Standards for Low Secure Services
CCQI publication number: CCQI 130
Editors: Sarah Tucker, Maddy Iqbal and Sam Holder
Date: June 2012
The Quality Network ran a competition to find a piece of service
user artwork to use on annual reports, standards and leaflets. This
design was painted by a service user from Edenfield Centre. The
team would like to thank all of the service users who submitted
entries.
Contents Page
Preface
4
Method
5
A: Model of Care
7
1:
2:
3:
4:
Admission
Recovery
Physical Health Care
Discharge
B: A Safe Therapeutic Environment
1: Physical Security
2: Relational Security
3: Procedural Security
C: Service Environment
1:
2:
3:
4:
5:
Environmental Design
Risk assessment and management
De-escalation and seclusion
Access to external spaces
Facilities for Visitors
D: Workforce
1: Capacity and capability
2: Training and continuing professional development
E: Governance
1: Reporting and management of adverse incidents
2: Business Continuity
F: Equalities
Appendix
Appendix
Appendix
Appendix
3
1:
2:
3:
4:
7
8
10
11
12
12
13
14
17
17
17
18
19
19
20
20
20
23
23
23
25
Delegates, Standards Working Group
Delegates, Standards Consultation Event
Advisory Group
Project Team
26
26
26
26
Preface
It is a pleasure to welcome these Standards for Low Secure Services developed
by the Quality Network. The Quality Network has worked closely with the
Department of Health following the consultation on ‘The Good Practice
Commissioning Guide for Low Secure Services’ which will provide guidance.
These standards will form the basis of the self-and peer-reviews in the recently
launched Quality Network’s dedicated low secure network. They are an
accessible way for services to engage in comprehensive on-going service
development and improvement for the benefit of patients in line with
Department of Health policy.
This new network will build on the Quality Network’s successful work with
medium secure services over the past six years. This work has been valued by
the specialised service commissioners and has provided demonstrable benefits in
terms of quality improvement. The dedicated quality network for low secure
services has the potential to further develop standards for these services and
through the peer-review process further improve quality. Over the next year
commissioners will be working closely with the Quality Network for Forensic
Mental Health Services to use these standards to provide an on-going national
structure for quality assurance and improvement in low secure services.
Ged McCann
Phil Brian
Associate Director of Commissioning,
Yorkshire and Humber Office,
North of England Specialised
Commissioning Group,
Forensic and Secure Clinical Reference
Group
Assistant Director (Specialised Mental
Health),
West Midlands Office
Midlands and East Specialised
Commissioning Group,
Advisory Group Quality Network for Forensic
Mental Health Services
4
Method
Context
This third consultation draft of Standards for Low Secure Services has been developed by
the Quality Network for Forensic Mental Health Services directly from the ‘Low Secure
Services: Good practice commissioning guide – consultation draft’ Department of Health,
February 2012. In addition some standards from the ‘Implementation Criteria for
Recommended Specification: Adult Medium Secure Units’ (second edition CCQI 105)
have been included. These standards have been developed with the purpose of forming
the basis of the self- and peer-review questionnaires for the Quality Network for Forensic
Mental Health Services low secure services self- and peer-reviews. Forming the
foundation of the iterative annual review cycle the standards provide an accessible way
for services to actively engage in on-going service development towards implementing
the Department of Health recommendations.
The Development of the Standards
The standards have been developed in the following ways and stages:
1) The tense and where appropriate, the sentence structure of the Department of
Health ‘Low Secure Services: Good practice commissioning guide – consultation draft’
has been edited. This provides user-friendly and easily accessible questions for use in
self- and peer-review questionnaires.
2) Where these standards capture more than one criterion, the standard has been
divided into separate criteria. This prevents ambiguous answers.
3) Where these standards make an ideal statement (e.g. ‘There should be….’) this has
been edited to a statement of fact (e.g. ‘There is….’). This provides more user-friendly
standards for the peer-review questionnaires.
4) The Standards for Low Secure Services have been mapped on to the Quality
Network’s Implementation Criteria for Recommended Specification: Adult Medium Secure
Units’. This enables comparison and avoids potential duplication.
5) The Standards for Low Secure Services have been mapped onto the Care Quality
Commissions ‘Essential Standards of Quality and Safety’ (March 2010)1. This enables
services to streamline the data collection process. The references denote the Outcome,
Regulation and Prompt number onto which the implementation criteria have been
mapped, following the format: Outcome Number, Regulation Number. Prompt Number,
e.g. 1.17.1a denotes Outcome 1, Regulation 17, Prompt 1a.
6) On 27 March 2012 the Quality Network consulted an expert standards working group
on a first consultation draft of these standards (see Appendix 1). Members of the
working group were asked to identify omissions and to comment on clarity,
measurability and importance. On the basis of feedback from this working group the
Quality Network edited a second draft of the standards.
7) On 31 May 2012 the Quality Network consulted more widely at a standards
consultation event on the second draft of these standards (see Appendix 2). Members of
the event (which included patients) were asked to identify omissions, in particular, those
in the ‘Implementation Criteria for Recommended Specification: Adult Medium Secure
Units’ which did not appear in the Low Service Standards). Members were also asked to
comment on clarity, measurability and importance. On the basis of feedback from this
event the Quality Network edited this third edition of the standards.
1
http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_FINAL_081209.pdf
5
6
No.
DH Guidance
LSU
Standard
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
A: Model of Care
1: Admission
There are clear admission procedures which centre on
a multi-disciplinary assessment process taking account
of a patients’ care, treatment (including physical health
treatments) and security needs.
There are clear inclusion criteria for the admission of
patients to the unit which include all of the following:
i.
A definable clinical risk to others or a legal
requirement to be in custody
ii.
Men and women aged 18 years and over and
detained under the Mental Health Act.
iii.
Prisoners or Immigration Act detainees meeting
the criteria for detention under the Mental
Health Act.
iv.
People who will benefit from a period of
rehabilitation.
v.
People who may require a long period of
rehabilitation.
vi.
People who may have a history of offending
behaviour with low levels of violence for
example assault.
vii.
People who do not require the degree of
security provided by medium or high secure
care.
viii.
People with challenging behaviour.
ix.
People with co-morbid substance misuse issues
(past or current).
There are clear exclusion criteria for the admission of
patients to the unit which include all of the following:
i.
People under 18 years who do not meet criteria
for detention under the Mental Health Act or
require treatment in a specialist service for
children and adolescents.
ii.
People with a primary diagnosis of substance
misuse without a secondary diagnosis of mental
illness, who are not engaging with substance
misuse interventions.
iii.
People requiring detention in medium or high
security.
iv.
People with complex needs who can be
managed and treated in adult services including
psychiatric intensive care or rehabilitation
services.
A1.1
A1.2
A1.3
7
27
26
28
29
4.9.4l
5.14.5a
A97
A96
A85
G3
B7
No.
DH Guidance
LSU
Standard
Patients who receive low secure services also
receive an assessment for additional specialist
treatment if they have a primary diagnosis of
dementia, a learning disability of sufficient severity
to preclude them from actively engaging,
personality disorder, acquired brain injury or other
neuro-cognitive deficits, Asperger’s and autistic
spectrum disorder.
Where low secure care is not considered the most
suitable option for an individual, service staff offer
advice and guidance on the management of the patient
where applicable.
A1.4
A1.5
A1.6
The provider identifies the responsible local
commissioner for every individual planned admission,
even where the service user is known to the service.
A1.7
All patients will have an initial care plan in place within
24 hours of admission.
30
A1.9
4.9.4b
4.9.4d
4.9.4n
6.24.6c
31
4.9.4p
B9
A95*
All patients have a link person/care co-ordinator from
their home area services whose responsibilities include
the facilitation of ongoing links and the patient’s care
pathway.
There are clear criteria for admission to and transfer
/discharge from services which will be agreed with
commissioners and will be communicated to all
referrers. The service ensures that the discharge
procedures are operated in line with the pathway
(appendix 4).
A1.8
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
6.24.6a
6.24.6b
7.11.7b
B10*
4.9.4c
4.9.4o
6.24.6a
6.24.6e
6.24.6g
7.11.7e
E2*
B13
A80
B2
2: Recovery
A2.1
Using the Care Programme Approach (CPA), the
multi-disciplinary team takes a comprehensive,
recovery-focussed approach aimed at building
resilience and preventing relapse.
32
1.17.1a
1.17.1b
1.17.1c
2.18.2a
4.9.4a
4.9.4e
4.9.4g
4.9.4n
4.9.4r
6.24.6a
16.10.16d
21.20.21a
A2.2
The recovery-focussed approach includes addressing
accommodation, employment and learning needs,
meaningful social contact and combating stigma.
32
1.17.1m
4.9.4a
A94.5
A107
A2.3
The service makes provision for men and women aged
over 18 years and complies with national guidance
about and expectations governing the provision of
single sex accommodation.
16
1.17.1a
4.9.4f
10.15.10a
10.15.10l
E6
E7
F2w
F3w
F4w
F9w
8
No.
Standard
There is evidence that the model of care and treatment
focuses on risk management, engagement and
rehabilitation within a safe and secure environment.
A2.4
There are facilities for detained patients including
those who require short periods of intensive care
within a low secure environment.
There is provision for patients requiring a period of
engagement and treatment away from the main
patient group. This may include the provision of
1.17.1h (Essential Standards of Quality & Safety,
CQC, 2010) for de-escalation and seclusion.
A2.5
A2.6
There are a variety of recreational activities and
occupational facilities available.
A2.7
There is a dedicated secure external garden/court
yard which can be used for recreational activities.
There are effective links with community organisations
(e.g. housing, leisure, employment, education) and
activities to support rehabilitation and sustainable
discharge.
A2.8
A2.9
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
17
1.17.1a
1.17.1b
1.17.1c
1.17.1f
1.17.1j
4.9.4a
4.9.4c
4.9.4e
7.11.7g
16.10.16b
16.10.16d
19
1.17.1h
20
1.17.1h
21
1.17.1h
4.9.4a
10.15.10a
21
10.15.10a
10.15.10m
21
1.17.1m
6.24.6a
6.24.6c
7.11.7b
1.17.1a
1.17.1b
1.17.1c
1.17.1f
1.17.1j
4.9.4a
4.9.4c
4.9.4e
7.11.7d
16.10.16d
1.17.1a
1.17.1b
4.9.4a
16.10.16c
16.10.16d
1.17.1c
2.18.2a
2.18.2b
4.9.4c
21.20.21a
A2.10
There is evidence that the service places the patient at
the centre of their care, supporting patient recovery
and choice within the unit where this is clinically
appropriate.
23
A2.11
Patients engage and participate in the formulating of,
and ongoing review of, a multidisciplinary therapeutic
evidence-based programme appropriate to their
individual needs.
24
A2.12
Patients are given a copy of the management or care
plan.
A2.13
There is a core day described in each patient's
individualised care plan (a description of the core day
may also be found elsewhere e.g. in the ward
programme or individual timetables).
A2.14
Patients receive information about medication and its
side effects.
25
1.17.1a
1.17.1e
4.9.4e
9.13.9d
16.10.16b
A2.15
Treatments take into account the relevant NICE
guidance.
25
2.18.2d
9
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
A93
C3
C32
D9
A94.1
A94
C22
D20
D2
D9
D19
A113
A100
A101
A10w
No.
A2.16
The programme of treatment includes psychological
sessions.
A2.17
The programme of treatment includes substance
misuse therapy.
A2.18
A2.19
A2.20
A2.21
A2.22
A2.23
A2.24
DH Guidance
LSU
Standard
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
A94.2*
1.17.1l
4.9.4n
4.9.4o
The programme of treatment includes offence related
therapy.
The programme of treatment includes structured
activity programmes.
The programme of treatment includes structured
leisure time.
The programme of treatment includes unstructured
free time.
There are facilities appropriate to the patient group,
e.g. a pool table and board/console games are
provided.
There are facilities for patients to make their own hot
and cold drinks and snacks.
Books and magazines are provided in recreation areas
for patients.
A94.3*
A94.4*
A94.6*
A94.7
A94.8*
1.17.1h
F12
5.14.5c
F13
F14
3: Physical Health Care
A3.1
A3.2
A3.3
A3.4
A3.5
A3.6
A3.7
A3.8
A3.9
A3.10
A3.11
Patients routinely undergo a full assessment of both
physical and mental health needs.
Care and treatment plans reflect both mental
health and physical healthcare needs.
Patients have access to a comprehensive range of
primary healthcare services.
Patients undergo follow-up investigations and
treatment for physical conditions identified in their
assessment during their admission.
Patients have routine monitoring of medication
including those used for physical health issues.
Patients are supported in their personal care including
dental hygiene.
The service meets screening targets expected of
primary care services.
The service provides general health promotion
activities including screening, diet advice and the
opportunity to exercise (with appropriate supervision).
The service provides targeted programmes on smoking
cessation and health promotion.
There is an identified duty doctor available at all times
to attend the unit.
Patients have access to comprehensive primary and
secondary care services to meet existing or newly
developed physical healthcare and treatment needs.
10
G3
A89
A1w
34
35
6.24.6c
G3.1
35
1.17.1i
6.24.6i
G1
G5
35
6.24.6c
G4
35
9.13.9a
9.13.9b
9.13.9d
6.24.6j
G5
G4w
36
36
D1*
1.17.1e
4.9.4a
5.14.5a
5.14.5c
36
G5
G11
G15
G12
G13
F10
G4w
G6
B31
22
1.17.1e
1.17.1i
4.9.4a
4.9.4p
6.24.6i
6.24.6j
G1
G5
G4
No.
DH Guidance
LSU
Standard
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
4: Discharge
A4.1
A4.2
A4.3
A4.4
A4.5
A4.6
A4.7
Social workers, care coordinators and offender
managers are actively involved in care planning
processes for treatment on the unit and postdischarge follow-up under Section 117 arrangements.
Discharge targets are agreed as part of the discharge
planning process.
There is a multi-disciplinary assessment to determine
readiness for discharge/transfer.
The multi-disciplinary team supports the patient to
develop and maintain links with community-based
organisations that can provide socially inclusive,
mainstream activities.
The provider facilitates links to the home area services
of each patient in terms of local statutory (health and
social care) and voluntary services and maintains
these to ensure timely and appropriate
discharge/transfer arrangements are put in place.
When a patient needs to transfer to services for older
people, a joint review is undertaken to ensure effective
hand-over takes place.
The service ensures there are regular reviews for
patients transferred from prison (a) on remand (b) on
sentence to assess suitability for return to prison.
11
33
6.24.6c
A123
A121
33
4.9.4c
B15*
1.17.1m
4.9.4a
6.24.6c
6.24.6i
7.11.7b
C22
4.9.4a
4.9.4c
6.24.6i
B11*
4.9.4c
A122
4.9.4c
16.10.16c
B21*
No.
Standard
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
B: A Safe Therapeutic Environment
B1
B2
B3
There is evidence that the three domains of security
(physical, relational and procedural) are developed
and managed in unison.
There is evidence that the three domains of security
(physical, relational and procedural) are used to
inform decisions about individual/population care.
The balance in emphasis between each domain of
security (physical, relational and procedural) changes
given the operational needs of the unit as a whole, or
the needs of a particular patient and/or group of
patients, and the setting in which the service is
provided.
40
10.15.10c
40
10.15.10c
41
10.15.10c
42
10.15.10c
A1
47
10.15.10a
10.15.10d
A10
A18
A19.2
48
10.15.10a
A15
A15.1
A15.3
49
10.15.10a
1: Physical Security
B1.1
B1.2
There is a clearly delineated external perimeter.
The external perimeter is designed to maintain service
integrity, privacy, eliminate climb points and manage
risk.
(The exact nature of the external perimeter, for example fence height, cladding, angled
weld mesh topping, and anti-climb capping, is determined by the size, layout and location
of the low secure service).
B1.3
B1.4
B1.5
B1.6
B1.7
B1.8
B1.9
B1.10
B1.11
Gates within the perimeter do not have bolts or
opening mechanisms that can be used as footholds
to assist climbing.
Where fencing forms all or part of the secure external
perimeter, it conforms to BS358 and is a minimum
height of 3 metres.
Access to the low secure unit for visitors, staff and
patients is via an airlock.
There is evidence that the secure external perimeter is
regularly checked.
There is a clearly defined internal perimeter
(normally bounded by the secure doors leading to
outside areas), which facilitates patients’ freedom of
movement within the internal perimeter area.
There are systems in place to ensure that buildings,
equipment and technology are well maintained.
Lockers are provided for staff away from the patient
area for the storage of any items not allowed on the
unit.
All keys, including those held at reception, are
controlled, issued and accounted for.
All keys held by reception are accounted for at least
twice in a 24-hour period.
12
53
A31
43
A4
46
42
10.15.10d
50
7.11.7m
10.15.10c
10.15.10f
A7
A7.1
A20.1
F5
51
A13
A28
51
A28.1
No.
B1.12
B1.13
B1.14
B1.15
B1.16
B1.17
B1.18
B1.19
B1.20
B1.21
Standard
Access to spaces where sharp implements e.g.
kitchen knives, utensils, equipment or tools are
available are to be controlled.
The use of sharp implements is monitored.
There is evidence that the staff team have current
knowledge and understanding of the units’ physical
security measures and mechanisms.
There is evidence that the staff team have current
knowledge and understanding of the procedures that
support the units’ physical security measures and
mechanisms for effective operation.
There is evidence that the staff team have current
knowledge and understanding of their own security
responsibilities and those of the wider team.
There is evidence that the staff team have current
knowledge and understanding of how relational and
procedural measures impact on physical security.
There is evidence that the staff team have current
knowledge and understanding of what constitutes the
internal perimeter.
There is evidence that the staff team have current
knowledge and understanding of alarm systems
including those used for staff/patient safety and fire.
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
52
11.16.11c
A71
52
11.16.11c
A71
45
10.15.10c
A92
C6
45
10.15.10c
A92
C6
45
10.15.10c
C4
45
10.15.10c
45
10.15.10c
45
4.9.4d
5.14.5a
7.11.7a
7.11.7d
7.11.7k
9.13.9g
10.15.10a
10.15.10b
10.15.10e
10.15.10g
10.15.10h
14.23.14a
C7
10.15.10p
F9.1*
There is a system in place for staff to report any
ligature points identified with prompt follow up action.
There is a full-time security lead.
A41*
2: Relational Security
B2.1
B2.2
B2.3
B2.4
B2.5
There is evidence that staff have a knowledge and
understanding of their patients and of the
environment, and of the translation of that information
into appropriate responses and care.
There is evidence that the entire staff team works
cohesively. This includes staff who do not have direct
patient contact.
All staff have an up to date enhanced CRB check.
There are clear and effective systems for
communication and handover within staff teams.
There are regular multi-disciplinary team meetings for
clinical matters and administration, and the team is
consulted on relevant management decisions such as
developing and reviewing operational policy.
13
55
6.24.6b
22.4.22b
50
12.21.12a
12.21.12d
A88*
12.21.12b
A102
16.10.16c
16.10.16d
23.5.23a
24.6.24a
A103
No.
Standard
DH Guidance
LSU
There are regular meetings where staff discuss and
reflect on relational security issues.
B2.6
B2.7
B2.8
This includes as a minimum: discussion of boundaries, therapy,
patient mix, patient dynamic, patient’s personal world, physical
environment, visitors and other external communication and may be
facilitated by the See, Think, Act Relational Security Explorer.
All staff can demonstrate an understanding of their
role in relation to meeting the complex needs of
patients.
The induction training programme covers relational
security.
This includes as a minimum material on: boundaries, therapy,
patient mix, patient dynamic, patient’s personal world, physical
environment, visitors and other external communication. This may
be facilitated by the See, Think, Act training slides.
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
7.11.7g
12.21.12b
B30
12.21.12a
A108
12.21.12b
14.23.14a
C5
There is annually updated staff training on relational
security.
B2.9
B2.10
B2.11
This includes as a minimum material on: boundaries, therapy,
patient mix, patient dynamic, patient’s personal world, physical
environment, visitors and other external communication. This may
be facilitated by the See, Think, Act training slides.
A92
Contact with visitors and other external communication
is regularly risk assessed.
There is a mechanism for measuring and monitoring
relational security against established outcomes such
as those in ‘See Think Act: Your guide to Relational
Security’ (DH 2010).
7.11.7h
16.10.16b
A51, A72,
A93, C3
2.18.2d
22.4.22c
C17
7.11.7h
RS.
RS.
RS.
RS.
RS.
1.17.1m
A107
1.17.1m
A94.5*
64
10.15.10h
A50
65
2.18.2d
22.4.22b
22.4.22c
66
10.15.10h
Please refer to ‘We know we are getting it right when:’ sections in
See, Think Act
B2.12
B2.13
B2.14
Staff have an understanding of their role in relation to
Relational Security in respect of the alcohol and
controlled or illegal substances policies.
101
The unit has access to a range of education
professionals which include teachers, a special
educational needs co-ordinator, an educational
psychologist, and career guidance.
The programme of treatment includes access to real
opportunities to work.
1
2
3
4
5
3: Procedural Security
B3.1
B3.2
B3.3
There is an up to date index of procedural security
policies used in the low secure service, including
contingency and business continuity plans.
Policies and procedures acknowledge the need for
proportionality and discretion and are in accordance
with the Mental Health Act Code of Practice and
guidance issued by NICE and professional
associations.
Policies, procedures and contingency plans are
reviewed at least annually and updated where
required.
14
A50.1
No.
Standard
B3.4
Staff have ready access to and demonstrate up to date
knowledge of policies and procedures governing the
service and guiding their practice.
B3.5
There are operational policies and procedures
governing, but not limited to, the safety of patients,
visitors and staff, risk, adverse incidents and
operational management.
B3.6
B3.7
B3.8
B3.9
B3.10
B3.11
B3.12
B3.13
B3.14
B3.15
B3.16
B3.17
B3.18
B3.19
B3.20
In addition to organisation-wide policies, there are
specific policies and procedures tailored to meet the
needs of the low secure service. These policies are
authorised by the wider organisation’s senior
management structure or board.
Staff, patients and visitors feel safe on the unit.
Staff, patients and visitors are clear about rules and
policies governing any prohibited items including
cameras and electronic devices and other items that
may be restricted such as mobile phones.
There are policies governing access to and appropriate
use of the internet by staff and patients.
Policies governing access to and appropriate use of the
internet by staff and patients contain particular advice
around the appropriate use of social networking sites,
confidentiality and risk.
There is a readily available policy for the authorisation
and governance of practice of, searching patients,
patient rooms, communal areas and visitors. This
policy is in accordance with the requirements of the
Mental Health Act Code of Practice.
There is a policy on observation.
There is an anti bullying policy (for those who are
bullying and those who are bullied).
There is a policy on prevention of suicide and
management of self harm.
There is a policy on transportation of patients (e.g. to
court or acute hospital).
DH Guidance
LSU
66
15
C4
58
4.9.4b
6.24.6d
7.11.7a
9.13.9b
10.15.10b
10.15.10e
59
23.5.23a
24.6.24a
F2
A93
A124
A125
60
60
10.15.10c
A72
A73
F15
61
61
2.18.2a
A73
F15
62, 63
22.4.22c
A51
A55*
7.11.7a
14.23.14d
A56*
4.9.4l
A57*
A58*
There is a policy on the control of prescribed
medication and drugs.
The unit has a robust policy on the use of and access
to alcohol and controlled or illegal substances by
patients and their visitors.
Policies regarding alcohol and controlled or illegal
substances cover the role of Relational Security.
Policies regarding alcohol and controlled or illegal
substances cover the management of incidents where
drugs and alcohol are brought in by patients and their
visitors.
There is a policy on the prosecution of offences within
the unit which is agreed with the police and CPS.
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
101
9.13.9a
9.13.9b
9.13.9d
9.13.9e
9.13.9f
9.13.9g
A64*
1.17.1l
A62
A63
101
101
9.13.9b
A65*
No.
B3.21
B3.22
B3.23
B3.24
B3.25
Standard
There is a smoking policy.
There is a policy on the management of patient’s
monies.
There is a policy on the censorship of material
including pornography.
There is a policy on the control of mail and use of
telephones.
There is a policy on visiting procedures including child
protection issues.
B3.26
There is a policy on patient confidentiality.
B3.27
There is a policy for managing critical incident reviews.
B3.28
There is a policy for response to staff alarms.
There is a policy on child visiting/child contact which is
annually reviewed.
There is a policy on safeguarding children which
complies with National Quality Principles which is
reviewed annually.
There is a clear written policy for referrals, admissions,
transfers and discharges.
There are clear policies on disciplinary and grievance
procedure; whistle blowing policy, discrimination,
harassment, bullying and violence.
B3.29
B3.30
B3.31
B3.32
B3.33
There is a clear complaints procedure.
B3.34
There is a procedure regarding obtaining consent from
patients.
B3.35
B3.36
DH Guidance
LSU
The procedure for resuscitation of patients is clearly
documented, resuscitation equipment is available and
its location is clearly identified.
Staff demonstrate a working knowledge of mental
health legislation and its application including their
authority in relation to escorting patients outside the
secure perimeter.
16
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
A67*
7.11.7m
A68*
A69*
10.15.10k
A70*
7.11.7e
A74*
2.18.2a
6.24.6b
6.24.6e
4.9.4b
6.24.6d
16.10.16b
16.10.16c
A75*
A76*
A83
A128*
7.11.7a
22.4.22b
A129*
4.9.4c
7.11.7e
B8*
7.11.7a
14.13.14d
16.10.16b
C11*
1.17.1h
6.24.6f
7.11.7a
16.10.16a
17.19.17a
17.19.17e
2.18.2a
2.18.2b
2.18.2c
2.18.2h
6.24.6e
11.16.11a
11.16.11c
11.16.11d
11.16.11h
67
12.21.12b
22.4.22c
C1*
A81
A82
C38
No.
Standard
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
C: Service Environment
1: Environmental Design
C1.1
C1.2
C1.3
C1.4
C1.5
C1.6
C1.7
C1.8
C1.9
C1.10
C1.11
C1.12
C1.13
C1.14
There is evidence of active planning for and
consideration of the impact on the therapeutic
environment and safety of ward size and layout,
patient numbers and population.
The patient and staff environment is homely, light and
bright.
All accommodation is provided in single rooms, with all
new builds and upgrading programmes providing ensuite accommodation.
There is a designated dining area.
There is a multi-faith room available for use by all
patients.
There are unrestricted lines of sight and no concealed
unsecured areas.
Furnishings minimise the potential for fixtures and
fittings being used as weapons, barriers or ligature
points.
Doors in rooms used by patients have observation
panels with integrated blinds/obscuring mechanisms.
These can be operated by patients with an external
override feature for staff.
Staff can override any locks that are lockable from
the inside e.g. patient bedrooms and bathrooms.
Patient bedroom and bathroom doors are designed to
prevent holding, barring or blocking.
There are lockable facilities (with staff override
feature) for patient’s personal possessions with
maintained records of access.
Patients have access to a telephone in a private area,
within the limits of safety and risk assessment.
Patients can wash and use the toilet in privacy unless
clinical risk prevents this.
There is a cleaning programme which is regularly
audited.
68
7.11.7g
10.15.10f
10.15.10i
10.15.10a
69
10.15.10a
F16
F17
A45
4.9.4f
10.15.10f
10.15.10l
F3*
5.14.5f
F11
1.17.1i
D7*
69
10.15.10p
A46
70
10.15.10p
71
73
73
7.11.7m
10.15.10c
A66
7.11.7h
D15
10.15.10f
10.15.10m
F3.1*
8.12
F1.1*
76
4.9.4a
4.9.4l
4.9.4n
5.14.5a
A99
A89
76
6.24.6c
16.10.16b
74
2: Risk assessment and management
C2.1
C2.2
There is evidence of a multi-disciplinary approach
to the identification, assessment and management
of risk.
Individual risk management programmes are
developed to identify the types of supervision,
therapeutic intervention and treatment required.
17
No.
Standard
DH Guidance
LSU
C2.3
Risk management programmes can be readily
adapted to meet a changed risk assessment
resulting from adverse incidents, observed
behaviour or concerns about security.
77
C2.4
Risk assessment and management is informed by
relational security issues.
78
C2.5
C2.6
C2.7
C2.8
There is an agreed approach to risk assessment
including which planning tools are used.
All staff working directly with patients are trained to
incorporate risk identification and management into
individual care, treatment and support plans.
Staff are skilled at identifying and assessing potential
risk factors/situations, planning how to manage
identified risks and managing identified risks.
Risk reduction is assessed and evidenced through
setting and monitoring treatment outcomes. These
outcomes inform discussions with the Ministry of
Justice (MoJ) regarding restricted patients, transferred
prisoners and/or MAPPA (where relevant) and
subsequent decisions about:
i.
escorted, unescorted or trial leave
ii.
rescinding leave
iii.
failure to return from leave and absconding
iv.
remission to prison
v.
transfer to higher level of security
vi.
discharge pathways
vii.
s117 follow-up care requirements
viii. preparation for Community Treatment Order
(CTO) arrangements.
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
4.9.4n
6.24.6d
7.11.7h
9.13.9b
10.15.10c
14.23.14d
16.10.16b
7.11.7h
10.15.10c
16.10.16b
79
7.11.7h
16.10.16b
81
13.22.13a
16.10.16b
A86.1
81
13.22.13a
14.23.14a
16.10.16b
A86.1
82
6.24.6b
16.10.16b
16.10.16d
A115
A116
A117
A118
A119
83
4.9.4q
7.11.7b
7.11.7f
7.11.7g
7.11.7h
14.23.14d
A52
A53
A2w
84
1.17.1a
1.17.1h
7.11.7i
10.15.10a
10.15.10f
E6
A3w
85
4.9.4q
86
9.13.9a
9.13.9b
9.13.9d
9.13.9e
9.13.9g
3: De-escalation and seclusion
C3.1
C3.2
C3.3
C3.4
There are clear policies and procedures governing the
use of de-escalation techniques and the management
of challenging behaviour including the appropriate use
of control and restraint and of seclusion.
There is evidence that the service has considered how
best to provide appropriate de-escalation facilities and
considered the need for providing an en-suite
seclusion room that will maintain the patient’s safety,
privacy and dignity.
Seclusion is only used as a last resort, and for the
shortest clinically appropriate period. Its use is
monitored according to the Mental Health Act Code of
Practice.
Where required rapid tranquilisation complies with
NICE guidance
(http://www.nice.org.uk/nicemedia/pdf/cg025fullguidel
ine.pdf)
18
A54
No.
DH Guidance
LSU
Standard
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
4: Access to external spaces
C4.1
C4.2
Access for patients to outside areas including secure
gardens and courtyards is determined by an individual
risk assessment and takes account of all factors that
may assist escape, e.g. weather.
Staff facilitate safe access for patients to outside areas
including those on s17 leave by implementing the
following safeguards:
i.
Consideration of appropriate staff supervision
(numbers and skill mix) given the mix and
number of patients outside or on leave at any
one time.
ii.
Retaining appropriate staffing levels and skill
mix on the unit whilst patients are outside or on
leave.
iii.
Provision of appropriate escorts given the
nature, purpose and location of leave.
87
7.11.7h
10.15.10c
10.15.10m
88
1.17.1m
14.23.14c
A60
A61
5: Facilities for Visitors
C5.1
There are facilities for visitors within the secure
perimeter.
89
10.15.10a
C5.2
There are separate, appropriately furnished facilities
for children’s visits.
89
10.15.10a
91
7.11.7m
10.15.10c
C5.4
C5.5
C5.6
There are lockers for visitors away from patient areas
to store prohibited or restricted items whilst they are
on the unit.
All visitors access the unit by the main reception
airlock.
The unit works with visitors and families on their
health and well being, for example, coping with stress,
conflict resolution and sustainable transport plans for
visiting.
19
A128.1
A12w
A13w
91
D12*
No.
Standard
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
D: Workforce
1: Capacity and capability
D1.1
D1.2
D1.3
D1.4
D1.5
D1.6
D1.7
There is a cohesive multi-disciplinary team in place
who have the capacity and capability required to meet
the complex needs of patients.
There is a robust leadership structure in place which
sets out professional, organisational and line
management accountabilities.
The staffing capacity is sufficient to deliver the care
and treatment model and maintain a safe environment
at all times.
The unit is staffed by permanent staff and agency staff
are used only in exceptional circumstances.
Extra nursing cover is available when needed, e.g.
there is access to additional on-call staff in an
emergency.
The staff mix and ratios are sufficiently flexible to meet
the changing levels of risk.
The multi-disciplinary team includes:
 medical staff
 nursing staff
 social workers
 pharmaceutical staff
 psychologists
 art therapist
 psychotherapist
 occupational therapist
 and education professionals.
92
13.22.13a
A104
B17
B18
92
23.5.23a
24.6.24a
C27
C27.1
93
7.11.7b
7.11.7g
13.22.13a
A110
B18
A112
A111
93
13.22.13a
94
A86.1
B18
A104
D1.8
The service has the capacity to respond to patient
need and gender specific issues.
95
1.17.1h
12.21.12b
13.22.13a
A1w
C4.1w
E6w
E7w
D1.9
All staff have a working knowledge of mental health
legislation and its application.
96
12.21.12b
22.4.22c
C38
2: Training and continuing professional development
D2.1
The multi-disciplinary team has the capacity and
capability to provide a range of multi-disciplinary
therapeutic interventions and clinical treatments within
the agreed model of care.
97
13.22.13a
D2.2
The staff at the service have completed the training
and education recommended by their professional
association or regulatory body.
97
12.21.12b
14.23.14.a
20
C15
No.
Standard
DH Guidance
LSU
D2.3
The staff at the service have completed the mandatory
and appropriate non-mandatory training provided by
the organisation.
97
D2.4
There is a system in place to continually identify and
review staff training needs on an annual basis.
97
D2.5
Training needs are monitored within the staff appraisal
system.
97
D2.6
D2.7
There is annually reviewed training and development
strategy, which includes the provision of security
training.
There is a strategic plan for training, encompassing all
known initiatives and that is subject to regular review.
D2.8
All staff receive supervision on a monthly basis.
D2.9
All staff receive training regarding Safeguarding
Children and Safeguarding Vulnerable Adults.
D2.10
D2.11
D2.12
D2.13
D2.14
D2.15
D2.16
D2.17
All staff receive equality awareness training.
Staff receive training on Physical Security as part of
the induction programme and prior to being issued
with keys, swipe cards or other means of operating
Physical Security mechanisms.
Staff receive training on Procedural Security as part of
the induction programme and prior to being issued
with keys, swipe cards or other means of operating
Physical Security mechanisms.
Staff receive training on Relational Security as part of
the induction programme and prior to being issued
with keys, swipe cards or other means of operating
Physical Security mechanisms.
All staff including non clinical staff receive training in
the management of violence and aggression.
Training addressing the management of violence and
aggression includes de-escalation techniques and the
use of control and restrain procedures.
All staff have a working knowledge of mental health
legislation and its application.
Training is provided on disciplinary and grievance
procedure; whistle blowing policy, discrimination,
harassment, bullying and violence policies.
21
97
97
97
Essential
Standards of
Quality & Safety
(CQC – March
2010)
4.9.4d
5.14.5a
7.11.7a
7.11.7d
7.11.7k
9.13.9g
10.15.10b
10.15.10e
10.15.10g
10.15.10h
14.23.14a
4.9.4d
12.21.12a
12.21.12b
14.23.14a
14.23.14c
4.9.4d
12.21.12a
12.21.12b
14.23.14a
14.23.14c
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
C7
A90.1
B24
A90.1
14.23.14.a
A91*
12.21.12b
14.23.14a
C18.1*
14.23.14c
A90
B28
7.11.7a
7.11.7e
7.11.7i
12.21.12b
22.4.22b
12.21.12b
A130
A15w
C10
97
12.21.12b
14.23.14a
C5
97
12.21.12b
14.23.14a
C5
97
12.21.12b
14.23.14a
C5
97
12.21.12b
14.23.14d
C8
97
12.21.12b
14.23.14d
C9
97
12.21.12b
22.4.22c
C38
12.21.12b
14.23.14.a
14.23.14d
16.10.16b
C11.1*
No.
D2.18
D2.19
D2.20
D2.21
D2.22
D2.23
D2.24
Standard
Training is provided on the management of
relationships between patients and between patients
and staff.
Training is provided on the user perspective and user
participation.
Staff are made aware of complaints that are relevant
to their work and the outcome of the complaints
process.
Staff take up of supervision and support is regularly
monitored and audited.
Frontline staff have regular supervision totalling at
least one hour per week and are able to contact a
senior colleague as necessary.
There are records of robust clinical supervision.
There is adequate time made available for supervision
to be delivered.
22
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
12.21.12b
14.23.14.a
C13*
12.21.12b
14.23.14.a
C14*
16.10.16a
16.10.16c
17.19.17a
D14
12.21.12b
14.23.14c
B27
12.21.12b
14.23.14c
B29
14.23.14c
C20*
14.23.14c
C20.2*
No.
Standard
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
E: Governance
1: Reporting and management of adverse incidents
E1.1
E1.2
E1.3
E1.4
E1.5
There is a structure in place for reporting, managing
and investigating Serious and Untoward Incidents
(SUIs).
The unit’s senior management are accountable for the
unit’s Serious and Untoward Incident reporting,
managing and investigating structure.
The unit uses the Department of Health and NPSA
definition of a Serious and Untoward Incident to define
SUIs within the service:
‘The definition of an adverse incident is an event or
circumstance that could have or did lead to
unintended, unexpected harm, loss or damage’.
All Serious Untoward Incident investigations are in line
with guidance on the discharge of mentally disordered
people and their continuing care in the community.
There is a system in place to report incidents to the
relevant commissioners in line with the lead
commissioners reporting policy on Serious and
Untoward Incidents. This includes initial notification
within 24 hours of the incident and a full detailed SUI
report within 7 days of the incident.
98
6.24.6d
10.15.10e
16.10.16a
20.18.20f
20.18.20g
98
20.18.20b
23.5.23a
24.6.24a
A125
99
100
10.15.10e
16.10.16a
20.18.20a
20.18.20f
20.18.20g
A126*
A127*
E1.6
Untoward incidents are continually monitored to
identify trends and learning points.
4.9.4b
6.24.6d
9.13.9b
16.10.16a
16.10.16b
16.10.16c
E1.7
There are mechanisms in place to share learning
beyond the immediate service/provider concerning
incidents.
6.24.6d
A127.1*
E2.1
The unit has a contingency plan in place, which has
been agreed with the police, regarding the reporting
and managing of:
 loss of control
 serious operational failures including those
resulting from fire (in agreement with the local fire
and emergency services)
 escapes
 absconds
 failure to return and
 hostage taking.
10.15.10e
10.15.10h
A78
2: Business Continuity
23
102
No.
E2.2
E2.3
E2.4
E2.5
E2.6
E2.7
E2.8
E2.9
Standard
The unit has contingency plans in place which outline
the arrangements for maintaining service integrity and
patient and staff safety in the event of an operational,
security or systems failure.
The business continuity plan incorporates the
contingency plans, which have been agreed with the
police.
The business continuity plan addresses:
 the chain of operational control
 communications
 patient and staff safety and security
 maintaining continuity in treatment and
 accommodation.
There is a strategic approach to planning to meet the
service needs.
Clinicians and managers maintain good links with the
Home Office and ensure their target
deadlines/requirements are met.
There is a clinical governance strategy, which is
implemented.
Contingency plans are annually tested by desktop
exercises.
Contingency plans are tested by a live exercise
involving one or other of the emergency services every
24 months.
24
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
103
10.15.10b
10.15.10h
104
10.15.10h
104
6.24.6a
6.24.6b
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
C18*
C23*
16.10.16e
C29*
6.24.6d
A79*
4.9.4b
A79.1
No.
Standard
DH Guidance
LSU
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
F: Equalities
F1
The service complies with equalities, mental health and
human rights legislation.
105
F2
All operational and clinical procedures, processes and
policies reflect the requirements of equalities, mental
health and human rights legislation.
105
F3
There is an implemented policy to ensure systems are in
place to allow for translation services and sign language.
Written information must be provided in an appropriate
number of languages and formats.
1.17.1g
7.11.7d
22.4.22b
22.4.22c
1.17.1g
7.11.7d
12.21.12a
22.4.22b
22.4.22c
1.17.1a
1.17.1e
4.9.4e
17.19.17e
1.17.1a
1.17.1e
1.17.1g
4.9.4e
4.9.4g
16.10.16b
22.4.22c
1.17.1a
1.17.1c
1.17.1h
2.18.2a
2.18.2h
17.19.17a
C37
C38
A84
C38
D6*
D6.1
D17
C41
A11w
F4
Patients are provided with a range of information, in
appropriate formats, regarding their rights under
equalities, mental health and human rights legislation.
106
F5
Patients have access to a range of appropriate advocacy
services.
106
F6
There are systems and support to enable a successful
independent civil advocacy service to be operated.
1.17.1a
D11*
The service provides patients with information regarding
what patients can expect from the service.
1.17.1a
1.17.1e
1.17.1g
4.9.4e
4.9.4g
10.16.10b
D17
There is an implemented policy setting out the
consultation and involvement of carers in the care
provided.
The unit’s policy and procedures are agreed through
discussion with the whole unit.
The views of patients, their carers and others are sought
and taken into account in designing, planning, delivering
and improving healthcare services.
1.17.1j
4.9.4a
16.10.16d
D8*
1.17.1a
D23
1.17.1j
4.9.4b
E1*
Feedback from patients and carers is used to improve
the quality of the unit
1.17.1j
16.10.16a
16.10.16c
D22
F7
F8
F9
F10
F11
F12
F13
F14
Staff receive training in equality issues and their impact
upon patient care.
Staff understanding of equality issues are monitored
through the appraisal system.
Complaints are continually monitored to identify trends
and learning points which are reviewed quarterly.
25
107
108
108
C42
D10
D1w
C10
14.23.14c
16.10.16a
C1.1*
No.
F15
Standard
There is an implemented policy to meet the individual
cultural needs of patients.
F17
Staff demonstrate respect for patients.
F19
Essential
Standards of
Quality & Safety
(CQC – March
2010)
Systems are in place that ensure patients (particularly
those vulnerable to exploitation e.g. financially,
emotionally or sexually) are not subject to bullying by
other patients or visitors or staff and that this is
managed effectively.
F16
F18
DH Guidance
LSU
Patients are encouraged to personalise their bedroom
spaces appropriately. (Pictures of nude bodies or
pictures of children may be inappropriate)
Patients are provided with meals which are of a high
quality, offer choice, address nutritional/balanced diet
and specific dietary requirements and which are also
sufficient in quantity, are varied and appealing and
reflect individual’s cultural and religious needs. (Better
Hospital Food – Department of Health 2004).
26
Implementation
Criteria for
Recommended
Specification:
Adult Medium
Secure Units with
supplement
Standards and
Criteria for Women
in
Medium Secure
Care
C2*
1.17.1a
1.17.1b
1.17.1g
1.17.1i
2.18.2b
4.9.4a
5.14.5d
1.17.1a
1.17.1b
1.17.1c
7.11.7i
17.19.17e
D5*
D13
10.15.10a
10.15.10l
D21
5.14.5a
5.14.5b
5.14.5c
5.14.5d
5.14.5f
5.14.5h
F10.1*
27
Appendix 1: Delegates, Standards Working
Group
First Name
Surname
Role
Nigel
André
Phil
Brian
Jean
Callender
Paul
Diane
Cartmell
Clayton
Sheryle
Cleave
Clinical Nurse Manager
Marc
Cookson
Clinical Nurse Manager
Maureen
Cushley
Senior Nurse Manager
Paul
Gilluley
Stephen
Simon
Carly
Joanne
Godwin
Lloyd
Morgan
Spears
Consultant Forensic
Psychiatrist
Deputy General Manager
Head of Clinical Services
Consultant Psychiatrist
Clinical Team Leader
Joseph
Neil
Vella
Woodward
Consultant Psychiatrist
Security Manager
28
Clinical Team Leader
Head of Secure Services
Commissioning
Ward Manager
Organisation
Northumberland Tyne and Wear
NHS Foundation Trust
West Midlands Commissioning
Team
Northumberland Tyne and Wear
NHS Foundation Trust
Northumberland Tyne and Wear
NHS Foundation Trust
Northumberland Tyne and Wear
NHS Foundation Trust
West London Mental Health
Trust
West London Forensic Service
Ridgeway
St. Andrew's Healthcare
Janet Shaw Unit
Northumberland Tyne and Wear
NHS Foundation Trust
Gerry Simon Clinic
Ridgeway
Appendix 2: Delegates, Standards
Consultation Event
First Name
Surname
Role
Organisation
Paul
Guy
Colin
Gilluley
Cross
Reynolds
Chair
James
Lee
Consultant Forensic Psychiatrist
Andrew
Anne
Duff-Miller
Herbert
Shirish
Bhatkal
Consultant Psychiatrist
Unit Manager
Consultant in Rehabilitation
Psychiatry
Lorna
Elliot
Modern Matron
Zena
Nasser
Consultant Psychiatrist LSU
Melanie
Evans
Assistant Director
Phil
Shackell
Steven
Chris
Pratish
Woolgar
Harden
Thakkar
Interim Deputy Director of Secure
Commissioning (Specialised Mental
Health and Learning Disabilities)
Director of Policy and Regulation
Group Security Officer
Consultant Forensic Psychiatrist
Jennifer
Berry
Commissioner
Adam
Townsend
Kate
Axford
David
Phil
Naomi
Munns
Broxton
Collier
Ward Manager
Occupational Therapy Professional
Lead
Clinical Governance Manager
Therapy Manager
Ward Manager
Service User
Mgcini
Nkomo
Senior Nurse
Dumisani
Lupahla
Ward Manager
Syed
Consultant Forensic Psychiatrist
Forensic Security Liaison Manager
Shaftesbury Clinic
Sallie
Husain
HamiltonHolman
Williams
Partnerships in Care
Partnerships in Care
Ridgeway
South Of England
Specialised Commissioning
Group -Specialised Mental
Health and Learning
Disabilities
St. Andrew's Healthcare
The Dene and Pelham
Woods
St. Magnus
St. Andrew's Healthcare
St. Andrew's Healthcare
St. Andrew's Healthcare
West London Forensic
Services
St. Andrew's Healthcare
Birmingham
Wickham Unit
Shaftesbury Clinic
Rick
Driscoll
Johanna
Tahti
Peter
Fornah
Neil
Woodward
Ward Manager
Consultant Forensic and
Rehabilitation Psychiatrist
Doctor for female LS services
Ward Manager for Female LS
Services
Security Manager
John
McCarron
Senior Nurse
James
Jackie
Alexander
Somers
Security Manager
Ward Manager
Marcus
29
Ward Manager
QNFMHS Advisory Goup
Department of Health
Ash Ward
Challenging Behaviour
Service - Memorial Hospital
Derby Ward
Farmfield Hospital
Horton Rehabilitation
Services
Horton Rehabilitation
Services
Kent & Medway NHS & SC
Partnership Trust
North London Forensic
Services
North of England
Specialised Commissioning
Thornford Park Hospital
Cygnet Hospital Beckton
Cygnet Hospital Beckton
Ridgeway
Shelton Hospital
Shrewsbury
Wells Road Centre
St. Andrew's Healthcare
Alison
James
Lesley
Joseph
Carr
Cooper
Wilson
Vella
Ward Manager
Hollis
McClatchie
Brian
Seb
Mandisodza
Pringle
Service Co-ordinator
Consultant Psychiatrist
Matron - Secure and Forensic Low
Secure Services
Registered Unit Manager
Service User Expert
Arlena
Ruben
Charge Nurse and Recovery Lead
Lina
Aimola
Research Fellow
Alice
Taylor
consultant clinical psychologist
Colette
Emmanuel
Gary
Gordon
Hamer
Onukwube
Stobbs
Tsubira
Service Manager
Clinical Services Manager
Registered Unit Manager
Senior Occupational Therapist
Imogen
Mortiboys
Clinical Services Manager
James
Mullins
James
Jeni
Tighe
Chamberlain
Integrated clinical lead, forensic
mental health services (sept)
Clinical Nurse Research Fellow
Unit Manager
John
Scott
Security Team
John
John
Hall
Abu
Kaysi
Thinn
Forensic Case Manager
Clinical Team Leader
Locum Consultant Forensic
Psychiatrist
Keith
Russell
General Manager
Larte
Leanne
Lisa
Lawson
Smith
Cairns
Nominated Individual
Lead Nurse
Clinical Services Manager
Nick
Badoorally
Ward Manager
Patrick
Simon
Steve
Susan
O'Sullivan
Lloyd
Godwin
Guchu
Medical Director
Head of Clinical Services
Deputy Head of Service
Clinical Team Leader
St. Andrew's Healthcare
Partnerships in Care
Brooklands
Gerry Simon Clinic
Hellingly and Chichester
Low Secure Services
Sutton's Manor
QNFMHS
The Dene and Pelham
Woods
Royal College of
Psychiatrists
North London Forensic
Services
St. Mary's Hospital
Cygnet Hospital Beckton
North London Clinic
St. Luke's Healthcare
St. Andrew's Healthcare
Birmingham
Robin Pinto Low Secure
Unit
The Bracton Centre
Thornford Park Hospital
The Dene and Pelham
Woods
Ridgeway
Sutton's Manor
Brockfield House
Secure and Forensic Low
Secure and Community
Services Sussex
Partnerships NHS
Foundation Trust
St. Luke's Healthcare
Kemple View
St. Andrew's Healthcare
Jupiter House Low Secure
and Forensic Services
St. Magnus
St. Andrew's Healthcare
Ridgeway
Sutton's Manor
Further Acknowledgements:
We are grateful to Dr Stephen Pereira, Chair of NAPICU and Dr Faisil Sethi, Vice Chair of NAPICU
for their advice and sight of the ‘NAPICU Response to Department of Health: Psychiatric Intensive
Care Unit and Low Secure Services Good Practice Commissioning Guides: March 2012’ .
30
Appendix 3: Advisory Group
First Name
Surname
Role
Head of Secure Services
Commissioning
Secure Services
Commissioning/ National
QIPP Programme
Phil
Brian
Rosie
Ayub
Ian
Carmichael
Service User Expert
Sheryle
Cleave
Clinical Nurse Manager
Paul
Gilluley
Stephen
Godwin
Consultant Forensic
Psychiatrist
Deputy General Manager
Julian
Haines
Social Work Manager
Quazi
Haque
Mary
Harty
Harry
Kennedy
Jeremy
Kenney-Herbert
Mat
Kinton
Clive
Long
Janet
Parrot
Group Medical Director
Consultant Forensic
Psychiatrist & Associate
Medical Director
Executive Clinical Director
& Consultant Forensic
Psychiatrist
Clinical
Director/Consultant
Forensic Psychiatrist
Mental Health Act Policy
Advisor
Associate Director of
Psychology and
Psychological Therapies
Consultant Forensic
Psychiatrist/Chair Forensic
Faculty
Susan
Riding
Carer Representative
Pete
Snowden
Medical Director
Anita
Trenfield
Carer Representative
31
Organisation
West Midlands Commissioning
Team
Yorkshire and Humber Secure
and Specialist Mental Health
Commissioning Team
Quality Network for Forensic
Mental Health Services
Northumberland Tyne and
Wear NHS Foundation Trust
West London Forensic Service
Ridgeway
North London Forensic Service/
National Group for Social Work
Managers in Secure Services
Partnerships in care
South West London & St
Georges Mental Health NHS
Trust
National Forensic Mental Health
Service, Central Mental Hospital
Reaside Clinic
Care Quality Commission
St. Andrew’s Healthcare
Royal College of Psychiatrists
Quality Network for Forensic
Mental Health Services
Partnerships in Care
Quality Network for Forensic
Mental Health Services
Appendix 4: Project Team
Name
Role
Sarah Tucker
Programme Manager
Michael Gray
Deputy Programme Manager - MSU
Sam Holder
Deputy Programme Manager - LSU
Sarah Stubbs
Project Worker
Ilham Sebah
Project Worker
Service User Experts
Abdirisak Hussein
Alex Sunyata
Ian Carmichael
Pebble Carmichael
Seb Pringle
Carer Representatives
Anita Trenfield
Susan Riding
32
33
34