document title engagement and observation policy… · 2020. 10. 5. · document title engagement...

Document Title Engagement and Observation Policy

Reference Number CNTW(C)19

Lead Officer Gary O’Hare - Executive Director of Nursing and Chief

Operating Officer

Author(s) (name and designation)

Vida Morris – Locality Group Nurse Director

Ratified by Business Delivery Group

Date ratified October 2020

Implementation Date October 2020

Date of full implementation

January 2021

Review Date October 2023

Version number V05

Review and Amendment

Log

Version Type of change

Date Description of change

This policy supersedes the following policy which must now be destroyed:

Document Number Title

CNTW(C)19 – V04.7 Engagement and Observation Policy

Engagement and Observation Policy

Section Contents Page No.

Purpose 1

2 Duties and Responsibilities 2

3 Principles 5

4.1

4.2

4.2.1

4.3

4.4

4.5

Categories of Engagement and Observation:

General Engagement and Observation

Intermittent Engagement and Observation

Within Eyesight Engagement and Observation

Within Arms-Length Engagement and Observation

Engagement and Observations at Night and Sleep Well

6

6

7

8

9

10

5 When should Observation Levels be set 13

6 Who should set the Levels of Observation and what should be considered?

13

7 Reviewing Levels of Observation 14

8 Communication and Engagement 16

9 Record Keeping 17

10 Who should carry out Engagement/Observations 18

11 Carrying out Engagement and Observation 19

12 Identification of Stakeholders 21

13 Equality Impact Assessment 21

14 Training 21

15 Implementation 22

16 Monitoring Compliance and Effectiveness – see appendix C

22

17 Standard/Key Performance Indicators 22

18 Fair Blame 23

19 Policy Leaflets for Engagement/Observation 23

20 Fraud, Bribery and Corruption 23

21 Associated Documentation 23

22 References 23

Standard Appendices – attached to Policy

A Equality Analysis Screening Tool 25

B Training Checklist and Training Needs Analysis 27

C Audit Monitoring Tool 29

D Policy Notification Record Sheet - click here

Appendices hyperlinked and listed separate to Policy

Appendix No: Description

1 Engagement and Observation Record

2 Leaflet – What does observation mean to me?- under development

3 Engagement and Observation Competency Assessment

4 Engagement and Observation Decision Tree

5 Role of Allocated Nurse/professional

6 Sleep well protocol

7 CNTW(C)19 Engagement and Observation Training Presentation September 2020

Practice Guidance Notes – listed separate to Policy

Appendix No: Description

EOP-PGN-01

Children, Young People and Specialist Service, Beadnell Mother and Baby Unit

EOP-PGN-02 Nurse Call System

https://www.ntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(C)19

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW (C)19 – Engagement and Observation Policy V05-Oct 2020

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1. Purpose 1.1 The purpose of this Policy is to ensure that all inpatients’ level of engagement

and observation within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust / CNTW) are allocated appropriate to their needs. The clinical risk assessment is the basis for determining levels of engagement and observation and applies to both informal and detained patients.

1.2 The Policy provides a framework for all inpatients in accordance with their

assessed level of risk and identified needs; the aim being to ensure a consistent and effective approach to patient engagement, observation and support within inpatient services across the Trust.

1.3 This Policy is based upon recommendations from National Institute for Health

and Clinical Excellence NICE Guideline 10 Violence and Aggression: Short term management in Mental Health, Health and community settings (2015), NICE Guideline 25 ‘the short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments’ and the Mental Health Act Code of Practice (2015) and is intended to address the mental health needs of patients who are considered to be vulnerable. This may include risk of suicide, self-harm, harm from or to others; risk associated with physical frailty or physical deterioration, increased risk of falls and sexual disinhibition. The Trust is committed to providing a safe, sound and supportive environment to all patients, carers, visitors and staff. It is recognised that patients may have changing clinical, emotional, behavioural and social needs and may require varying degrees of support, including supportive engagement and observation and a higher level of engagement.

1.4 This Policy sets out the process and procedures for guiding practitioners in

making decisions to ensure a safe and therapeutic environment, to facilitate the assessment and management of an in-patient’s level of engagement and observation, and the rationale for supporting those decisions.

1.5 Positive therapeutic and good engagement and observation can protect the

safety of patients who would be at risk of harm and should never be substituted by containment through the locking of doors in clinical environments. Therapeutic engagement and observation should always be carried out in the least restrictive environment. For more information see CNTW(C)03 – Leave, absent without leave and missing persons Policy, practice guidance note LP-PGN-02 - Entry and Exit from Wards and CNTW(C)10 - Seclusion Policy. Restraint Reduction Policy CNTW(C)16, Positive & Compassionate Management of Self-Harm Policy ( Inpatient settings) CNTW(C) 14

1.5 In addition, the Policy sets out the duties and responsibilities of all Trust and

agency staff in relation to engagement and observation. It is imperative that this policy is read in conjunction with the current safety policies and procedures.

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2 Duties and Responsibilities 2.1 Chief Executive 2.1.2 The Chief Executive is responsible for ensuring that:-

An appropriate and adequate infrastructure exists to support the engagement and observation of patient

2.2 Board of Directors

2.2.1 The Board of Directors is accountable for ensuring that:-

The engagement and observation policy is in place and current and that it is reviewed regularly including following incidents and near misses

The appropriate level of support is provided, including guidance or training for employees, patients and agency staff, in order to meet the needs of this policy and statutory legislative requirement

2.3 Executive Director of Nursing and Chief Operating Officer 2.3.1 The Executive Director of Nursing and Chief Operating Officer is responsible

for:-

The strategic and operational management of the engagement and observation of patients within the Trust. This includes ensuring that a robust policy is developed to ensure appropriate levels of engagement and observation are in place and that monitoring systems are identified to ensure the effectiveness of practice

2.4 Group Directors (North, Central and South Locality Groups) 2.4.1 Group Directors are responsible for ensuring that:-

The engagement and observation policy’s requirements are operationally appropriate

The engagement and observation policy’s requirements are implemented in practice via a robust dissemination process

There is a system in place that ensures all staff receive and have access to this policy

A record is kept that each staff member has seen and understood this policy

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2.5 Managers 2.5.1 Managers have a responsibility to:

Ensure that all staff are made aware of policies and receive appropriate training in their application

Ensure that policies are implemented and evaluated appropriately

Ensure that periods of observation are viewed as opportunities for therapeutic engagement and relationship building

Identify/manage and deploy resources to meet service requirements and changing clinical needs

2.6 Nurse in Charge 2.6.1 The nurse in charge of an inpatient area is responsible for ensuring within their

sphere of responsibility that staff are identified who are best placed to carry out supportive observations and under what circumstances.

All staff have been assessed against the relevant level of competency to carry out supportive engagement and observations (Appendix 3)

This policy is implemented and all documentation completed- this will be monitored via audit.

They will take action with individual staff where necessary when the policy is not being adhered to

Their ward has appropriate resources to carry out supportive observations

They will ensure that Associate Directors and Clinical Managers are briefed on any incidents occurring during working hours in relation to the implementation of this policy and in accordance with the Trust’s CNTW(O)05 – Incident Policy

They will ensure that the Point of Contact is briefed on any incidents occurring out of hours in relation to the implementation of this policy and in accordance with the Trust’s CNTW(O)05 – Incident Policy

2.7 Registered Professionals 2.7.1 Registered professionals have a responsibility to:-

Ensure that periods of Engagement and observation are viewed as opportunities for therapeutic engagement and relationship building

Complete engagement and observation care plans for their named patients, involving the patient wherever possible and other people including family/carers, and for other patients in their care as the need arises

http://nww1.ntw.nhs.uk/services/?id=6016&p=5539&sp=5545

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Discuss with each patient of the level of engagement and observation they have been allocated and the reasons for this using appropriate means of communication recognising that not everyone is the same

Review any patients level of observation based on clinical need/risk assessment (increasing or decreasing observations where clinically indicated) involving the patient and carers (with consent) where applicable and appropriate. Ensure that the engagement and observation care plan, wherever possible, is co-produced with the patient and is implemented and engagement and observations recorded in line with this policy

Review the engagement and observation care plan on a regular basis as specified within the review time frames in the plan

Identify, manage and deploy resources (with guidance from other senior staff or the Point of Contact/Night Coordinator if required). This may include additional staff or a review of the skill mix of staff required.

This includes being accountable for the decision to delegate engagement and observation to a non-registered member of staff or student in their third year of training, and for ensuring they are sufficiently knowledgeable and competent to undertake this role

Third year students may only undertake engagement and observation following an assessment of their competence by their mentor, co-mentor or Nurse in Charge

2.8 Non-registered staff 2.8.1 Non-registered staff have a responsibility to:-

Ensure that periods of Engagement and observation are viewed as opportunities for therapeutic engagement and relationship building

Be familiar with and implement the engagement and observation care plan for each individual in their care

Complete documentation contemporaneously in preparation for the validation discussion with the Nurse in Charge for that span of duty

Report any relevant information to assist in the effective review of patients’ levels of observation

2.8.2 Multidisciplinary Team ( MDT)

The MDT has a responsibility to understand their role in initiating and reviewing supportive observations. They must balance the potentially distressing effect on the patient of observations, particularly if these are proposed for many hours or days, against the identified risk of self-injury or

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behavioural disturbance. Levels of observation and risk should be regularly reviewed by the MDT and a record made of decisions agreed in relation to increasing or decreasing the observation. The MDT must discuss and develop a plan of how engagement and observations can be undertaken in a way which minimises the likelihood of patients perceiving the intervention to be coercive and how it can be carried out in a way that respects the patient’s privacy and dignity as far as practicable and minimise any distress.

When enhanced observations are used for longer than 14 days, the MDT should use the skills of the entire team to support the patient’s recovery and well-being.

2.8.3 All clinical staff have a responsibility to familiarise themselves with the

engagement and observation policy and act in accordance with the stated requirements.

3. Principles 3.1 Restriction of Liberty

The least intrusive level of observation that is appropriate for the situation should always be adopted so that due sensitivity is given to the patient’s privacy and dignity whilst maintaining the safety of those around them. It is recognised at times MDT’s will adopt harm minimisation and positive risk taking approaches. Where these approaches are used, the clinical strategies should be clearly documented in the patients care plan and clinical notes as agreed by the MDT. This should be clearly communicated to all staff working with the patient. All decisions about the specific levels of observation should take into account

The patient’s mental disorder

Any prescribed medications and their effects

The current assessment of risk should include the patient’s ability to perceive potential risk

The views of the patient and relevant family/friend with agreed consent.

3.2 Human Rights Issues 3.2.1 The European Convention on Human Rights (ECHR) has been enshrined in the

United Kingdom law since 2000. The provisions indicate that everyone has the right to respect for his/her private life (Article 8). No patients should therefore be subject to unnecessarily intrusive observations in a way that would breech this right. In order for this policy to comply with the law observations must be justified; the ECHR permits breaches of Article 8 that are necessary for one or more of the following reasons:

The interests of national security, public safety or the economic wellbeing of the country; or

The protection of disorder or crime; or

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The protection of health or morals; or

The protection of the rights or freedoms of others

Proportionate: even if the use of observations is justified, it will only be lawful if it goes further than is reasonably necessary in each individual case to achieve the relevant objectives. When operating this policy clinicians will need to make sure that the use of observations remains ‘proportionate’ and that it is no more intrusive or continues longer than is required by the circumstances.

4 Categories of Engagement and Observation 4.1 The Trust has adopted the terminology as outlined in NICE Guideline 25 (2005):

‘the short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments’. This policy also supports compliance with the Care Quality Commission’s five domains.

General Engagement and Observation

Intermittent Engagement and Observation

Within Eyesight Engagement and Observation

Within Arm’s Length Engagement and Observation

For levels of observation greater than general a specific engagement and observation care plan is required. For patients on general engagement and observations this can be included as part of the mental health and treatment care plan.

The least intrusive and restrictive level of observation that is appropriate to the

situation should always be adopted so that due sensitivity is given to a patient’s dignity and privacy whilst maintaining the safety of the patient and/or those around them.

4.2 General Engagement and Observation

This is the minimum level for all patients. It will therefore apply to the majority of patients who are considered to be at low risk of vulnerability, suicide, self-harm or harm of others

Throughout the span of duty there will be a number of opportunities for staff to be aware of the wellbeing and location of all patients on general observations and in particular during shift handovers, meal times and medication times

The member of staff undertaking the engagement and observation should be able to see clearly that the patient is breathing

The member of staff undertaking the engagement and observation should be able to see the patient’s head and ensure nothing is impeding the patient’s breathing

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If the member of staff undertaking the engagement and observation is not assured about the patient’s breathing they should enter the bedroom to ensure the patient is breathing

Consideration should be given to how an individual’s dignity could be maximised without compromising safety when individuals are in a state of undress, such as when using the toilet, bathing, showering, dressing, etc

At least once during a shift, on both day and night duty, the nurse in charge should ensure that time is set aside to review the mental and physical state of the patient and engage positively with them and this should be clearly documented in the progress notes. The level of observation should be appropriate to meet individual needs, however, if the clinical risk escalates use of increased observation should be considered

An evaluation of the patient’s moods and behaviours should be documented in the progress notes following this in accordance with this policy. This will facilitate effective handover

The location of all patients on day and night duty should be known to staff but not all patients need to be kept within eyesight, however at the commencement and end of each shift the Nurse in Charge should be aware of the location of each patient and briefly engage with them. This will also inform a robust handover process.

4.2.1 Intermittent Engagement and Observation

This level is appropriate for patients ‘potentially, but not immediately’, at risk of disturbed/violent behaviour, increased vulnerability, suicide, self-harm and may include those who have previously been at higher risk and have had their observation level reviewed by the Multi-Disciplinary Team and reduced

A specific engagement and observation care plan is required that details either the exact intervals at which the observations should be carried out or a specific number of times within a specified time frame that the patient should be observed. This care plan can include individual protective factors which may influence the level or frequency of observations

An appropriately trained staff member (who has been assessed as competent by a qualified member of staff) responsible for carrying out intermittent observations over the prescribed period will have an awareness of the patients whereabouts and safety at specified intervals. These intervals may range from every five minutes to a maximum of every thirty minutes

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For some patients in order to enhance safety intermittent observations should be carried out at varied intervals within a time frame. The varied intervals should be agreed between the Nurse in Charge and the members of staff completing the periods of observation during any shift

To ensure that positive engagement can take place, consideration needs to be given to the number of patients a staff member is allocated to observe at any one time. Consideration needs to be given by the Nurse in Charge to the number of staff required for the physical environment and how positively this lends itself to patient engagement and observation


Leave outside of the ward area should be considered in relation to the Trust’s CNTW(C)03 – Leave, absent without leave and missing patient policy, however responsibility for engagement and observation of the patient remains with a member of Trust staff at all times

4.3 Within Eyesight Engagement and Observation 4.3.1 This level would usually be prescribed when the patient is assessed as

being a significant risk which would be reflected both in the risk assessment and individual care plan

A specific engagement and observation care plan is required. The staff member responsible for carrying out the prescribed observations over the period must document an hourly brief summary of the patient’s behaviour, mental state and general wellbeing

Issues of privacy and dignity, gender and environmental dangers should be discussed and incorporated in the care plan

The care plan must stipulate what the observing nurses are required to do to support the individual during these situations

Consideration should be given to whether the patient may only require ‘within eyesight observation’ at specific times or within specific environments, e.g. times using the bathroom and toilet within specific areas of the ward, at meal times, post visiting time or whilst in education

This should be based on clinical risk assessment and incorporated into the patient’s individual care plan

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The allocated nurse will provide one to one support throughout the whole period of prescribed ‘within eyesight observation’. On specified occasions more than one member of staff may be necessary to carry out this level of observation. The care plan will stipulate the number of nurses required

The responsibility for within eyesight observation should not be transferred to family members, carers and friends; unless in exceptional circumstances which have been agreed, risk assessed and care planned by the multi-disciplinary team.

Leave outside of the ward area should be considered in relation to the Trust’s CNTW(C)03 – Leave, absent without leave and missing patient policy, however the patient will be escorted at all times by a member of the Trust staff. It is important for patients to have access to daylight for a minimum of one hour per day.

If patients under 18 years of age are admitted to an adult environment they must be placed within eyesight observation or a higher level of observation on admission and for the duration of their stay (as per the Trust’s policy CNTW(C)08 - Young People requiring Emergency Admissions policy)

4.4 Within Arm’s Length Engagement and Observation

4.4.1 This level will be prescribed for patients at the highest levels of risk and thus they will need to be nursed in close proximity. Where the care plan identifies a risk in relation to potential violence and aggression consideration must be given to maintaining a safe distance in line with training.

The allocated nurse will provide one to one support throughout the whole period of prescribed ‘within arm’s length observation’. On specified occasions more than one member of staff may be necessary to carry out this level of observation. The engagement and observation care plan will stipulate the number of nurses required

Issues of privacy, dignity and the consideration of gender in allocating staff, and environmental risks need to be discussed and incorporated into the care plan. The staff member responsible for carrying out the prescribed engagement and observations over the period must document hourly, a brief summary of the patient behaviour and mental state


Consideration should be given to whether observations can be reduced to ‘within eyesight’ once the patient has retired to bed and


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is asleep. This should be fully discussed within the multi-disciplinary team and reflected in the engagement and observation care plan

Leave outside of the ward area should be considered, only in exceptional circumstances in accordance with the appropriate risk assessment in place, in relation to the Trust’s CNTW(C)03 - Leave, absent without leave and missing patient policy, however the patient will be escorted by a member or the appropriate number of Trust staff at all times. It is important for patients to have access to daylight for

a minimum of one hour per day. 4.5 Engagement and Observations at Night

The Mental Health Act Code of Practice, (2015) states that: “Staff must balance the potentially distressing effects on the patient of increased levels of observation, particularly if these levels of observation are proposed for many hours.

Night time can be a high risk period for some patients and nationally there have been concerns raised about in-patients wards failing to address this period adequately However, there is a balance to be sought with enabling patients to get a good night’s sleep. Therefore, each individual patient will be assessed for the level of observations to be carried out at night time and this will be recorded on the patients risk management plan/ Care Plan.

During night duty it is acknowledged that there are reduced natural opportunities to engage with patients. It is expected that each patient should be checked at a minimum of hourly intervals. (Any individual exceptions to hourly intervals must be underpinned by a clear clinical rationale and fully discussed and supported by the Multi-Disciplinary Team. The exception must be based on a defensible risk assessment and have a resulting risk management plan in place. The risk management plan must be subject to regular review at timeframes specified in the plan)

It is acknowledged that there are reduced natural opportunities to engage within patents during the night and engagement and observation levels should be discussed in the evening handover between the staff on the late shift and the staff on the night shift communicating if the patient is part of sleep well and care plan in place.

4.5.2 What is Sleepwell?

Avoiding sleep disruption on the in-patient wards

Introduction

Normal sleep, both total hours and the timing of sleep, is vital for normal brain function and physical health. Sleep regulates mood, memory and metabolism. Sleep disturbance in hospital populations causes distress and worsens mental and physical health. It can also lead to aggression and behavioural disturbance.

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In addition, sleep disorders such as sleep apnoea are common in those with mental health problems and remain under diagnosed.

It is a CNTW initiative to promote a healthy sleep pattern for patients whilst they are in hospital. The aim is to provide at least six hours uninterrupted sleep for patients who have been screened and assessed as being suitable for this intervention. A pilot involving 7 in patient wards was carried out over a year and evaluated very positively by patients, carer’s and staff.

The initiative requires a change in culture and attitudes towards sleep at night on the inpatient wards. There are also some environmental changes that can enhance the patients sleep experience also. These may include;

Subdued lighting on the wards

Blackout curtains

Soft closing bins

Non ringing ward phones

The use of wireless headphones for service users

Information in welcome packs regarding Sleep Well

A range of activities during daylight hours for service users (where possible promoting outdoor activity in day light)

Education regarding good sleep

Education regarding diet and fluid intake promoting good sleep

Education regarding Hypnotics (Sleep promoting medication)

Correct footwear for staff to promote quietness on the wards

Relaxation techniques

Informative information promoting healthy sleep A change to the current Engagement and Observation policy that is pertinent to the wards who are undertaking the sleepwell initiative.

A necessary level of engagement and observation is part of good nursing care to effectively treat patients and reduce the risk of harm to the patient and staff. This should be tailored to the needs of the patient based on a current risk assessment. The World Health Organisation have recommended standards to avoid noise levels on hospital wards above 35 decibels at night (the level of quiet speech).

The Sleep Well initiative requires that there is a change to this policy for patients who are deemed suitable. This would enable a healthy sleep pattern and avoid hourly observations at night as routine on Sleep well wards.

The default position for all staff is that if they have any concern whatsoever during the night for the patient then it is their duty to enter the room to ensure the patients safety etc.

4.5.2 How Do Wards Join The Sleep well Initiative?

There is a strict protocol that must be adhered to stringently before any ward commences Sleep well. Please refer to Appendix 6. The Ward is required to gain approval and backing from their Trust Group and the whole MDT first and then they apply via email to register the ward with the Talk 1st Team.

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4.5.3 What Happens when the ward is registered to commence Sleep well.

Once the Ward Team has been registered they will have access to the Sleep well Product that contains, all back ground information, the assessment tools, documentation, and other related material via the Trust Nurse Share point site.

4.5.4 How are Patients selected for their suitability for Sleep well?

This involves assessments to establish a sleep care plan within 72 hours of admission. The STOPBANG assessment which screens for Obstructive Sleep Apnoea and Restless Legs Questionnaire are utilised. This would then determine whether the patient is suitable to commence Sleep well or not.

For appropriate patients, a protected sleep period of 6 hours (midnight to 6am) would be documented and adhered to. To assess the impact of this change in nursing practice, there would be 3 monthly reviews of prescribed hypnotic medication, frequency of violence and challenging behaviours on the ward and patient self-report of sleep quality. This would be delivered alongside education about sleep and sleep disorders to nursing staff within the wards. There would also be a review of the available support and self-help literature within the trust regarding sleep and sleep disorders.

4.5.5 Patients who are assessed as not being suitable for Sleep well.

For Patients who may be excluded from joining Sleep well due to the results of their STOPBANG assessment they may be referred to a Sleep Clinic via the Trust or a referral would be made via their GP.

It is acknowledged that there are reduced natural opportunities to engage within patents during the night and engagement and observation levels should be discussed in the evening handover between the staff on the late shift and the staff on the night shift. Night staff carrying out observations should be able to satisfy themselves that they are able to observe the patient to determine their safety and well-being in relation to the level of observation appropriate to their needs and care plan.

Patients, and where appropriate family, will be informed around what level of observation they are on at night and what that involves.

The member of staff undertaking the engagement and observation at night and at any time the patient is sleeping, should be able to:

Observe the patient in the room

See clearly that the patient is safe e.g. Not fallen or self-harmed

See clearly that the patient is breathing normally

See the patients head and ensure nothing is impeding their breathing

If the staff member is not assured about the patient’s safety or breathing they should assess the situation and either enter the room or call for assistance from a colleague and enter together if there are any concerns about the person’s mental state or physical wellbeing.

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NOTE : Sleepwell is currently not supported in Children and Young Peoples Services therefore the requirement will be to undertake observations as described in previous sections and a minimum of hourly at night.

Governance

The progress of the ward implementing Sleepwell would be monitored via the Positive and Safe Team via the talk 1st Cohort reviews on a quarterly basis.

5. Process for prescription of supportive observations 5.1.1 When Should Observation Levels be set? The decision to introduce supportive observations will take place at a different

times throughout a patients stay in hospital and will be based on an appropriate risk assessment at that point in time and the rationale should always be clearly documented in the clinical records and care plan.

Assessing levels of observation is an integral part of the admission process,

therefore all patients should be allocated a level of observation as soon as they arrive on the ward, this may in the first instance be by registered nursing staff or mental health practitioner and where possible in conjunction with a member of the medical staff. Following a thorough risk assessment by the medical and nursing team on the ward the level of observation should be agreed, the rationale documented and care plan formulated. The record of observation (see Appendix 1) must also be completed with full details of the rationale and risks why the observations are necessary.

6. Who/when should set the Levels of Engagement and Observation and

what should be considered? 6.1 The prescribing of observation levels should, wherever possible, be the result

of an assessment by the Multi-Disciplinary Team and where appropriate the patient/carer/family should be included in this discussion. Nursing staff may need to initiate a level of observation above general level on admission or following a rapid change in the patient’s clinical presentation before discussion with the wider Multi-Disciplinary Team and/or medical staff can take place.

6.2 All decisions about the specific level of observation In line with NICE Guideline

25 (2005), observation above a general level should be considered if any of the following are present:

History of previous suicide attempts, self-harm or attacks on others

Hallucinations, particularly voices suggesting harm to self or others

Paranoid ideas where the patient believes that other people pose a threat

Thoughts or ideas that the patient has about harming themselves or others

Vulnerability of harm from others

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Self-control is reduced

Past or current problems with drugs or alcohol

Recent loss

Poor adherence to medication programmes or non-compliance with medication

Programmes.

Marked changes in behaviour, emotional state or medication

Known risk indicators including escape, absconding and going missing from the ward,

risk/vulnerability, sexual behaviour

Patients on adult wards, under age of 18 must be placed within eyesight observation

This policy should also be considered if any of the following risks are indicated:-

Deterioration or exacerbation of physical health conditions

Cognitive impairment

Risk of falls

Any prescribed medications and their effects and/or illicit substances and alcohol

The views of the patient and carer as far as possible

The timing of the review 6.3 Consideration should be given to periods of identified increased risk such as

evenings and night; nursing handover periods, meal times, post visiting times; following a reduction in the levels of engagement and observation; improvement in mood, etc and document how specified actions can be taken. Where appropriate the patient/carer/family should be included in this discussion

6.5 A patient on observation levels greater than general should NOT be

automatically excluded from off ward therapy, education, faith/religious or leisure activities and should be reviewed as part of the risk assessment and reflected in the care plan.

7. Reviewing Levels of Engagement and Observation 7.1 Throughout a patient’s stay, the level of risk will be determined, and the

appropriate observation levels prescribed accordingly. Any member of the Multi-Disciplinary Team can raise the need for further consideration of a

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patient’s observation level and ask for a review of the necessary level of observation of a patient at any time.

7.2 Observation levels should be reviewed at the Multi-Disciplinary Team Meeting

in conjunction with the Designated Responsible Clinician. In exceptional circumstances this can delegated to another doctor or multi professional approved clinician who knows the patient.

7.3 Where a patient is on a level of observation above general, the continued need

for this should be reviewed at a minimum of every 24 hours, or more frequently if required by the nurse in charge and designated responsible clinician or nominated deputy and documented in the clinical record. For services where medical staff are not readily available at weekends, a review can be undertaken by the nurse in charge. Under such circumstances this should be agreed in advance by the Multi-Disciplinary Team and recorded in the care plan.

7.4 Changes to a patient’s observation status must be informed by team members

who have knowledge of the patient in line with a previously agreed care plan, which is clearly documented and agreed by the patient’s designated responsible clinician and Multi-Disciplinary Team. A new risk assessment must be undertaken and documented with clear risk management plans in place within the care plan.

7.5 Any decision to increase levels of observation including night time or when

sleeping should be made by the Multi-Disciplinary Team and wherever possible include the patient, however, where necessary qualified nursing staff have the authority to increase the level of observation in response to urgent changes in need. The increase in the level of observation should be communicated to the patient, family and carers where appropriate and to the Multi-Disciplinary Team at the earliest opportunity.

7.6 Any decision to decrease the level of observation including night time or when

sleeping should be made by the Multi-Disciplinary Team and wherever possible include the patient. However, where necessary the following will have the authority to decrease the level of observations according to changes in presentation as agreed in the care plan:-

Either a minimum of 2 members of qualified nursing staff, 1 of which will be a Band 6 Nurse or above, who are familiar with the patient

Or a registered nurse and the doctor/ multi professional approved clinician who are familiar with the patient

7.7 At the time of any decrease, as soon as practicable thereafter, the other

members of the Multi- Disciplinary Team should be informed. 7.8 Whenever the level of observation has been reviewed a rationale should be

provided to the patient wherever possible, recorded in the patient’s notes by a member of the Multi-Disciplinary Team involved in the decision to review and the patient’s individualised care plan by the nurse in charge; whenever the level of observation changes, a new Engagement and Observation Record is

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created. The nurse in charge should ensure the rest of the care team are informed of the change in the level of observation.

7.9 For any level of observation where there is significant clinical disagreement,

particularly concerning a reduction of the level of engagement and observation, the level of engagement and observation must be left unchanged until this can be reviewed by the Multi-Disciplinary Team. A consensus of agreement must be reached explaining rationale and the outcome of the discussion must be documented in the patient record.

7.10 Whenever there is a change in a patient’s level of observation the rationale

underpinning the change must be carefully and comprehensively documented in relation to defensible decision making.

7.11 Where the Responsible Clinician feels that observations should not be reduced

without medical consultation this requirement should be clearly recorded in the clinical record and communicated verbally to all members of the MDT. If necessary, any out of hours concerns can be addressed through the on- call Consultant

7.12 Any extended continuous use of within eye sight or arm’s length observations

longer than 14 days should trigger a peer review with monthly reviews every month thereafter or until observation levels change.

8 Communication and Engagement 8.1 Every effort should be made to discuss, inform and explain to the patient about

the level of observation and any requirements to assist in implementation. With some patients it may be necessary to use a range of mechanisms to explain this. Patients should be offered the opportunity to talk to a member of the Multi-Disciplinary Team re any concerns or questions they have with regards to the level of observation. The clinical team should support and encourage patients to co-produce the engagement and observation care plan with a member of staff, this may also include family or carers as appropriate. The patient should also be offered a copy of their care plan detailing observations and this should also be communicated with the patient’s consent and approval to the nearest relative/carer/friend.

8.2 Levels of observation should be discussed and/or negotiated with the patient

and (whilst taking into consideration patient consent, confidentiality and capacity issues) their carer/family wherever possible. Staff must clearly explain the reasons for the level of observation. This will be based on a rigorous ongoing risk assessment, which is reactive to dynamic risk factors.

8.3 Engagement with a patient, including the observation, reporting and recording

of a patient’s mental state, wellbeing and behaviour is central to the care provided within an in-patient unit. Observation and skilled engagement enables staff to learn about patients in their care, to assess their needs, work collaboratively and facilitate the development of a therapeutic and meaningful relationship.

8.4 It is essential that when staff are involved in any level of engagement and

observation that they are fully engaged with the process. Feedback from

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patients through Trust surveys, questionnaires, comments and complaints show how much they value individual time with ward staff and how important it is to their progress and recovery when an inpatient.

8.5 The act of engaging with and observing patients should be more than ‘seeing’

them. Observations should be viewed as an opportunity for therapeutic engagement in which there should be some benefit for the patient. This benefit needs to outweigh the impact of observations on the patient’s privacy and dignity and the fact that some patients’ often see observations as intrusive, unhelpful and coercive.

8.6 Engagement should centre round the use of activity, discussion and distraction

processes, but recognition should also be made of the need for silence and as much privacy as is safely achievable. While the safety of the patient always comes first, the encouragement of communication, listening and conveying to the person that they are valued and cared for are important components of skilled nursing engagement and observation. Observing a patient who is deeply distressed is a skilled intervention and calls for empathy, engagement and readiness to act in the best interests of the patient.

8.7 Nursing staff, and in particular the nurse in charge/shift coordinator, ward

manager or deputy must be aware of the observation levels on the ward at all times. Observation status should be discussed during each ward handover and daily clinical review to ensure continuity of care.

9 Record Keeping 9.1 The observation levels prescribed must be recorded in such a way as to reflect

the Multi-Disciplinary Team discussion and rationale for the level of observation in the patient record. All patients must have an individualised engagement and observation care plan outlining their level of observation which, wherever possible, should be co-produced with the involvement of the patient.

9.2 The care plan should include:-

Level of observation and intervals at which the observation should be carried out; this may be at exact time intervals or irregular time intervals

The clinical rationale for observation, including identification of risk factors

Any particular requirements as outlined in this policy with regard to specific times or places

Stipulations of what clinical interventions, including engagement, are required in order to support the patient

Any advanced statements offered by patient/carer

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9.3 Any changes to the level of observation should be amended on the care plan/risk assessment and the patient advised accordingly. This should also be updated on patient status at a glance boards

The level of observation, including the risk behaviours and factors identified,

should also be recorded and signed, as indicated on the Observation Record (Appendix 1). Records of engagement and observation should always accurately reflect prescribed levels of observation.

9.5 Participating staff will make a brief summary of the patient’s behaviour, mental state, physical health and level of observation record sheet in accordance with the care plan.

9.6 Patients will be offered a copy of their care plan detailing engagement and observations, this should also be communicated with the patient’s approval to the nearest relative/carer/friend.

9.7 For all inpatients there should be, over a 24 hour period, a minimum of 3 documented summaries regarding the patient’s presentation and level of observation in the patient’s clinical record (minimum of 2 during the day and 1 at night).

9.8 Where more than one member of staff is on observations for example a patient is on eyesight or arms length observations with 2 staff both staff member’s names and signatures must be documented on the observation record.

10 Who should carry out Engagement and Observations? 10.1 The patient’s views and needs should be taken into account when allocating

staff to undertake engagement and observations (including factors such as ethnicity, sexual identity, age and gender and trauma informed practice including knowledge of past sexual/physical/mental trauma) it is the responsibility of the nurse in charge to ensure that engagement and observations are carried out according to the agreed level. The staff member responsible for carrying out within eyesight and within arm’s length observation will usually:-

Be a Registered Nurse, Non Registered Nurse, Allied Health Professional or third year student who has been assessed and deemed competent by a registered nurse, to carry out observations in accordance with this policy. The Competency Assessment Form (Appendix 3) must be completed for all staff (including bank/agency/student in all cases). Competency should be reassessed on an annual basis.

If the patient is being supported off the ward by other clinical staff than the ward staff then they will be responsible for the recording of the observations and provide a handover on the patients return to the ward, likewise the ward staff will provide an handover to the person taking the patient off the ward.

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11 Carrying out Engagement and Observation 11.1 Engagement and observation usually involves a number of nurses, with care

being handed over at intervals determined by the nurse in charge, wherever possible staff should not undertake continuous periods of observation above the general level for longer than 2 hours unless this is specifically identified within the care plan of the individual patient. Excellent communication amongst staff must be maintained.

At the beginning of each shift, the nurse in charge will allocate and record the engagement and observation for that span of duty taking into account each individual patient’s characteristics and circumstances (including factors such as ethnicity, sexual identity, age and gender). The nurse in charge shall ensure that all members of the ward team, who are involved in engagement and observations with a patient, understand the individualised engagement and observation care plans for each patient, in terms of who is being observed at what level, and why. During the handover each patient’s mental and physical state will also be reviewed, identifying potential risks and patients views towards the prescribed level of observation

Before taking over the patient’s engagement and observation, each nurse will have familiarised themselves with the patient’s individualised engagement and observation care plan, the type of engagement required, current risks and individual needs

At the point of handover between members of staff carrying out engagement and observation the patient should be involved, wherever possible, so that they are aware of who is continuing to work with and support them

11.2 The member of staff undertaking engagement and observation:

Should have been assessed and deemed by a registered nurse as being competent in carrying out engagement and observation in line with this policy

Should take an active role throughout the period of observation in engaging positively with the patient in line with their current care plan

Should maintain the patient’s privacy and dignity in line with the current care plan, acknowledging professional boundaries and the appropriate use of therapeutic touch. Consideration should be given to how an individual’s dignity could be maximised without compromising safety when individuals are in a state of undress, such as when using the toilet, bathing, showering, dressing, etc

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Should be appropriately briefed about the patient’s history, background, specific risk factors and particular needs which where possible have been identified by the patient/family/carer where appropriate.

Should be briefed about any specific risks, interventions and contingency plans should this patient require to be escorted outside of the ward environment in line with their current care plan

Should be familiar with the ward, the ward policy for emergency procedures and potential risk in the environment

Should be familiar with the Trust’s policy CNTW(C)03 – Leave, absent without leave and missing patient policy;

Should be approachable, listen to the patient, know when self-disclosure and the therapeutic use of silence are appropriate and be able to convey to the patient that they are valued

11.3 If the nominated staff member cannot continue the engagement and

observation for any reason, he/she will be responsible for notifying the nurse in charge, whilst maintaining the patient’s safety, who will ensure that another member of staff carries out the engagement and observation.

11.4 When engaging/observing with patients staff should be assessing/monitoring

specific issues noted within the care plan, other changes may include the following:-

General behaviour

Movement

Posture

Speech

Expression of ideas

Appearance

Orientation

Mental Health

Physical Health

Mood and attitude

Interaction with others

Reaction to medication

Level of consciousness

Cognitions

Immediate environment

11.5 These observations should be viewed as an excellent opportunity to undertake

therapeutic engagement and intervention in which there should be some benefit for the patient.

11.6 Staff should also aim to actively engage with the patient and enable them to be

as independent as possible. 11.7 Staff should also be aware of the other team members’ current duties/locations

and how to gain rapid access for assistance if required.


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11.8 Wherever possible staff should not undertake continuous periods of observation

above the general level for longer than 2 hours unless this is specifically identified within the care plan of the individual patient.

12. IDENTIFICATON OF STAKEHOLDERS 12.1 In line with CNTW(O)01 – Development and Management of Procedural

Documents, this policy was circulated for Trust wide consultation to the following:

Corporate Decision Team

Business Delivery Group

North Locality Care Group

North Cumbria Locality Care Group

Central Locality Care Group

South Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

Health Safety Security and Resilience

13. EQUALITY IMPACT ASSESSMENT 13.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

14. TRAINING 14.1 Observing patients at risk is a highly skilled activity. The Trust will ensure that

all staff (qualified, unqualified, other clinical staff, bank and agency staff) have access to appropriate levels of training. It is the responsibility of each Care Group Director to ensure staff attend. Levels of training are identified in the training needs analysis (see Appendix B) and are included within the Essential Training Guide which forms part of CNTW(HR)09 - Staff Appraisal Policy and Practice Guidance Notes. Essential components of adequate training include:


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Risk assessment

Developmental Issues and their influence on risk assessment

Management and engagement of patients at risk of harming self and others

Service specific issues;

Factors associated with self-harm/harm to others

Indications for observation

Levels of observation

Attitudes to engagement and observation

Therapeutic opportunities in observation

Roles and responsibilities of the multi-disciplinary team in relation to observation

Making the environment safe

Recording engagement and observation

The use of reviews and audit (SNMAC, 1999)

14.2 Levels of training are identified in the training needs analysis and are included within Appendix B Training Needs Analysis

15. IMPLEMENTATION 15.1 This will be monitored by the North Cumbria, North, Central and South Care

Groups. This policy will be implemented upon ratification and full implementation upon completion of training for clinical staff.

16. MONITORING COMPLIANCE AND EFFECTIVENESS – See Appendix C 16.1 Audit of engagement and observation should be facilitated at ward level. A

minimum data set would include:

Reason for observation

Specific level, or levels of observation

Length of time observed

Any untoward incidents

16.2 Random samples of engagement and observation records should be examined

by managers and monitored for compliance to the policy. 17. STANDARD/KEY PERFORMANCE INDICATORS 17.1 The Care Quality Commission require assurance and information relating to the

observation and engagement policy within the Trust. Information may also be considered by the NHS litigation authority. Key performance indicators within service specifications maybe outlined relating to the observation and

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engagement policy, it is therefore required that records/procedures are maintained as specified within this policy.

18. FAIR BLAME 18.1 The Trust is committed to developing an open learning culture. It has endorsed

the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

19. POLICY LEAFLETS FOR OBSERVATON 19.1 Any information given to patients needs to be in an accessible format, accurate

and ‘branded’ correctly. The Trust follows the process around production of this information as outlined in the Trust’s policy, CNTW(O)03 Accessible Information for Patients, Carers and Public.

19.2 Patient Information leaflets will be reviewed every 3 years with the exception to those documents which are reviewed on an annual basis. However, should there be any changes in legislation or practice; all documents will be reviewed immediately irrespective of review date. 20. FRAUD, BRIBERY AND CORRUPTION 20.1 In accordance with the Trust’s policy, CNTW(O)23, Fraud, Bribery and

Corruption, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

21. ASSOCIATED DOCUMENTATION

CNTW(O)01 Development and Management of Procedural Documents Policy

CNTW(O)05 Incident Policy and practice guidance notes

CNTW(C)03 Leave, absent without leave and missing patient Policy

CNTW(C)08 Young people requiring admission to hospital policy

CNTW(C)10 Seclusion Policy

CNTW(C)11 Search Policy

CNTW(C)16 Positive and Safe, Physical Management of Violence and Aggression Policy

CNTW(C)48 Care Coordination/Care Programme Approach for Children and Young People Specialist Service Policy

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CNTW(HR)09 Staff Appraisal Policy and Practice Guidance Notes 22. REFERENCES

HMSO 1999 Mental Health Act, Code of Practice

NICE May 2015 Violence and Aggression: The Short Term Management in Mental Health, health and community settings.

NIMHE National Institute for Mental Health in England

Preventing Suicide: A toolkit for mental health services 1. Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473-482. 2. Tembo AC, Parker V. Factors that impact on sleep in intensive care patients. Intensive Crit Care Nurs 2009;25(6):314-322. 3. Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012 Sep;73(9):e1160-7. 4. Anderson KN, Waton T et al. Sleep disordered breathing in community psychiatric patients. Eur. J. Psychiat. 2012; 26(2):86-95. 5. Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep. 2015 Mar;17(3):554. 6. Appleby L. National confidential enquiry into suicide and homicide by people with mental illness. H.Q.I. partnership. The University of Manchester. [Internet]. 2015 [cited 2016 Feb 7]. Available from: http://www.bbmh.manchester.ac.uk/cmhs/centreforsuicideprevention/nci/reports/Annualreport2014.pdf

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Christopher Rowlands October 2020 October 2023 Trust wide

Policy to be analysed Is this policy new or existing?

CNTW(C)19 – Engagement and Observation Policy- V05

Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The aim of this policy is to ensure a consistent and effective approach to patient observation, engagement and support within inpatient services across the Trust. This policy is based upon recommendations from National Institute for Health and Clinical Excellence (NICE) Guideline 25 (2005) and is intended to address the mental health needs of patients who are considered to be vulnerable or at risk of suicide, self harm or harm to others. The Trust is committed to providing a safe, sound and supportive environment to all patients, visitors and staff. It is recognised that patients may have changing clinical, behavioural and social needs and may require varying degrees of support (including observation) to be offered during these phases

Who will be affected? e.g. staff, service users, carers, wider public etc

Clinical Staff, service users in inpatient environments, relatives and carers

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Dignity, privacy and respect issues for patients being observed within eyesight and arms length. For patients with a learning disability easy-read material explaining the reasons for the level of observation should be prepared. Advocates will need to be available. Material will need to be prepared in a variety of accessible formats for people who have visual impairments. Deaf people will need an interpreter present throughout the observation period for the clinician to effectively observe and engage therapeutically.

Sex Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Race Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Will be a need for presence of translated material and or interpreter, need for advocacy to negotiate level of observation

Age Dignity, privacy and respect issues for patients being observed within eyesight and arms length.

The suitability of presence on an adult ward for children and young people.

Accessible information will need to be produced to meet the needs of those with dementia.

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There may be a need for advocacy.

Gender reassignment

(including transgender)

Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Sexual orientation. Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Religion or belief Dignity, privacy and respect issues for patients being observed within eyesight and arms length – especially an issue at prayer time. What will be a suitable observation time for patient during Ramadan? – clearly not meal time

Marriage and Civil Partnership

N/A

Pregnancy and maternity

Dignity, privacy and respect issues for patients being observed within eyesight and arms length

Carers N/A

Other identified groups N/A

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard policy process

Pilot to be undertaken in order to gather evidence and test the new policy

How have you engaged stakeholders in testing the policy or programme proposals?

Full Trustwide consultation undertaken

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Advance equality of opportunity

Promote good relations between groups

What is the overall impact?

Addressing the impact on equalities

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Chris Rowlands Date: October 2020

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Appendix B

Communication and Training Check List

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Change to existing policy.

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

Staff required to carry out patient engagement and observation should be aware of CNTW(C)19 Engagement and Observation policy including levels of observation issues relating to patient engagement and written records required.

Training will incorporate the changes as outlined in the policy

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Solutions etc.

Please identify the risks if training does not occur

Local standards and NICE Guidelines recommendations.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

All ward based clinical staff who are required to carry out patient engagement and observation, including staff (e.g. medical) involved in making decisions around observation levels. This is also relevant to bank staff, agency staff, and students in training who have been assessed as competent to carry out observations.

Is there a staff group that should be prioritised for this training / awareness?

Staff will be trained to safely carry out patient observation and complete relevant documentation

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning

Local Ward/Unit Induction

Newly Qualified Orientation Programme

Cascade

Raising staff awareness of the amended policy will also be carried out via the Chief Executives Bulletin and internal CAS alert/safety message as appropriate.

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Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Executive Director of Nursing and Chief Operating Officer

Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of training

Duration of

Training

Frequency of Training

Qualified nursing staff

Unqualified nursing staff

Medical staff

Allied health Professionals working with the inpatient wards

Student Nurses

Awareness of policy, documentation, roles and responsibilities, competencies, care plans.

1 hour Induction to inpatient wards

3 yearly

Administration

Ancillary

Technical, scientific and professional

Awareness of policy

1 hour 3 yearly

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Appendix C

Monitoring Tool Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)19 – Engagement and Observation Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1. Documentation relating to patient observation and engagement will adhere to the Trustwide Engagement and Observation Policy

Weekly review of documentation by Ward Manager

Findings to be taken to Supervision with Clinical Nurse Manager and Associate Director

Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Locality Care Group Quality and Performance

2. At Ward level competency records will be completed for all new staff – 3rd year nurisng students, and bank and agency staff working on the wards



Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Group Quality and Performance

3. Training records will be maintained of all staff who have attended Engagement and Observation policy awareness and training

Reviewed within JDR process by Ward Manager via the Dashboard

Locality Care Group Quality and Performance

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Continued …..

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where Results and Any Associate Action Plan Will Be Reported To, Implemented and Monitored; (this will usually be via the relevant Governance Group).

4. Patient observation records demonstrate clearly the level of observation prescribed, an individual care plan has been drawn up in line with record keeping standards and the observation has been completed as per policy



Any action plans developed will be monitored through the supervision process, or, if necessary, escalated to Locality Care Group Quality and Performance

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.