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Document Title Young People Requiring Admission to Hospital

Reference Number NTW(C)08

Lead Officer Medical Director

Author(s) (name and designation)

Mark Knowles – Directorate Manager

Ratified by Trust Policy Group

Date ratified February 2016

Implementation Date March 2016

Date of full implementation

June 2016

Review Date February 2019

Version number V04

Review and Amendment Log

Version Type of change

Date Description of change

V04 Review Feb 16 Reviewed documentation updated within Sections 1-8, 10, 12, 14-21 and 23

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

Reference Number Title

NTW(C)08 – V03.5 Young People Requiring Admission to Hospital Policy

Young People Requiring Admission to Hospital

Section Contents Page No.

1 Introduction 1

2 Background 2

3 Purpose 2

4 Procedures 3

5 Consent to Admission and Capacity 4

6 Designated Adult Wards 6

7 Admission 6

8 Reporting the admission of a young persons to an adult ward 7

9 Risk while accommodated on a designated adult ward 8

10 Care while accommodated on a designated adult ward 9

11 Education needs 10

12 Carers, Families and Peers 10

13 Advocacy 11

14 Review of care 11

15 Discharge 12

16 Liaison, advice and support when a young person is admitted to a designated adult ward 13

17 Training and practice development (designated adult ward) 13

18 Identification of Stakeholders 14

19 Definitions of terms used 15

20 Equality impact assessment 15

21 Implementation 15

22 Monitoring compliance and effectiveness 15

23 Standards/Key Performance Indicators 16

24 Fair Blame 16

25 Associated documentation 16

26 References 17

Standard Appendices listed within policy

A Equality Impact Assessment Tool 18

B Communication and Training check list and Needs Analysis 20

C Audit/Monitoring Tool 22

D Policy Notification Record Sheet - click here

Appendices – listed separate to Policy

Appendix No: Description Issue No:

Date issued

Review Date

Appendix 1 Chapter 19 MHA 1983 (2015) 1 Mar 16 Mar 19

Appendix 2 Emergency Out of Hours Pathway 1 Mar 16 Mar 19

http://nww1.ntw.nhs.uk/services/?id=2550&p=2780&sp=1

NTW (C) 08

Northumberland, Tyne and Wear NHS Foundation Trust NTW(C)08 – Young People Requiring Admission to Hospital – V04 – Issued Mar 16

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1. Introduction Particular issues arise in relation to children (under 16 years of age) and young

people (16 or 17 years old). In addition to the Mental Health Act, other relevant

legislation includes the Children’s Acts 1989 and 2004, the Mental Capacity Act

(MCA) 2005 and the Human Rights Act (HRA) 1998. Professionals, practitioners

and others responsible for the care of children and young people should be

familiar with this legislation

This policy must be read and implemented with the Mental Health Act 1983; Code

of practice 2015 with particular reference to Chapter 19 “Children and Young

People under the age of 18” – see Appendix 1

1.1 The vast majority of children and young people with severe, complex or persistent mental health problems never require hospital admission. Instead they can be safely and successfully assessed and treated in the community 1.2 Inpatient admission and treatment units are an essential part of the overall care

pathway; however children and young people should only be admitted to hospital if they cannot be safely supported, assessed or managed within a community setting due to levels of risk or complexity, or if they require a specialist assessment admission. Where appropriate, and depending on specific circumstances, consultation with carers may help, particularly in the case of children and young people.

1.3 As more adolescent units are offering emergency access, unplanned admissions have been steadily increasing. At the same time, the number of planned admissions has been steadily reducing. This trend is of concern since research shows that services are more effective if access to them is not dependent upon crisis situations. 1.4 In the last few years the numbers of young people being admitted to hospital in

England has been increasing. The reasons for this are complex, but causal factors appear to relate to lowering of thresholds for managing self-harm and suicidal behaviour in the community; direct access to emergency beds; and the impact of reductions in community health and local authority children’s services.

1.5 An over reliance on hospital admission to meet the needs of young people in

crisis has led to an increasing number of out of area referrals and admissions. The demand for local beds for young people deemed to require admission is increasingly in excess of local supply in many areas. Where local adolescent units are full young people are being admitted to other areas of the United Kingdom, (UK). This isolates them from their family and friends and makes visiting and involvement by parents and professionals difficult.

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1.6 Hospital admission may make some young people’s overall difficulties worse rather than better. This is due to the potential to disrupt personal, social, education and family functioning and to impede rather than assist recovery therefore hospital admissions should always be carefully considered and regarded as a major intervention in a young person’s life. Where hospital admission is necessary, the child or young person should be placed as near to their home as reasonably practicable, recognising that placement further away from home increases the separation between the child or young person and their family, carers, friends, community and school. Evidence of consideration of less restrictive options must be recorded with a clear rationale explaining why admission is the preferred option. 2. Background 2.1 This policy sets out the circumstances and criteria for the admission of children

and young people into a Northumberland, Tyne and Wear NHS Trust (the Trust/NTW) inpatient bed. It includes pathways for young people under the age of 18 years who have overriding or atypical needs and procedures for managing referrals when no bed is available in an NTW Children and Young People’s Service (CYPS) inpatient admission ward.

3 Purpose

3.1 The purpose of this policy is to ensure that the Trust provides an appropriate

response to requests for admissions of children and young people within the current legislation and government guidelines and that young people who need to be admitted in urgent or planned circumstances receive the highest standard of care and treatment during their admission to hospital.

3.2 The policy should define how NTW provides information to support:

Commissioning and providing sufficient safe and secure health-based places of safety, including for people under the age of 18

Ensuring that local agency boundaries are not an overriding constraint, and that there are arrangements to ensure children and young people can access a place of safety in their local area

3.3 In line with the code of practice a person less than 16 years is referred to as a ‘Child’ and a person between 16 years and 17 years is referred to as a ‘Young Person’.

3.3.1 This policy is intended for all multi professional/agency teams, managers and administration staff who are potentially involved in the process of admitting a young person into hospital. The policy does not cover admission procedures for medium secure and low secure CYPS wards.

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3.4 Whilst this policy and associated procedures provide guidance and a framework there are sometimes circumstances whereby the presentation of the young person and / or complexities associated with the individual case may influence decisions about the appropriate place for admission, which could require additional clinical discussion between agencies and professionals involved.

4 Procedures

4.1 Assessment and CYPS Inpatient Bed Status

4.1.1 Procedures will be in place to ensure that up to date information about the CYPS inpatient bed status is available and accessible to the CYPS Intensive Care and Treatment Services, the Ferndene Point of Contact (POC) and the On call CYPS /Learning Disability (LD) Specialist Registrar (SPR) or Consultant via the RiO bed status system and the national NHS England bed management website

4.1.2 All referrals for an urgent admission to the mental health and learning disability admission wards Redburn and Fraser coming from NTW Community CYPS, North Tyneside Children and Adult Mental Health Service (CAMHS) or NTW Working Age Adult Crisis Teams need to be discussed in the first instance with the local Intensive Care and Treatment Service (ICTS) or the On Call CYPS / LD SPR or Consultant outside of ICTS working hours who will assess, in collaboration with the referrer, whether or not an intensive community treatment package of care or alternative community based interventions can be provided which may prevent the need for admission to hospital.

4.1.3 Where an admission to Redburn or Fraser is deemed necessary this will be facilitated by the local ICTS or the On Call CYPS / LD SPR or Consultant (outside of ICTS working hours) in conjunction with the nurse in charge of the relevant ward. If there are no mental health beds available on Redburn then the referral should be diverted in the first instance to The Newberry Centre, Middlesbrough.

4.1.4 Referrals or requests for admission to Redburn or Fraser from areas where NTW do not provide ICTS will be directed straight to the On Call CYPS / LD SPR or Consultant for consideration.

4.1.5 In all cases the referrer must complete an NHS England access assessment request.

4.2 Admission Criteria and Appropriate Placement

4.2.1 Criteria for admission to Ferndene are:

Aged under 18 years

Requiring admission for assessment and/or treatment of mental health problems that cannot be safely supported, assessed or managed within a community setting

Behavioural emotional disorders of children and young people that fall within the definition of mental disorder

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4.2.2 Admission criteria for units within Ferndene are:

Fraser (open unit): young people with a mild LD and complex mental health or behavioural issues

Redburn (open unit and with attached Intensive Care Unit (ICU): young people with severe and complex mental health needs

4.2.3 If a young person is assessed as having “atypical” needs (e.g. a 17 year old

requiring admission with her baby to a Mother and Baby Unit), the referral will be directed to the appropriate facility.

4.2.4 If a young person is assessed as requiring a low secure environment then ICTS

or the On Call CYPS / LD SPR or Consultant (outside of ICTS working hours) will direct the referral to either the Westwood Unit in Middlesbrough (mental health low secure) or Stephenson at Ferndene (LD low secure).

4.2.5 All requests for admissions of children under 12 years will be directed to Riding

Ward at Ferndene.

4.2.6 All young people who might be at risk of admission to hospital who either have a diagnosed learning disability or autism/ASD need to be referred to their local CCGs who can then undertake a Care and Treatment Review prior to admission. Local clinicians should therefore be making the CCG aware of patients in this situation and be following the Care and Treatment Review policy adopted by CCGs and NHS England.

4.2.7 The planning of after-care needs to start as soon as the patient is admitted to hospital. Clinical commissioning groups (CCGs) and local authorities should take reasonable steps to identify appropriate after-care services for patients in good time for their eventual discharge from hospital.

4.3 Progressing referrals when no bed is available on Ferndene for a young

person from within the Trust’s catchment area

4.3.1 If there is no bed available on Ferndene or The Newberry Centre (mental health) and an urgent admission is required then ICTS will seek an out of area placement. Outside of ICTS hours the On Call CYPS / LD SPR or Consultant will provide advice to referrers about accessing out of area beds. Details of this process and relevant contacts are provided in (Appendix 1) of this policy.

4.3.2 If no age appropriate out of area bed can be found, ICTS or the On Call CYPS /

LD SPR or Consultant (outside of ICTS working hours) will discuss alternative strategies with the referrer. If there is absolutely no other option or the young person has ‘overriding’ needs, then the young person can be admitted to selected NTW adult wards (see section 6 Designated Adult Wards). When a young person under 18yrs is admitted to an adult admission ward the local ICTS will liaise with and support the designated ward accommodating the young person for the duration of the young person’s stay.

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5 Consent to Admission and Capacity

5.1 Before relying on the consent of a child or young person it is necessary to ascertain whether they can give valid consent. The test for assessing whether a child under 16 can give valid consent differs from that of a young person aged 16 or 17. The capacity of a young person aged 16 or 17 to consent is assessed in accordance with the Mental Capacity Act (MCA), while the test for children under 16 is determined by considering whether they are ‘Gillick competent’. Practitioners with expertise in working with children and young people should be consulted in relation to these assessments.

5.2 Practitioners should consider the following three questions which should be read

in conjunction with the paragraphs below:

has the child or young person been given the relevant information in an appropriate manner (such as age appropriate language)?

have all practicable steps been taken to help the child or young person make the decision? The kind of support that might help the decision-making will vary, depending on the child or young person’s circumstances. Examples include:

steps to help the child or young person feel at ease

ensuring that those with parental responsibility are available to support their child (if that is what the child or young person would like)

giving the child or young person time to absorb information at their own pace, and

considering whether the child or young person has any specific communication needs (and if so, adapting accordingly)

can the child or young person decide whether to consent, or not to consent, to the proposed intervention?

5.3 The MCA applies to people aged 16 or over, so young people must be assumed

to have capacity to make the decision about a proposed admission to hospital and/or treatment unless it is established that they lack capacity, as is the case with adults.

5.4 Section 2 of the MCA states that a person lacks capacity in relation to a matter if at the relevant time they are unable to make a decision for themselves in relation to the matter ‘because of an impairment of, or a disturbance in the functioning of, the mind or brain’. It does not matter whether the impairment is permanent or temporary. Section 3 of the MCA then states that a person is unable to make a decision if they are unable to:

understand the information relevant to the decision

retain that information

use or weigh that information as part of the decision-making process, or,

communicate their decision (whether by talking, sign language or any other means)

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5.4.1 These factors must be taken into account when planning the admission of a child

or young person.

5.5 From 1st January 2008, 16 and 17 year olds with capacity who do not consent to their informal admission to hospital for the treatment of mental disorder cannot be admitted to hospital for such treatment on the basis of consent from someone with parental responsibility for them. This change is brought in by section 43 of the Mental Health Act (MHA) 2015 which amends section 131 of the Mental Health Act 1983. The requirements of the Mental Capacity Act 2005 need to be taken into consideration.

5.6 This means that where a young person aged 16 or 17, who has the capacity to make a decision on their health care, decides that they do not want to consent to treatment for mental disorder, the young person cannot be admitted to hospital for that treatment unless they meet the conditions to be detained under the Mental Health Act 1983 (as amended 2015), even if a person with parental responsibility is prepared to consent.

5.7 It also means that where a young person aged 16 or 17, who has the capacity to make a decision on their health care, consents to being admitted to hospital for treatment of a mental disorder they should be treated as an informal patient in accordance with section 131 of the Mental Health Act 1983 (as amended 2015) even if a person with parental responsibility is refusing consent.

5.8 Guidance is given in the MHA 1983 (as amended by the MHA 2015) Code of Practice regarding the informal and formal admission and treatment of children to psychiatric hospitals.

5.9 The MHA 1983 Code of Practice (as amended 2015) must be available on all

wards within the Trust either in printed form or as an on-line resource. 6 Designated Adult Wards 6. 1 There are four NTW adult mental health and LD admission wards which are

designated to accept admissions of young people between 16 and 18 years in circumstances outlined in 4.2.3 those wards are:

Alnmouth, St Georges Park, Morpeth, Northumberland (Female)

Shoredrift, Hopewood Park, Ryhope, Sunderland (Male)

Rose Lodge (LD), Hebburn, South Tyneside (Mixed Gender)

Beckfield PICU, Hopewood Park, Sunderland (Mixed Gender)

6.2 Each unit will allocate a single room at the time of admission that will be used for the young person. 6.3 Appropriate resources such as age appropriate furnishings and leisure equipment will be obtained so as to be available as required (e.g. reading materials, age appropriate DVDs, electronic games).

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6.4 Prior to admission a risk assessment must be undertaken by the nurse in charge

of the adult ward to ascertain whether there are any patients on the ward who pose a particular risk towards the young person who may be admitted. The risk assessment should focus on current volatility and known history of violence or sexually inappropriate behaviour particularly when directed at minors.

7. Admission 7.1 Section 131A of the Mental Health Act says that children and young people

admitted to hospital for the treatment of mental disorder should be accommodated in an environment that is suitable for their age (subject to their needs). This duty applies to the admission of all under 18s, whether or not they are detained under the Mental Health Act and includes children and young people who are subject to a Community Treatment Order, who are recalled to hospital, or who agree to informal admission.

7.2 All quality standards and elements of care that apply to the admission of an adult will apply equally to the admission of people aged 16 to 18 yrs. For example, welcome packs, ward orientation, rights. However, all Care Coordination documentation must be completed on RIO using the CYPS version. This means that children and young people should have:

appropriate physical facilities

staff with the right training, skills and knowledge to understand and address their specific needs

a hospital routine that will allow their personal, social and educational development to continue as normally as possible, and

equal access to educational opportunities as their peers, in so far as that is consistent with their ability to make use of them, considering their mental state

7.3 Once a young person is admitted to an adult ward, on the next day the local

ICTS will attend the adult ward in order to begin the process of transfer to an age appropriate unit at the earliest opportunity. Consideration will be given to an out of area placement if there are still no beds available in the Trust CYPS inpatient service or the Newberry Centre at that time.

7.4 On the admission of a young person to an adult admission ward, there will be a

multi-disciplinary team meeting involving CYPS and the adult ward representatives in order to coordinate services. This will be held within 24 hours of admission or on the first available working day if admitted at the weekend.

8. Reporting the admission of a young person to an adult ward 8.1 Children under the age of 16 must not be admitted to adult wards as of

November 2008. All admissions of young people to adult wards (under 18 years of age) must now be reported as a Serious Untoward Incident within the Trust. The Care Quality Commission (CQC) must be informed if a young person is on an adult ward for more than 48 hours.

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8.2 The admitting adult ward will report the admission of a young person, in

accordance with the Trust’s procedure within NTW(O)05 – Incident Policy (including the management of serious untoward incidents) and practice guidance notes and procedures.

8.3 The Incident and Claims Department will collate data regarding the number of

young people admitted to adult wards and their length of stay, and will provide reports to the Quality and Performance Group and the Lead Doctor for Safeguarding Children on a quarterly basis.

8.4 The Mental Health Act Department will be informed with regards to any young

people who are detained under the Mental Health Act 1986 8.5 The admitting ward will inform the Trust Safeguarding Nurse of the admission. The Trust Safeguarding Team will then decide with the Clinical Team if there are Safeguarding issues to be considered. 8.6 If the young person is in full-time education, the admitting nurse should inform the School Health Advisor of the person’s admission as part of Working together to Safeguard Children (Department of Health (DOH) 1999).

“Working together to Safeguard Children, 2013” 8.7 If the young person is already known to a CYPS Team and has a Care

Coordinator the admitting ward will notify them. If the admission is out of hours a message will be left for the local CYPS Team and the Ferndene POC will be informed.

8.8 If the young person is not known to a CYPS Team and/or does not have a Care Coordinator the admitting ward will make an urgent referral to the relevant local CYPS Team, who will allocate a Care Coordinator the same day. If the admission is out of hours the admitting ward will leave a message for the CYPS Team who will allocate a Care Coordinator the next working day. 8.9 ICTS will notify the relevant CYPS clinicians and managers of the admission. 9. Risk while accommodated on a Designated Adult Ward 9.1 All clinical risk standards and elements of care that apply to the admission of an adult will apply equally to the admission of a young person to an adult ward. For example, collaboration, involvement of appropriate others and communication. 9.2 Clinical risk will be re-assessed on a daily basis, and the outcome of this assessment documented within the Trust risk documentation.

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9.3 Staff must be aware of the often difficult safe dosage limits of medication and use

of unlicensed medication for children and young people. If there is concern over such limits clarification may be sought by consulting the British National Formulary (BNF) for children, which is available online, and/or specialist expertise from Children and Young Peoples (CYPS) doctor. Pharmacy advice should be sought as standard for all prescribing for people aged 18 or under.

9.4 The child or young person will be placed on a minimum level of ‘within eyesight’

observation throughout their stay on the adult ward in accordance with the Trust’s NTW(C)19 – Observation Policy. In exceptional circumstances observation levels may be reviewed if this is thought to be detrimental to the care of the individual. Such decisions must always be made in the context of safeguarding children responsibilities of the organisations. There may be occasions when it is deemed appropriate to offer young people free time or leave from the ward. At these times an appropriate care plan should detail the level of observation required.

9.5 If deliberate harm to the child or young person is suspected or observed by staff, or reported to staff, then all safeguarding procedures must be followed. Harm may include emotional harm as well as physical injury, sexual assault or neglect. 10. Care while accommodated in a Designated Adult Ward 10.1 The child or young person must be allocated a single room, appropriate to gender, taking into account the vulnerability of the young person. 10.2 Designated wards will offer young people and their visitors a visiting room separated from other adult patients and their visitors. 10.3 Designated wards should offer discrete day areas where young people can be cared for away from adults if required. 10.4 Staff at Band 6 or above, working on designated wards, will complete relevant awareness raising in relation to the safe and therapeutic care of young people admitted to adult wards. These identified nurses will be responsible for disseminating information within their respective units. They will act as liaison nurses and a point of reference on the ward for any young person admitted to their units. 10.5 Liaison/link nurses will be responsible for ensuring the provision of up to date welcome packs for people aged 16 to 17. 10.6 The young person should be kept as fully informed as possible about their care and treatment, and their views and wishes ascertained and taken into account, having regard to their age and understanding. It is important to remember that the wishes of the young person may have an impact on the parents or other persons with parental responsibility. This potential impact must always be considered (MHA Code of Practice 31.4), (United Nation (UN) Convention on the Rights of the Child, 1989, Article 12)

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10.7 The needs of a child or young person are not the same as those of adults

therefore support and guidance will be available from the CYPS Intensive Care and Treatment Service in the relevant locality.

10.8 Any intervention in the life of a child or young person must be considered necessary by reason of their mental disorder, should be as least restrictive as possible and result in the least possible segregation from family, friends, community and school (MHA 1983, Code of Practice, section 31.4 as amended at 2015). 10.9 Safeguarding of children and young people matters will always be in mind when a young person is admitted to an adult ward. A Trust named professional for Safeguarding Children must be informed as soon as practicable in the event of such an admission.

10.10 Should any concerns relating to the safeguarding of children and young people arise staff should discuss their concerns with the review team and follow Trust and Local Authority agreed procedures.

11. Educational Needs 11.1 During admission to hospital the Local Education Authority is duty bound to make provision for a child or young person up to the statutory school leaving age of 16. If a child is still at school the ward must contact the School Health Advisor. 12. Carers, Families and Peers 12.1 Those with parental responsibility have a central role in relation to decisions about the admission and treatment of their child (see paragraphs. It is therefore essential that those proposing the admission and/or treatment identify who has parental responsibility. 12.2 If a child or young person is voluntarily accommodated by the local authority,

parents or others with parental responsibility have the same rights and responsibilities in relation to treatment as they would otherwise. Admission and/or treatment decisions should therefore be discussed with the parent or other person with parental responsibility who continues to have parental responsibility for the child.

12.3 Hospital managers should set up systems to ensure that directors of children’s services are notified of cases in which their duty to visit and consider the welfare of children and young people in hospital arises. 12.4 Local authorities should be alerted if the whereabouts of the person with parental responsibility is not known or if that person has not visited the child or young person for a significant period of time. When alerted to this situation the local authority should consider whether visits should be arranged.

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12.5 The involvement of the carers, families and peers of the child or young person must be actively encouraged, particularly if the young person resides within the family home. The carer should expect that mental health/learning disability staff will encourage the young person to allow their carer to be involved, unless that person has clearly expressed the wish to exclude them. Confidentiality should not be accepted as an excuse for not listening to carers. If there are concerns relating to family/carers being perpetrators of abuse, advice should be sought from the Trust’s Safeguarding Nurse. The Consent to Sharing Information policy should be taken into consideration. 12.6 Disagreements between carers and the person they care for happen from time to time. Staff should work towards involving carers as far as is practical. 12.7 Visiting siblings and family members should be encouraged unless the effects on the young person or siblings are considered detrimental. Contact with peers should also be supported. If contact is ‘in person’ account must be taken of children visiting mental health units within the Trust’s policy NTW(O)11 – Children Visiting. 12.8 There is no minimum age limit for detention in hospital under the Act. It may be used to detain children or young people who need to be admitted to hospital for assessment and/or treatment of their mental disorder, when they cannot be admitted and/or treatment on an informal basis and where the criteria for detention under the Act are met. 12.9 Where practitioners conclude that admission to hospital is not the appropriate course of action, consideration must be given to alternative means of care and support that will meet the needs of the child or young person. The appropriate action will usually be to refer the child or young person’s case to the relevant local authority’s children’s services, in accordance with local protocols for interagency working to safeguard and promote the welfare of children and young people. 12.10 In cases where admission to hospital under the Act is not appropriate but the child or young person has significant needs which mean that the level and type of intervention is likely to amount to a deprivation of liberty, their placement in secure accommodation under section 25 of the Children Act 1989 may be required. This will be a matter for the local authority children’s services to consider in the light of the provisions of section 25 of the Children Act 1989, and relevant Children Act 1989 guidance. Children who are not Gillick competent or young people who lack capacity whose needs are severe and long-term, and where deprivation of liberty is one necessary element of their education or care, may also be accommodated in other placements. 13. Advocacy 13.1 Young people, whether informally admitted or detained have a right to advocacy.

Staff must ensure that the child or young person is aware of the availability of advocacy and child help line numbers. An IMHA (Independent Mental Health Advocate) should be available as for all detained patients.

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14. Review of Care 14.1 If a young person has been admitted to a designated adult ward the young person should be reviewed by a member of the CYPS ICTS Team within 24 hours of admission to an adult ward. A member of the CYPS/ICTS Team must attend all reviews. 14.2 If a young person is admitted to a designated adult ward a full multi-disciplinary review performed jointly with the appropriate team (e.g. Children and Young People’s Services, EIP, Neuro), should be undertaken every 72 hours. A key consideration within the review will be whether transfer to a more age appropriate environment is possible. 14.3 Where possible, appropriate relatives, such as parents should be invited to reviews, with the young person’s permission. 14.4 The outcome of all reviews should be clearly recorded as per the Trust’s NTW(C)20 – Care Coordination and Care Programme Approach Policy. 14.5 Comments about the quality of care should be sought from young people as they are from all patient groups. Young people should be encouraged to give feedback to an advocate or a trusted team member on any aspect of their care that they wish to comment on at any point during their stay in hospital. 15 Discharge 15.1 The planning of after care needs to start as soon as admission is agreed. All

standards that apply to the safe and clinically effective discharge of adults from hospital equally apply to the discharge of young people.

15.2 Prior to discharge, a meeting will be held in order to coordinate various services and a follow-up appointment within 48 hours to be organised by the CYPS Team or other community team responsible for providing aftercare on discharge. If the client requests discharge over the weekend, the discharge has to be agreed by Child and Adolescent Psychiatrist on-call doctor at least at SpR (SpR4-6 or to Advanced Psychiatry Trainee) level and/or discussed with original CYPS Team Practitioner/or Early Intervention Psychosis (EIP) Team to ensure continuity.

15.3 If a discharge prescription is required for ongoing treatment the prescription must bear the age of the young person.

15.4 The child or young person will be discharged in accordance with Care Coordination procedures. The recommendations of the Laming Inquiry (2003) into the death of Victoria Climbié relating to discharge will be followed (applies to all discharges whether there are Child Protection concerns or not).

15.5 No child or young person about who there are safeguarding children concerns

will be discharged from hospital without the permission of the consultant/Multi- Disciplinary Team (MDT) and Local Authority Children’s Services in charge of the young person’s care during their inpatient stay and without the consultation of the practitioner accepting responsibility for post discharge care.

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15.6 No child or young person about who there are safeguarding children concerns will be discharged from hospital without a documented plan for future care of the child or young person. The plan must include follow up arrangements.

15.7 Transfer/ Discharge MDT planning meetings should commence on the day of admission or the closest working day to admission.

15.8 Face to face follow up by community team whether adult (e.g. EIP) or Children and Young People Services should be planned in advance and take place within 48 hours of discharge. 16 Liaison, Advice and Support when a young person is admitted to a Designated Adult Ward 16.1 The Ward Manager of an NTW designated adult ward is responsible for ensuring that qualified nurses on the ward, are equipped to support the admission of a 16 or 17 year old young person. Senior nurses have the following responsibilities within the designated adult ward:-

Band 7 Ward Manager – will ensure that staff are trained to the appropriate level (as outlined in section 17 below). The Ward Manager will be the key point of contact during a period of admission of a 16 / 17 year old to an adult designated ward

Band 6 Clinical Nurse Leads – will update their knowledge and skills in relation to the care and treatment of young people admitted to an adult designated ward through a combination of CYP specific training, experiential learning and resource information (as outlined in section 17 below). The Clinical Nurse Lead will also act as the young person’s link / liaison nurse with CYP services.

Band 5 Staff Nurses & Band 2 & 3 Nursing Assistants – will be made aware through a local cascade model of relevant information in relation to the admission of a young person to an adult designated ward (as outlined in section 17 below)

16.2 The Ward Manager and Clinical Nurse Leads within the designated adult wards will be responsible (in their role as liaison/link nurse) for cascading relevant information to the ward team, to ensure they are aware of the needs in relation to the admission of a young person. 16.3 Advice and support regarding the care of children should be sought initially

through the CYP Intensive Community Treatment Service, who will provide a key role in supporting designated adult wards during the period of a young person’s admission. ICTS will also provide a link function to the CYP inpatient service.

16.4 Out of hours advice and support can be obtained from the Ferndene or Alnwood POC via St Nicholas’ Hospital switchboard (0191 213 0151).

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17 Training and Practice Development (Designated adult wards) 17.1 The first line of support to the adult designated wards will be provided by local

CYPS ICTS teams. However, it is recognised that CYP specific training of staff in designated adult wards, may support the better care of young people admitted to their service.

17.2 All clinical staff working into an adult designated ward should be trained to the minimum standards of Safeguarding Children Level 3.

17.3 As per guidance in the revised MHA Code of Practice, anyone working with children and young people must always have enhanced disclosure clearance from the disclosure and barring service (DBS), including a barred list check, and that clearance must be kept up-to-date. 17.4 As is the case in CYP inpatient services, designated adult ward staff can expect advice and support from the Trust Children’s Safeguarding team if required. The children’s safeguarding team should be notified as a matter of routine practice, in the event of a young person being admitted to a designated adult ward 17.5 To support the better understanding of the routines normally associated with a

young person admitted to a CYP service, Band 6 Clinical Nurse Leads from the Trusts designated adult wards will be offered the opportunity to work a ‘shadowing’ shift on a CYP inpatient admissions unit. This supernumerary shadowing opportunity will assist with :-

Closer working links between adult designated wards and CYP inpatient services

A better understanding of the locality and environments normally associated within a CYP ward

Strategies for supporting and engaging young people in their treatment plans

17.6 Band 6 nurses will have this as part of the updated Trust’s, NTW(O)09 - Staff Appraisal Policy, practice guidance notes and procedures (or induction for new starters)

18 Identification of Stakeholders

18.1 This is an existing policy which has been circulated to the list below for a two week consultation period

Corporate Decision Team

Local Negotiating Committee

Consultant Psychiatrists

Community Services Group

Specialist Care Group

In Patient Care Group

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Psychological Services

Medical Directorate

Group Business

Safeguarding

Trust Allied Health Profession Services

Finance, IM&T, Estates and Performance

Staff-side

Trust Pharmacy

Workforce

Communications

Audit 19 Definition of Terms Used 19.1 The Nature of Abuse - A child or young person may be at risk of abuse from:

a member of staff

another child

another service user/patient

family members, neighbours, friends

a member of the public

Visitors to community homes/wards/units/departments including professional staff, paid care workers and volunteers

19.2 Within this policy the term ‘child’ will be taken to mean any person under 16 and

young person to mean anyone between the ages of 16 and 18 years. 20 Equality and Diversity Assessment – See Appendix A

20.1 The impact of this policy will be monitored upon its introduction via the Trust’s NTW(O)05 Incident Policy, practice guidance notes and procedures. SUI reporting for any people under the age of 16 who are admitted should lead to full management review. Service managers should also consider a full management review for people under the age of 18 who have been reported within the incident reporting process.

20.2 Information supplied via SUI and incident reporting will determine if this policy will undergo an Equality and Diversity Impact Assessment taking 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. 21 Implementation 21.1 Taking into consideration all the implications associated with this policy, it is considered that a target date of June 2016 is achievable for the contents to be embedded within the organisation.

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21.2 This will be monitored during the review process. If at any stage there is an indication that the target date cannot be met, then the Specialist Care Quality and Safety (Q&S) Group will consider the implementation of an action plan. 22 Monitoring and Compliance 22.1 The policy will be monitored for compliance Specialist Care Q&S Group by

audit of the standard requirements using audit/monitoring tool in Appendix C. This process should be undertaken prior to each review date.

23 Standard/Key Performance Indicators 23.1 The standards outlined in this policy will be assessed as part of the SUI reporting process to the Strategic Health Authority and internal safety reporting audits undertaken by Clinical Governance. Any young people admitted formally via the MHA 1983 (as amended by the MHA 2015) will be monitored via the CQC. Further standards are being developed at a national level, and these will form part of the review of the standards when developed. 24 Fair Blame 24.1 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. 25 Associated Documents

NTW(C)04 - Safeguarding Children Policy

NTW(C)05 – Consent to Treatment or Examination

NTW(C)19 - Observation Policy

NTW(C)34 - Mental Capacity Act 2005

NTW(C)48 – Care Coordination/CPA in Children and Young People Specialist Services

NTW(C)55 – Mental Health Act Policy

NTW(O)01 - Development and Management of Procedural Documents

NTW(O)05 – Incident Policy and practice guidance notes

NTW(O)11 – Children Visiting Policy

NTW(HR)09 – Staff Appraisal Policy and practice guidance notes

Joint Working Protocol: Mental Health, Substance Misuse and Child Care (Oct 2003)

Mental Health Act (MHA) 1983 Code of Practice (as amended at MHA 2015)

What to do if you think a child is being abused (DOH, 2003)

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MHA Commission Tenth Biennial Report – Chapter 17 IM&T Information Sharing Policy

MHAC Safeguarding children and adolescents detained under the Mental

Health Act 1983 on adult psychiatric wards (Dec 2004) MHA 1983 (as amended MHA 2015)

Local Authorities Safeguarding Policies & Procedures “What to do if you’re

worried a child is being abused”. Working together to safeguard children. DoH 2006.

The Children Act 2004 26 References

· Great Britain. Department of Health (DoH) 2002. ‘Developing services for carers & families of people with mental illness’. London. HMSO

· Great Britain. Department of health (DoH) 1999. National Service Framework for Mental Health. London. HMSO.

· Mental Health Act Commission. (2004) Safeguarding children and

wards. London. HMSO

· The Children’s Act 2004. London. HMSO.

· The Code of Practice: Mental health Act 1983 – revised 2008. London. HMSO.

· The Human Rights Act 1998. Great Britain. The Office of Public Sector

Information. London. HMSO.

· The Laming Inquiry 2003. The Victoria Climbie Inquiry. London. HMSO.

· The Mental Health Act 1983 (as amended by the MHA 2015). London HMSO.

UN Convention on the Rights of the Child, 1989. Geneva. United Nations.

Working together to Safeguard Children, 2013

Children and Families Act 2014

Children’s Act 1989 & 2004

Mental Capacity Act (MCA) 2005

Information sharing; guidance for Practitioners and Managers

When reviewing Policy Ref needs to be Code of Practice 2015

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Directorate

Mark Knowles Nov 2015 Nov 2018

Policy to be analysed Is this policy new or existing?

NTW(C)08 - Young people admitted to adult wards – V04

Existing

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

The aim of this policy is to ensure the safe and therapeutic care of young people who have to be admitted to adult wards. This policy is based on guidance and legislation from the government and is intended to address the needs of young people admitted. The Trust is committed to providing a safe, sound and supportive environment to all patients.

This policy needs to be implemented, read and understood within the context of:

NTW(C)20 - Care co-ordination Policy

NTW(O)05 - Incident Reporting Policy

NTW(C)04 - Safeguarding Children Policy

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

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 Young people who are disabled

Sex

Race There is a need for translated material in welcome packs, interpreters and advocacy for young people from minority ethnic groups.

Age Children and Young People - Dignity, privacy, respect, issues as well as safety and support issues

Gender reassignment (including transgender)

Yes. Dignity, privacy, respect, issues

Sexual orientation.

Religion or belief Young people with particular religious/faith needs

Marriage and Civil Partnership

Pregnancy and maternity

Carers

Other identified groups

Staff Clear support and training required for staff, as well as access to specialist advice such as safeguarding.

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

Through standard policy process procedures

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

Through standard policy process procedures

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

Appropriate policy review author/team

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.

The emphasis in this policy is about keeping young people safe whilst they are in hospital, while also providing therapeutic care. There is an emphasis on providing care that is very gender and culture sensitive in an appropriate and safe ward environment. There is also an emphasis on including relevant others, family and relatives, where cultural background engenders strong family involvement.

Recommendations

The impact of this policy will be monitored upon its introduction via the SUI and IR1 process. SUI reporting for any people under the age of 16 who are admitted should lead to full management review. Service managers should also consider a full management review for people under the age of 18 who have been reported within the incident reporting process. 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

This policy applies equally to all equality target groups.

Advance equality of opportunity Yes

Promote good relations between groups Yes. The policy relies on joint training and communication across statutory organisations.

What is the overall impact? Positive

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: Mark Knowles Date: November 2015

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Appendix B

Communication and Training Check list for policies

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?

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.

Safe and therapeutic care of young people admitted to adult wards. Amendments take into account new legislation and also that young people have to be admitted to the least restrictive setting if admission cannot be avoided. Sets out clearly the roles and responsibilities for staff involved

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, NHSLA etc.

Please identify the risks if training does not occur

Yes. Some of the training relates to legislation around consent, confidentiality and capacity. Also safeguarding of young people and the amended Mental Health Act (1983 as amended at 2008). Reporting around admission also a statutory requirement.

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 disciplines. Designated ward staff, Crisis Team staff.

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

Awareness of policy. Understanding of roles and reporting mechanisms.

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

Locality based joint training to ward and Crisis staff. Delivered by Clinical Nurse or Community Clinical Managers and CYPS staff.

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

John Padget – Service Manager

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group

Type of training Duration of Training Frequency of Training

All designated ward areas

All in relation to young people

All in relation to young

people

Policy and

procedure

Capacity, consent

and confidentiality

Medication for

young people

MHA (1983 as

amended 2008)

Information sharing,

communication and

good practice

Locality support and

resources

Third sector help for

young people

Q&A session for

staff

Relevant legislation

and documentation

Risks and young

people

Safeguarding

3 yearly

Crisis Teams Policy and

admission

procedure

Relevant legislation

Risks and young

people

Safeguarding

3 yearly

Copy of completed form to be sent to:

Training and Development Department, St. Nicholas Hospital

Should any advice be required, please contact:- 0191 223 2216 (internal 32216)

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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.

NTW(C)08 – Young People requiring emergency admissions - 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. All admissions will be to a designated ward, as audited via SUI and IR1 reporting.

Data reviewed monthly via CLIP report at Q&S and directorate meetings. In addition an annual summary will be produced to review trends.

Reported to Specialist Care Q&S group

2. Length of stay will be under a two week period

The summary outlined above will include incidents and length of stay, this will be prepared by the Service Manager from review od RiO and After Action Review notes.


3. Young people will be involved in their care planning as evidenced in written notes.

Monitored by Service Manager via CQUIN targets and performance reports


4. Multi-disciplinary team meetings will take place as per the timescale in this policy and evidenced within written patient notes.

The summary outlined above will include incidents, length of stay and evidence of MDT meetings. This will be prepared by the Service Manager from review of RiO and After Action Review notes


Continued…….

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NTW(C)08 – Young People requiring emergency admissions - 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).

5. All designated wards will be able to produce relevant young people information on request, e.g. welcome pack and resource file for staff.

As part of compiling the summary report the Service Manager will ask Ward managers of all designated wards to confirm that the welcome pack and resource files are in place. This will be reported in the summary


6. SUI’s will show that no-one under the age of 16 has been admitted to an adult ward

Is monitored via CLIP reports at Q&S monthly and at directorate meetings,. Summary will be included in the annual summary by the Service Manager.


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.