missing from the mental health unit or fails to return from leave, effective locally agreed processes need to be in place to ensure the safe return of the patient. This will be based on a shared understanding with key stakeholders such as the police of each other’s roles and responsibilities. Therefore, it is good practice to have a policy for missing patients which includes a locally agreed integrated protocol of what can and cannot be done, in relation to locating and returning those patients back to the ward.
In reporting a missing patient, the police will require certain information about the patient. Such information needs to be readily available in the patient’s notes, prior to such an incident occurring (e.g. a description of the patient should be gathered upon admission). This ensures good communication with the police, and help to achieve a timely and safe return of the patient. Other people who are often involved when patients go missing are carers and relatives. We often rely on relatives to inform us if a patient turns up at their home. This can put them in compromising positions, as patients can then believe that their relatives are ‘informing’ on them rather than helping to ensure their safety. It is often upsetting and worrying for relatives and carers to find out that their loved ones are missing. Missing patient incidents take up many hours of valuable nursing and police time. Any opportunity to save time and resource need to be seized, while still maintaining patient and public safety.
1) Develop a missing person’s policy, with integrated joint protocol with local police force. Consider using Missing Patients Toolkit: A Resource for acute hospitals, community hospitals and mental health units (see Reference section for details). 2) Have pertinent information about patients to hand. Gather this information upon admission to the ward. It should include a full description of the patient, the name and contact details of next of kin, the patient’s present and past risks (if relevant), contact details of family and friends, also any information of where the patient may go. 3) Services will need to make sure that services users, relatives and carers are aware of the purpose of acute care, ie to provide safe and sound interventions, to assess and respond to acute manifestations, and for relatives/carers to understand inherent risks (Rae 2007). 4) Arrange regular meetings with police to address and update issues. Seek agreement with local police force for the effective joint management of missing patient incidents. 5) Invite the Police to visit the unit to understand how mental health units operate. Develop a shared understanding of each other’s roles and responsibilities in relation to missing patients.
6) Attempt to develop a good working relationship with family members or carers. This could be done by inviting them to MDT meetings, or by encouraging regular contact with nursing team. Clearly, this would need to be done within the boundaries of confidentiality. Make carers/relatives aware of the role of nursing staff, the ward environment, including the limitations of nursing strategies.
What did not work so well? Initially these meetings took place on a quarterly basis. This was not frequent enough and was therefore increased to monthly. Key benefits or outcomes: • Prior to the regular police liaison meetings, the service operated in a reactive manner to issues requiring police involvement. The majority of this related to incidents of service users going missing, an issue that was using a large amount of Police resources and subsequently placing a strain on the relationship of operational staff within both services. • Through the regular meetings, with missing patients as a regular agenda item, a shared understanding of the problem was developed. Whilst this cannot be evidenced as reducing incidents, it formed an essential component of the “Salford Absconding Project” highlighted in Good Practice Example 1. Lessons learnt: • Where there is a problem that causes a drain on another organisation’s resources, relationships can become strained when reactive approaches are employed. • Through the regular liaison meetings it has been possible to develop a more proactive approach to problem solving with longer term benefits.
EXAMPLE 10 Police Liaison
Greater Manchester West Mental Health Foundation Trust Issue(s) addressed re missing patients: • Inter-agency Collaboration • Information Sharing. Approach adopted to reduce the number of missing patients: Establishment of regular Police Liaison Meetings. What worked well? • It created a regular opportunity to discuss the problems experienced by both services in order to identify collaborative solutions. • It provided the opportunity to resolve issues at a strategic level.
For more details contact: David Bartholomew, Senior Manager Adult Services David.Bartholomew@gmw.nhs.uk
The five strategy self-assessment tool
The self-assessment tool template can be downloaded as a user friendly word document from www.virtualward.org.uk
You may find it useful to share the tool in advance and encourage members of staff to think about the statements before the meeting.
Each of the five good practice strategies has a self-assessment tool linked to it. The purpose of this tool is for you to assess where you are in relation to the strategy. Complete red, amber or green as appropriate for the statement, which most nearly matches the situation on your ward. Choosing red indicates that you are not achieving this strategy. Therefore you would move to the development planning stage. How you go about planning and implementing is entirely up to you. We would recommend group discussion with colleagues, patients and carers. Enter in the Development Plan what is required to achieve the strategy. Choosing amber highlights that the strategy is only partially being achieved, and that more planning and developmental work needs to be done in this area to achieve the full strategy. Again you should enter in the Development Plan what is required to meet the strategy. Evidence demonstrating partial achievement would also need to be present. If green is chosen this means that you are achieving this strategy. Evidence to support this need be documented. Each tool will not take too long to complete, but it will be important to allow enough time for discussion. Your team should ideally complete the tool collectively, having met and discussed it fully.
Scoring and Incident evaluation
To understand the effectiveness of the strategies within the guidance it is necessary to look at changes in the nature of incidents within the service. One way of doing this is to complete a quarterly evaluation of the score. It is anticipated that there will be a positive correlation between understanding the degree to which the strategies are being implemented and the number of reported incidents: i.e. if a service is achieving 100% green on all strategies, they could expect to have a reduction in incidents, both serious and none serious. Conversely, a service that has 100% red could expect to have a high level of incidents. It is not necessary to measure against all incidents but is suggested that information on the following categories are used: 1) Incidents of patients going missing. 2) Incidents of self harm 3) Incidents of verbal abuse/threatening behaviour. 4) Incidents of actual violence. 5) Incidents of property damage. Through completing a quarterly evaluation against incidents reported, it is possible to track progress not only with regard to reduction in missing patients but also the overall impact. This information can be used to generate a report as needed as one means of evaluating effectiveness.
Strategy One: Analysis of Missing Person Data
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
1.1 There are systems in place that effectively record all incidents of missing patients. 1.2 There is a feedback mechanism for data on incidents which is forwarded to senior managers/matron for the service. 1.3 Data has been obtained on missing patient incidents for the previous 12 months and includes: • Disaggregation by race, gender, age, sexual orientation, religion and disability • Time of day incidents occur. • Individuals who frequently go missing. • Specific points of exit. (i.e. Fire exits) • Particular themes as to why. (i.e. to secure property, post MDT meeting) 1.4 Contact has been made with the Police for their data on missing patient incidents over the last 12 months. 1.5 There is evidence that all missing patient incidents result in a review by the clinical team. 1.6 Risk assessments are updated and collaborative management plans are developed to prevent further incidents.
Strategy Two: Entrance and Exit Policy
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
2.1 An Entrance and Exit policy is in operation within the clinical area. (If RED go to 2.5). 2.2 The current policy clearly identifies who is on or off the ward at any time. 2.3 Information on the policy is routinely given to patients upon admission to the ward.
Strategy Two: Entrance and Exit Policy continued . . .
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
2.4 All staff have been trained in and demonstrate understanding of the Entrance/Exit policy. 2.5 Absence of an Entrance/Exit policy is recorded on the risk register/Acute care forum agenda, (or appropriate forum to take to senior level).
Strategy Three: Meaningful Engagement
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
3.1 The shift co-ordinator allocates patients to staff at start of every shift. 3.2 Staff arrange 1:1 time with their allocated patients, and demonstrates evidence of this. 3.3 Primary nurses and allocated staff members are aware of their responsibilities to their patients. 3.4 All ward staff are trained in risk assessment. 3.5 All patients who can have leave from the ward have a daily risk review. 3.6 Through risk assessment patients who are likely to go missing are identified. 3.7 Current risks are discussed and management plans agreed with patient. Patient signs care/management plan) 3.8 All patient 1:1 interactions are clearly documented. 3.9 Patient engagement is encouraged and protected time occurs regularly in the week.
Strategy Four: Structuring the Day
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
4.1 All patients can access a range of therapeutic activities, either group or individual (including recreational), both on and off the ward. 4.2 Activities are tailored to meet individually assessed needs. 4.3 There is a daily patients meeting, where daily/weekly activities can be promoted to all patients. 4.4 Patients are able to plan their week with their named nurse. 4.5 Ward staff become involved in ward based group activities. 4.6 Information is displayed around the ward promoting therapeutic groups and activity. 4.7 Weekend and evening activities are consistently available. 4.8 Patients are encouraged to give feedback on groups or activity attended 4.9 Patients are needs assessed and referred for Occupational Therapy.
Strategy Five: Engaging Stakeholders
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
5.1 The trust has an up to date missing person policy. 5.2 An integrated joint protocol with the local police force is established and agreed within this policy 5.3 All staff are clear on their responsibilities in relation to missing patients and trust policy
Strategy Five: Engaging Stakeholders continued . . .
Criteria R A G Where we are now Development Plan Evidence of Achievement By By Who? When?
5.4 A system exists where nursing staff has easy access to all relevant information required for the reporting of a missing patient. 5.5 A senior manager is trained in liaison and holds regular meetings with the local police/missing person’s lead. 5.6 The police provide annual figures on reported missing persons from your ward or unit. 5.7 The police have been to the unit or ward and are aware of the nurse’s role in helping people with mental health problems. 5.8 All clinical staff are clear about the Police’s role when reporting an incident. 5.9 All relevant information upon admission is routinely given to relatives/carers i.e. Contact details for ward, name of Primary nurse etc… 5.10 Relatives and carers are routinely invited to Multi Disciplinary Meetings. 5.11 Whilst ensuring confidentiality, relatives/carers are kept informed of decisions made at MDT meetings.
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DH HC HDU MDT NIMHE NPSA OT PALS PCT PICU SAP SCMH STR worker Univ. Man Department of Health Healthcare Commission High Dependency Unit Multi-Disciplinary Team National Institute for Mental Health in England National Patient Safety Agency Occupational Therapist Patient Advice and Liaison Services Primary Care Trust Psychiatric Intensive Care Unit Salford Absconding Project Sainsbury Centre for Mental Health Support, Time and Recovery Worker University of Manchester