An Organisation-wide Document for the Observation and Engagement of Service Users
NHS Mental Health & Learning Disability Trust
An Organisation-wide Document for the Observation
and Engagement of Service Users
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for the Observation and Engagement of Service Users
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 4
4.1
4.2
5
Duties within the Organisation ............................................................................................... 4
Committees and Groups with Overarching Responsibilities .................................................. 5
Principles of Observation ......................................................................................... 6
5.1
5.2
6
Communication ....................................................................................................................... 6
Engagement ............................................................................................................................ 6
Levels of Observation .............................................................................................. 6
6.1
6.2
6.3
6.4
7
General Observation ............................................................................................................... 6
Intermittent Observation ........................................................................................................ 6
Constant Observation ............................................................................................................. 7
Enhanced Observation ............................................................................................................ 7
Prescription of Observation ..................................................................................... 7
7.1
7.2
Increasing Observation ........................................................................................................... 7
Decreasing Observation .......................................................................................................... 7
8
Recording Observation ............................................................................................ 8
9
Risk Assessment ....................................................................................................... 8
10
Care Planning ........................................................................................................ 8
11
Skills and Training ................................................................................................. 8
12
Reporting Incidents .............................................................................................. 8
13
Equality Impact Assessment ................................................................................. 8
14
Monitoring Compliance with the Document ....................................................... 9
14.1
14.2
15
15.1
16
Process for Monitoring Compliance ....................................................................................... 9
Standards/Key Performance Indicators .................................................................................. 9
References ............................................................................................................ 9
Guidance from Other Organisations ....................................................................................... 9
Associated Documentation ................................................................................ 10
Appendix A - Template Document for the Observation and Engagement of Service
Users ............................................................................................................................. 11
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An Organisation-wide Document for the Observation and Engagement of Service Users
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.4
Annual review
Mar 2011
Update to section 16 ‘References’
V.4
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.5
Annual review
Mar 2012
Update to section 4 ‘Duties’
Update to section 5 ‘Principles of Observation’
Update to section 6 ‘Levels of Observation’
Update to section 11 ‘Skills and Training’
V.5
Amendment
Mar 2012
Change to format including automated
contents page
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-16, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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An Organisation-wide Document for the Observation and Engagement of Service Users
1
Introduction
This section should identify the requirement for guidance to inform the development of
local strategies and procedures for the management of service users who require
observation, either because of a combination of an assessed mental health problem, or a
potential mental health problem awaiting assessment, and it being in the interests of the
safety of the service user to minimise risk.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure the
implementation of high quality and robust systems for observing service users.
Formal observation systems should be flexible and not rigid; it is important that policy and
clinical practice developments are not restrictive.
3
Explanation of Terms
This section should list and describe the meaning of the terms used within the context of the
document. For example:

Risk assessment
A gathering of information and analysis of the potential outcomes of identified behaviours.
Identifying specific risk factors of relevance to an individual and the context in which they
may occur. This process requires linking historical information to current circumstances to
anticipate possible future change.
The following list is a guide only and is not exhaustive:
a
4

Engagement

Observation
Duties
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
4.1
Duties within the Organisation
Some example responsibilities have been identified below; however, these should
be considered within the context of the individual organisational structure.
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
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Individual Professional Duties
This section should include the duties and accountabilities of medical staff,
unit/specialist staff, nursing staff, and other staff groups involved in the observation
process.
Senior Manager(s)
Roles and responsibilities of senior manager(s) and their involvement in
management of the observation of service users should be documented.
Line Manager(s)
Roles and responsibilities of line manager(s) management of the observation of
service users should be documented.
Risk Manager
Roles and responsibilities of the risk manager in relation to the management of the
observation of service users should be documented.
4.2
Committees and Groups with Overarching Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for the
Observation and Engagement of Service Users there must be active support from the
most senior members of the organisation. Organisations should detail how the chief
executive and the nominated directors are to gain assurance that this document is
being implemented within the organisation. There must be effective cooperation at
all levels of the organisation in order for this process to be successful.
Committees/Groups
This section should identify the committee/group which will have overall
responsibility for the management of the observation of service users. The section
should include:

how this committee/group links with all the other relevant risk management
committees;

the role this committee/group has with ensuring continuous development of
this document;

the role the committee/group has in the analysis of the management of the
observation of service users;

how this committee/group communicates both up to board level, and down
to the local management levels; and

how the committee/group facilitates organisational learning and
improvement as a result of monitoring the provision of staff support
mechanisms.
It would be considered good practice if the organisation developed terms of
reference for this committee/group including: accountability, responsibility,
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authority, membership (including identified co-opted members and deputies),
meeting schedule and quorum, etc. In addition the terms of reference should be
dated and signed.
5
Principles of Observation
Observation can be defined as “regarding the patient attentively”, (Standing Nursing and
Midwifery Advisory Committee, 1999, p.20) whilst minimising the extent to which they feel
that they are under surveillance. Encouraging communication, listening and conveying to
the service user that they are valued and cared for are important components of skilled
observation. Maintaining privacy and dignity are challenging aspects for health care
professionals undertaking observation. The level of risk of harm occurring to the service
user should be considered against the effects that this potentially intrusive activity may have
on the individual.
5.1
Communication
The organisation is required to detail the communication needs for all concerned as
it is essential that all members of the mental health team caring for service users are
aware of the level of observation being used. The service user should be informed
of the process starting, and be given written information as well as the opportunity
to discuss any concerns or questions they have with an appropriate member of the
multidisciplinary team.
5.2
Engagement
Observation should be safe and therapeutic. Consideration should be given to the
use of activity, discussion and distraction processes, but recognition should also be
made of the need for silence and as much privacy as is safely achievable.
b
6
Levels of Observation
A definition of the principles of observation and the different levels of observation utilised
within the organisation should be included here to ensure that all staff are aware of the
requirements for each level of observation.
6.1
General Observation
The general level of observation is intended to meet the needs of most service users
most of the time. It should be compatible with giving service users a sense of
responsibility for their use of free time in a planned and monitored way. The staff
on duty should have knowledge of service users’ general whereabouts at all times,
whether they are in or out of the ward. Service users on general observation are
considered not to pose any serious risk of harm to themselves or others and are
unlikely to leave ward areas or other treatment departments without prior
permission, escort, or at least informing staff of their planned destination.
6.2
Intermittent Observation
The intermittent level of observation is intended for those service users who may,
although not immediately, be at risk of self harm, disturbed or violent behaviour.
The service user’s location should be checked every 15-30 minutes with the exact
times documented in the service user’s records. Checks should be carried out
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sensitively in order to cause as little intrusion as possible and to be seen as positive
engagement with the service user.
6.3
Constant Observation
The constant level of observation should be used for services users considered to
pose significant risk to themselves or others. An allocated member of staff should
be constantly aware at all times of the precise whereabouts of the service user
through visual observation or hearing. The method and purpose of maintaining
observation must be clearly determined and stated at the time of review. A balance
should be struck on the side of safety in all matters such as escorting to the toilet,
bathroom, public telephone, etc. Appropriate members of the multidisciplinary
team should review the need for constant observation at least every 24 hours.
6.4
Enhanced Observation
The enhanced level of observation will hopefully be rarely prescribed. The service
user should be assessed as requiring intensive and skilled intervention as a
consequence of their serious mental and/or physical state. The service user should
be in sight and/or within arms reach of a member of staff at all times and in all
circumstances. Consideration of privacy would be subordinate to those of safety. In
the event of the service user leaving the ward an appropriate number of escorts
should accompany him or her. As this form of observation is potentially very
intrusive, it should only be used when judged strictly necessary by the
multidisciplinary team, and this level of observation should be subject to frequent
review (at least every 24 hours) involving appropriate members of the team.
7

Within eyesight (at all times without exception): The service user should be
observed at all times, by day and night and, if deemed necessary, any tools
or instruments that could be used to harm themselves or others should be
removed.

Within arms length (at all times without exception): Service users at the
highest level of risk of harming themselves or others (possibly awaiting
transfer) may need to be supervised in close proximity. On specified
occasions more than one member of staff may be necessary.
Prescription of Observation
Ideally the multidisciplinary team should always make decisions with regard to the
prescription of observation. However, on many occasions (particularly at weekends and
evenings), decisions may have to be made by a doctor and the ward nursing team. Such
decisions should always be discussed at the first available opportunity with a larger number
of the full team.
7.1
Increasing Observation
Local procedural documents should clarify the procedure for increasing levels of
observation.
7.2
Decreasing Observation
The reduction in the level of observation should ideally be a team decision to ensure
service users are not left on an increased level of observation inappropriately. There
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should be a specific documented plan for each service user outlining the agreed
changes in behaviour that would facilitate a reduction in observation level and the
exact procedure for this decision to be actioned.
d
8
Recording Observation
The record should include the date and time of initiation, level of observation, the time
frequency of the observations where appropriate, and should be signed by those taking the
decision to initiate and/or make changes to observation(s). It could also include the name
and designation of the person undertaking the observation. Details as to where this
information is recorded should be included in the approved document.
Documentation that the organisation uses in the observation process, such as particular
forms, should also be included as part of the appendices.
9
Risk Assessment
A concurrent risk assessment should be used to inform decisions regarding the appropriate
level of observation.
10
Care Planning
The care plan should indicate the level of observation, the reason for the level of
observation and the interventions which may be used to engage with the service user.
c
11
Skills and Training
Observing service users at risk is a highly skilled activity. Staff should be trained in the skills
and competencies required to conduct observation, and be supervised in their practice of
this therapeutic activity as they would with any other form of treatment.
This section should describe how the organisation trains all necessary staff (qualified,
unqualified, other clinical staff, bank and agency staff). You should include a cross-reference
to the organisation’s training needs analysis.
12
Reporting Incidents
When observation fails, service users may die, come to serious harm or cause harm to
others. This section should outline the process for reporting incidents and/or link to the
organisation’s incident reporting documentation.
13
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
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e
14
Monitoring Compliance with the Document
14.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for the Observation & Engagement of Service
Users. As a minimum it should include the review/monitoring of all the minimum
requirements within the NHSLA Risk Management Standards. The following list is a
guide to issues which could be considered within this section and should be added
to where appropriate:
14.2

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
15
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
V.5
15.1
Guidance from Other Organisations

Clinical Resource and Audit Group (CRAG) (2002) Engaging People: Observation of
People with Acute Mental Health Problems: A Good Practice Statement

Department of Health (2002) Mental Health Policy Implementation Guide: Adult
Acute Inpatient Care Provision

Department of Health (2006) Mental health observation, including constant
observation: Good practice guidelines for staff working in prisons

HM Government (2010) New Horizons: A shared vision for mental health

Morgan, S. (2009) Clinical Risk Management: A Clinical Tool and Practitioner Manual

National Institute for Health and Clinical Excellence (NICE) (2004) CG16 Self-harm:
The short-term physical and psychological management and secondary prevention of
self-harm in primary and secondary care
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16

National Institute for Health and Clinical Excellence (NICE) (2005) CG25 Violence: The
Short-Term Management Of Disturbed/Violent Behaviour In In-Patient Psychiatric
Settings And Emergency Departments

Office of the Children’s Commissioner (2007) Pushed into the Shadows: Young
people’s experience of adult mental health facilities

Patient Safety First ‘How to Reduce Harm from Deterioration’ Patient Safety First
website page

Royal College of Psychiatrists (2010) Self-harm, suicide and risk: a summary. Position
statement

University of Manchester website lists all the National Confidential Inquiries into
Suicide and Homicide by People with Mental Illness (NCI/NCISH):
www.medicine.manchester.ac.uk
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and is not exhaustive:
V.5

Training needs analysis

Care Programme Approach (or other care planning processes dependent upon
configuration)

Absent without leave

Clinical risk assessment tools

Incident reporting
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An Organisation-wide Document for the Observation and Engagement of Service Users
Appendix A - Template Document for the Observation and Engagement of Service
Users
NHS Trust
An Organisation-wide Document for the Observation
and Engagement of Service Users
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for the Observation and Engagement of Service Users
Contents
1
Introduction ........................................................................................................... 14
2
Purpose .................................................................................................................. 14
3
Explanation of Terms ............................................................................................. 14
4
Duties ..................................................................................................................... 14
4.1
4.2
5
Duties within the Organisation ............................................................................................. 14
Committees and Groups with Overarching Responsibilities ................................................ 14
Principles of Observation ....................................................................................... 14
5.1
5.2
6
Communication ..................................................................................................................... 14
Engagement .......................................................................................................................... 14
Levels of Observation ............................................................................................ 14
6.1
6.2
6.3
6.4
7
General Observation ............................................................................................................. 14
Intermittent Observation ...................................................................................................... 14
Constant Observation ........................................................................................................... 14
Enhanced Observation .......................................................................................................... 14
Prescription of Observation ................................................................................... 14
7.1
7.2
Increasing Observation ......................................................................................................... 15
Decreasing Observation ........................................................................................................ 15
8
Recording Observation .......................................................................................... 15
9
Risk Assessment ..................................................................................................... 15
10
Care Planning ...................................................................................................... 15
11
Skills and Training ............................................................................................... 15
12
Reporting Incidents ............................................................................................ 15
13
Equality Impact Assessment ............................................................................... 15
14
Monitoring Compliance with the Document ..................................................... 15
14.1
14.2
15
15.1
16
Process for Monitoring Compliance ..................................................................................... 15
Standards/Key Performance Indicators ................................................................................ 15
References .......................................................................................................... 15
Guidance from Other Organisations ..................................................................................... 15
Associated Documentation ................................................................................ 15
Appendix A
Checklist for the Review and Approval of Procedural Documents ...... 16
Appendix B
Version Control Sheet ........................................................................... 16
Appendix C
Plan for Dissemination .......................................................................... 16
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Appendix D
Equality Impact Assessment Tool ......................................................... 16
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
Review and Amendment Log
Version No
V.5
Type of Change
Date
March 2012
Description of change
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An Organisation-wide Document for the Observation and Engagement of Service Users
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
5
6
7
V.5
4.1
Duties within the Organisation
4.2
Committees and Groups with Overarching Responsibilities
Principles of Observation
5.1
Communication
5.2
Engagement
Levels of Observation
6.1
General Observation
6.2
Intermittent Observation
6.3
Constant Observation
6.4
Enhanced Observation
Prescription of Observation
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7.1
Increasing Observation
7.2
Decreasing Observation
8
Recording Observation
9
Risk Assessment
10
Care Planning
11
Skills and Training
12
Reporting Incidents
13
Equality Impact Assessment
14
Monitoring Compliance with the Document
15
14.1
Process for Monitoring Compliance
14.2
Standards/Key Performance Indicators
References
15.1
16
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Guidance from Other Organisations
Associated Documentation
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V.5
Appendix A
Checklist for the Review and Approval of Procedural Documents
Appendix B
Version Control Sheet
Appendix C
Plan for Dissemination
Appendix D
Equality Impact Assessment Tool
March 2012
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