8 minute read
Patient Safety
Patient Safety
Priority 1
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Priority 2
Clinical Effectiveness
Priority 3
Priority 4
Patient Experience
Priority 5
Priority 6
Reducing violence and aggression New priority
Suicide Prevention New priority
Refreshed Clinical Strategy
Improving Physical Health New priority
New priority
Service user and carer experience New priority
Expanding the peer workforce New priority
Priority 1: Reducing Violence and Aggression
Priority 1: Promote safe and therapeutic ward environments by reducing violence and aggression, conflicts and containments.
Description of the quality issue and rationale for prioritising
Incidents of violence and aggression may also affect the perception by staff of services and service users in a manner that has a strong negative impact on the overall experience of care (De Benedictis et al., 2011 cited by NICE, 2015)
A safe environment has an impact on how therapeutic and safe our service users, staff and visitors feel; service users and staff experience can be negatively impacted if the environment is perceived to be unsafe.
Evidence tells us that challenging behaviours, such as aggression and violence, are relatively common in mental health settings, with potential serious consequences that can negatively affect not only the health and safety of staff, service users and carers, but can impact on the recovery of service users (NICE Guideline 10, 2015; Mental Health Act Code of Practice, 2015).
The Trust is therefore committed to safe clinical environments for all staff, service users and visitors and has committed resources and engaged in evidence-based based interventions to tackle this issue.
Dedicated Specialist
The Trust has employed a dedicated Violence Reduction Specialist/Reducing Restrictive Practice (RRP) Lead who started in post in February 2020. They are focusing specifically on reducing aggressive and violent incidents, supporting staff to understand conflicts and containment patterns, and is key to our reducing restrictive practice goals. They have been working with colleagues across the Trust to embed a culture
of identification and prevention, as well as promoting less restrictive environments with early feedback from staff being very positive.
Implementing SafeWards
This is an evidence-based, non-pharmacological clinical model known to reduce violence and aggression in mental health inpatient settings.
The SafeWard Model also places an emphasis of psychologically-informed communication, structured activity and service user participation in the day-to-day operation of wards. We have incorporated safe ward training as part of our induction and into various training programmes. The Trust worked with Bright Charity to provide staff training and support on implementation. We hope to continue to work with SafeWards experts over the coming 12 months to continue to embed the 10 identified interventions on all our wards.
Policy review, development and Implementation
COVID-19 restrictive intervention protocol
The Coronavirus pandemic brought an additional challenge across the globe but a more unique challenge for mental health inpatient health care providers. There were concerns that restrictive interventions will increase across care due to implementing government guidance for people in inpatient services.
We developed a COVID-19 restrictive intervention protocol that reflects a least restrictive approach and that also ensures that people’s human rights were not impacted on while in care and gives a balance that promotes the health and safety of staff and other people.
Other guidance
We have updated our seclusion policy in line with the current evidence-based and legal framework to promote the use of least restrictive principles and a human right-based approach that we hope would impact positively in the reduction of the use of seclusion and the service users experience when this intervention is needed.
We continue to monitor and review all use of restrictive intervention via our monthly Positive and Proactive Care Group.
Reducing Restrictive Practice (RRP) Training
There is a vast amount of available evidence that indicates a restrictive, overbearing and controlling culture in inpatient settings can itself increase service user frustration, gives rise to flash points, cause conflict and lead to more containment (Bowers et al., 2014).
Our RRP Lead is delivering a bespoke training to staff that is focused on a human rights-based approach that will support staff understanding and create an extensive awareness of the impact of a restrictive environment and culture, with the aim of reducing conflict and containment and so reducing restrictions and prompting a least restrictive approach.
External Post-Restraint Debrief
Nice Guidelines 10 recommends a post restraint incident debrief following the use of restrictive intervention. They also recommend that an independent debrief takes place within 72 hours. This is a unique intervention that is quite challenging to implement.
Our Trust have experts by experience who are working as volunteers, facilitating post restraint intervention debrief. This is a unique project that has received positive feedback across the country.
Prevention and Management of Violence and Aggression Training Standard
From April 2021, it will become compulsory for all NHS Trusts to ensure that the training staff receive conforms to the Restraint Reduction Networks (RRN) training standards. This
requirement will be made mandatory and regulated by the Care Quality Commission. Among other aspects, the standard is aimed at ensuring all training syllabuses across the country meet the same criteria, with the overall aim of focusing on reducing the use of restrictive interventions. C&I has engaged, and is currently working with, a provider who has been assessed and certified in line with the RRN standards via the BILD Association of Certified Training. As part of the standard, and in line with other best practice guidance, the Trust is now providing refresher/update training to staff, in line with Covid IPC guidance and use of appropriate PPE.
Implementing team safety huddles
Safety huddles continue to be embedded across our inpatient teams as one of our interventions in identifying, preventing and managing violence and aggression. The safety huddle is a short briefing that takes place on the wards during the course of a shift involving all staff; its focus is to quickly discuss potential escalating behaviour or risk that needs addressing and attend to it in order to prevent a potential conflict situation escalating. It is also used to feed back outcomes of interventions with service users and celebrate positive interactions during a shift.
Body Cam Pilot
The Trust is also planning a Body Cam Pilot as part of its violence and aggression reduction strategy. A research article on the feasibility of using body worn camera in an inpatient mental health setting carried out by Northamptonshire NHS Foundation Trust reported a reduction in complaints and incidents following the introduction of Body Cams on an inpatient ward. The project is led by the QI team with input from our RRP Lead, nurses, medical staff, OTs, psychologists and service users. The pilot will start with two inpatient acute wards in the autumn. We now have an established police liaison team across the boroughs of Camden and Islington and the officers visit both the St Pancras site and Highgate sites weekly. They are supporting staff and service users with any concerns or questions and helping with solving any major issues regarding incidents of violence and aggression.
Violence and Aggression Data Collection
All violence and aggression data is captured via our online incident reporting system DATIX. The Positive and Proactive Care Group, held monthly and chaired by Deputy Director of Nursing, reviews and analyses violence and aggression data regularly and discusses themes from incidents in monthly meetings with wider Trust team. All learning from incidents, suggestions on how to reduce incidents are discussed and solutions disseminated to staff on the wards and various departments via the Acute and Rehab Quality forums.
With services responding to the global pandemic, this response will be the focus over the coming six months. However, we need to continue to ensure that service users and staff are working together to keep environments safe, reduce the levels of violence and aggression and continue to identify and reduce restrictive interventions.
• Development of a Promoting Safe and
Therapeutic Services Strategy with targets including agreed % reductions in restraints, seclusion and restrictive interventions
• Decrease in staff assaults and increased support for staff when an assault has happened.
• To have an increase in staff and service user positive feedback on their experiences while an inpatient or working on the ward
• Embedding of the Relational Security model and using this to review incidents.
SUICIDE PREVENTION
Suicide prevention is a national and local priority. A Trust wide suicide prevention initiative and ambition plan is being developed. This will be rolled out during the next 12 months. Key to this, will be raising staff awareness and knowledge around risk and prevention. The learning package the Trust intends to use has been successfully used at another Trust and focuses on staff engagement with services users in co-production of safety plans.
Clinical Risk Assessment and Suicide Prevention Workstream Overview
A Task and Finish Group was established in 2018; a multi-disciplinary group with service user and carer participation, and representation from all clinical divisions has been in place since mid-2018 to review the Trust’s risk management model, training and documentation. This has been aligned to the Trust’s Suicide Prevention Strategy.
This workstream has been significantly delayed since February 2020 because of COVID-19. The Task and Finish Group reconvened in September 2020 with a focus on delivering this work in the likelihood of a continuing pandemic and recognising the pandemic’s impact on mental health need and service delivery. Overview was presented to the Quality and Safety Programme Board in January 2020 and endorsed by CCG partners.
The training schedule was developed by the Task and Finish Group with input from service users and carers, divisional representation and external partners. The Group recommended one day face-to-face core training for all clinical staff with additional training for managers. The pandemic prevents face-to-face training, and this will now be replaced with online / virtual training. develop online training from November 2020. The group has recommended the Zero Suicide Alliance Training is part of core training; this will be recommended at the Quality and Safety Programme Board in November 2020
Carenotes’ (Electronic Patient Record) review and development; the Task and Finish Group has undertaken a review of current documentation templates and agreed to:
• Introduce a risk chronology document (reflecting an evidence base that this assists service users and clinicians assess clinical risk)
• Introduce a safety plan that is co-produced whenever possible with service users and / or carers
• Align the safety plan with the revised care planning tool
• Initial development of these tools has commenced but has significantly delayed by the pandemic
The Suicide Prevention Strategy has been developed by the Task and Finish Group with input from service users, carers, divisional representation and partner agency. The draft requires further development and will be taken
