This guideline is for use with children and young people at Calderdale and Huddersfield
Foundation Trust with Mental Health needs/problems or Medical Conditions and underlying Mental Health Issues who are admitted to the Paediatric Unit.
This guidance should be considered in conjunction with the Trusts Deliberate Self-Harm
Guidance.
Version Control Date Contribution
Initial Document
2 nd Draft
March 2015
May 2015
3 RD Draft June 2015
Gill Harries (General Manager)
Jonathan Garside Clinical Director Paediatrics,
Mini Pillay (Clinical Director CAMHS), and Angie
Salmons Ward sister, Victoria Cox (A&E
Consultant Paediatric lead)
Shared with task and finish group, ADN,
Directorate leads for comments , CAMHS ,
Paediatric Clinicians
4 th Draft
5 th draft
July 2015
Sept 2015
All Paediatrician’s, Ward managers
1.
Paediatric forum for ratification2
2.
Acceptance through SWYMFT governance procedures
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CONTENTS
1
2
3
5
6
4
3.1
3.2
3.3
4.1
4.2
6.1
6.2
6.3
Introduction
Purpose
Decision to admit to the ward 3 Paediatric
Unit at CRH
Prior to Patient arriving on the ward
On Admission
Ongoing assessment and management
Defining the level of observation
General Observation
Special Observation
Considerations
Use of Section 5(2) of the Mental Health Act detaining voluntary patients
Nature of the power
Patients right’s
Transfer of Patients detained under Section
5(2)
Sedation 7
8
9
9.1
9.2
9.3
Safeguarding
Restraint
Circumstances of Restrictive Physical
Intervention (Restraint)
Principles in the use of Restrictive Physical
Intervention (Restraint) of a Child/Young person
Restrictive Physical Intervention/Therapeutic
Holding
Appendix 1 Risk Assessment Page 10
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Page 4
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Page 5
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Page 6
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Page 7
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Page 8
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Page 9
Page 9
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1 INTRODUCTION
This Joint guidance has been produced by the trust in partnership with the Provider of
Child and Adolescence Mental Health services to ensure the safe care and supervision of
Children and Young people (CYP) admitted to the inpatient unit at Calderdale Royal infirmary presenting with mental health problems. The inpatient unit does not routinely have appropriately trained staff deal with patients with severe serious mental health issues and therefore needs to minimise risk to patients, carers and staff on the unit.
This guidance should be considered in conjunction with the Trusts Deliberate Self-Harm Guidance.
For these patients the environment is risk assessed and adapted where possible to meet the individual needs of the patient. The inpatient ward may not be able to fulfil all of these requirements and therefore may not be able to provide a suitable and safe environment for individual patients and an alternative placement will be sought .
2 Purpose
The purpose of this policy is to ensure children and young people with mental health or emotional problems receive the appropriate support and intervention throughout their inpatient episode.
3. Decision to admit to the ward 3 Paediatric Unit at CRH
The Paediatric Unit at Calderdale and Huddersfield Foundation Trust is a General Paediatric
Ward and not a specialist mental health unit. Children or young people admitted for
CAMHS must need emergency admission or be medically unwell. The admission may be due to
1. Self-harm and require a period of cooling off as per NICE guidance
2. Children who present with mental health issues but have not self-harmed need assessment by the CAMHS team before they come to the ward. If there is a decision to admit then the patients should have a joint care plan and discussion had with the responsible paediatrician
3. Prior to admission on the ward the nurse in charge and responsible Paediatric Consultant should accept the referral from CAMHS
3.1 Prior to Patient arriving on the ward:
Any admissions should always be reported to the nurse in charge as soon are accepted as an admission to Ward 3 Calderdale and Huddersfield Foundation Trust will take patients up to their 16 th birthday.
Consider which bed is most suitable for the Patient – Normally this will be room 35 on Ward
3D as some safety modifications which have been made to the room. Patients aged16 and over will not be admitted to ward 3 a. Remove the sharps bin from the room/bed space b. Remove any equipment, including tubing, instruments that are not essential c. Check that pull cord in the room are anti-ligature
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d. Brief all Clinical staff in order to increase awareness of potential risks. e. In cases of high risk the bed frame and waste bins should be removed from the room.
3.2 On Admission
1. The patient’s belongings should be checked if appropriate to assess they do not have any items on them that could be used to harm themselves or others. If this cannot be undertaken for any reason, this should be clearly documented in the patient’s notes explaining the rationale to the patient.
2. Ensure no medications are stored in the room/bed space
3. Complete risk assessment (appendix 1) If the Patient requires 1:1 for Mental Health reasons please ensure the CAMHS Team have specified in the treatment plan the level of supervision required with a review date
4. Ensure the 1:1, is fully briefed about the patient’s history, risks and management plan
5. All patients admitted to the paediatric unit who have Mental Health needs are always admitted under the attending Paediatrician but the ir care should be under “Shared Care” principles with the CAMHS Team, leading on the mental health aspect of care.
3.3 Ongoing assessment and management
1. Paediatric Medical staff will review patients daily on the ward round to assess for any medical issues.
2. All patients should be reviewed by a member of the CAMHS team at least once a day who would ensure a more comprehensive assessment and plan is formulated.
Any changes updated to the management plan should be communicated to ward nursing staff. The review should include the following

Level of risk

Level of observation required

The need for continued stay on the ward.

Care plan review
3. CAMHS reviews where the inpatient stay falls over a weekend; the care plan should clearly state the arrangements for daily review over the weekend, using the same principles as in point 2.
4. The review should be aimed at reducing the length of stay on the paediatric ward and actively looking for alternatives – in cases where a Tier 4 unit is appropriate, this will be led by CAMHS. In all other cases, e.g. safeguarding, this will need to be discussed between Paediatrics and CAMHS to ensure the appropriate lead professional is in place
5. A Nurse must always be assigned to the patient as well as the1.1, to carry out all liaison work to meet the needs of the patient in relation to medication, vital signs safe environment and the monitoring any other health needs
6. If a Patient tries to leave and it is felt they may be mentally ill and at risk to themselves or others then a Paediatric Medical Doctor may decide to place the Patient on a section 5(2)
– Doctors Emergency Holding Power. The Code of Practice says that the doctor who does so should make immediate contact with a psychiatrist or approved clinician, preferably before placing the patient on a 5(2).
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7. Liaison with the school nurse and social worker if appropriate should be carried out on discharge to ensure smooth communication. It should be clearly documented in the medical notes who is taking responsibility for this.
8. In complex cases or instances when the admission of the Child/Young Person is longer than initially anticipated there should be a multi professionals meeting of key stakeholders to ensure a realistic plan of care are in place with key stake holders/partners in the children or young persons care.
9. In cases of extended stays on the ward over 48 hours a Datix form should be completed, General manager and Lead clinical nurse informed who will escalate to appropriate CCG
4. Defining the level of observation
For the purposes of defining the level of observation that all CYP need the following categories are to be used. All enhanced levels of observation must be documented on the risk assessment form set out in Appendix 1. The following categories of supervision/observation are provided to support staff in identifying the most appropriate level of supervision and care needs for a specific child or young person.
4.1 General observation
CYP subject to this type of observation are not deemed to be a current risk to themselves or others this level of support must be identified on the risk assessment
(Appendix 1).They are informed they should remain within the care setting which has been designated unless permission from the shift leader has been given and that this has been clearly documented in the nursing records.

General observation allows for regular contact with and access to the children’s allocated nurse.

A visual check is made on the CYP at regular intervals which have been agreed in the care plan and formally recorded.

This can only be done when the CYP is on the ward or its immediate vicinity .

If the CYP leaves the ward to the extent that his/her observation is not possible, this is recorded on the observation record in accordance with an agreed care plan.

All children/young people admitted for mental health reasons must be subject to at least this level of observation
4.2 Special Observation
This type of observation will be used with children and young people who are deemed to present an immediate risk to themselves or others. Special observation can potentially be perceived as intrusive and should only be used when appropriate.
Staffing assigned to undertake this level of support must be identified on the risk assessment (Appendix 1).

The frequency and regularity of visual checks of the CYP should be agreed by between CAMHS and nursing and medical staff and documented within the care plan.
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
The care plan should stipulate the maximum distance which is permissible between supervising staff and the CYP and whether the supervisor should remain in the same room

The staff member will remain with the CYP when they are in the company of visitors and care must not be handed over to the visitor at any time

All checks are recorded on the appropriate documentation.

A child/young person subject to special observations must not leave the ward area unescorted.
5. Considerations
A. Respect for privacy is important and should be balanced against the safety in matters such as going to the toilet/ bathroom, using the telephone or receiving visitors.
B . All decisions to raise or reduce the level of supervision should be part of a risk assessment process and discussed with the, relatives and carers.
C . Bed location must be considered. The child or young person may need to be nursed in a single room to reduce stimulation and enable rest or because they cause a disturbance to other patients or disruption to care delivery.
D. Where more than one child or young person requires enhanced supervision there may be a requirement to cohort patients into a same sex bay. Patients requiring 1:1 supervision will be identified on the staff handover
E. Staff must have the appropriate levels of skill and competence to undertake high level observation/supervision of patients and where possible staff will be familiar with the patient.
This may require the employment (via staff bank of Registered Mental Nurses (or Clinical
Support Workers) with the appropriate training on a temporary basis to observe the patient and provide therapeutic care These staff must be orientated to the ward environment and should be employed until the patient is either discharged or the level of supervision downgraded to low risk. Ideally the same group of staff should be employed to provide continuity of patient care rather than employing cover on an ad hoc basis.
6. Use of Section 5(2) of the Mental Health Act- detaining voluntary patients
Section 5(2) is a section of the 1983 Mental Health Act (Amended 2007) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/396918/Code
_of_Practice.pdf
Authorizes the detention of a patient for up to 72 hours it is commonly referred to as a
Doctors Emergency Holding Power and can only be used where the Doctor in charge of the treatment of an informal in-patient, or that doctor's nominated deputy, concludes that an application for admission under one of the relevant sections of the Mental Health Act is appropriate. There is no age limit on its use but it is vital that the Child/Adolescent meets the criteria as detailed below before it is put in place. Decision-makers should always consider whether there are less restrictive alternatives to detention under the Act (chapter 14).
In order to consider Section 5(2), the Doctor must have a belief that there is a psychiatric reason that is affecting the patient’s decision making ability that warrants further
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assessment under the Mental Health Act and believes that if the patient leaves they may be placing themselves or others at risk. A section 5(2) can only be used where the patient is already an in-patient receiving treatment. It can not be used in the Accident and Emergency or Out patients Department. Doctors and approved clinicians should use the holding power only after having personally examined the patient.
Doctors employed by South West Yorkshire Mental health NHS Trust working within
CAMHS or as a duty Psychiatrist do not have the power to detain an in-patient of
Calderdale and Huddersfield Foundation Trust under section 5(2) of the Mental Health Act.
If they are “Section 12 approved” they can however complete a medical recommendation for a Section 2 (Assessment) or a Section 3 (Treatment).
6.1 Nature of the power
The identity of the person in charge of a patient’s medical treatment at any time will depend on the particular circumstances. A professional who is treating the patient under the direction of another professional should not be considered to be in charge.
The period of detention starts at the moment the doctor’s or approved clinician’s report is completed. In this context, a hospital in-patient means any person who is receiving inpatient treatment in a hospital. It does not apply to a patient who is already liable to be detained under section 2, 3 or 4 of the Act, subject to a community treatment order, or a person who is being kept in a hospital as a place of safety under section 135 or 136. It includes patients who are in hospital by virtue of a deprivation of liberty authorisation under the Mental Capacity Act 2005 https://www.gov.uk/.../ mental capacity act -making-decisions
(see chapter 13). It does not matter whether or not the patient was originally admitted for treatment primarily for a mental disorder. The patient could be receiving in-patient treatment in a general hospital for a physical condition.
6.2 Patient’s Rights
The Nurse in charge and responsible Consultant must ensure that patients detained under this section are informed immediately (unless their mental state is such that it will be inappropriate to provide this information).
1. Their detention under section 5(2), or other section of the Act following completion of their mental health assessment,
2. Why it is necessary.
3. The rights the patient has whilst subject to detention
4. Any change in their liability to detention under the Act
5. If the Patient does not understand their rights when they are read to them, further attempts must be made on each subsequent shift. Each attempt must be documented in the patient’s notes.
6.3 Transfer of Patients detained under Section 5(2)
There is no authority for the compulsory transfer of patients liable to detention under this section of the Act from one hospital to another. The patient must remain in the Hospital
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where the section was applied until the Mental Health Act assessment is complete and their liability to detention under section 5(2) is brought to an end.Children and young person
7. Sedation
Children and young people, who are placed under an enhanced level of supervision, may by the nature of their underlying clinical presentation require sedation. A senior doctor must be involved in any decision regarding the prescribing and administering of sedation following consultation with specialist resources. It may also be appropriate to involve family members or carers. The principles for administration of sedation must be: a. Prescription adheres to the Trust’s Medicine Policy b. Administration is conducted in line with the Consent Policy and
Trust’s Medicine Policy. c. If once-only medications are prescribed, an appropriately skilled member of the medical team must review the Children and young person after administration d. Frequency of observation requirements must be requested by the medical prescriber and documented in the care plan.
8. Safeguarding
All staff members have a responsibility to safeguard the welfare of children and young people. Information regarding safeguarding the child and young person including additional assessment can be found on the Safeguarding section of the Trust Intranet,
9. Restraint
In all cases the overriding principle is that a child’s welfare is paramount. Under common law restraining a child in their best interests to protect them from immediate risk of harming themselves will be lawful (subject to the proviso of using reasonable force). However, the law relating to children is complex and in individual cases advice should be sought from experts such as the trust child protection leads to consider the steps needed to minimise any legal or safeguarding risks. Guidance is also available from the Royal College of
Nursing (2010). Any form of restraint should be document in the patient’s record
9.1 Circumstances of Restrictive Physical Intervention (Restraint)
If a child is detained under a Court Order or is subject to detention under the Mental Health
Act 1983, the expectation is that the ‘staff intervene positively’ if that child attempts to leave without authority. In other circumstances, staff should only intervene where immediate action is necessary to prevent a child from significantly injuring themselves or others or causing significant serious damage to property. Injury in this context is taken to mean
‘’significant injury’’ and would include actual bodily harm or grievous bodily harm, physical or sexual abuse, risking the lives of, or injury to self or others by wilful or reckless behaviour, and self-poisoning. This includes preventing a Child from leaving if they would present a risk to themselves or others. The law requires that force should only be used when every other approach has been tried and that all practical methods to de-escalate the situation have been employed. Any form of restraint should be document in the Children and young person
’s record
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9.2 Principles in the Use of Restrictive Physical Intervention (Restraint) of a
Child/Young Person
Staff must always attempt to use de-escalation techniques before any form of physical intervention. As soon as it is safe, restraint should gradually be relaxed to allow the child to regain self-control. Physical restraint should only be used as a last resort and it is in the judgement of the staff member involved what degree of force is necessary to prevent the child causing injury to themselves, others or to property.
If the Children and young person has Mental Health needs, Specialist Mental Health
Professionals must be actively involved in any decision making regarding restraining a
Children and young person, unless it is an emergency in which case they should be informed at the earliest possible point. A clear account must be documented in the Children and young person’s medical notes and a Datix form must be completed. Whenever Security
Officers are requested to be involved in restraining a child/young person they can only do so with the agreement of the senior clinician involved in the situation.
Consideration must be given to the gender of the Child/Young Person. There should always be at least one person of the same gender as the child/young person involved in the management of the incident.
9.3 Restrictive Physical Intervention/Therapeutic Holding
This means immobilisation, which may be by splinting, or by using limited force. It may be a method of helping children, with their permission, to manage a painful procedure quickly or effectively. Therapeutic holding for a particular clinical procedure also requires nurses to give careful consideration of whether the procedure is really necessary, and whether urgency in an emergency situation prohibits the exploration of alternative sedation
In all but the very youngest children, obtain the child’s consent or expressed agreement and for any situation which is not a real emergency situation to seek the parent/ carer’s consent.
This agreement should be clearly documented in the plan of care and any event fully documented
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Appendix 1: Risk Assessment
Name:
Ward:
Hospital Number:
D.O.B:
Risk Category identified :
(i.e. Risk to self, others, environment, exploitation, vulnerability)
1. Risk to Self: history of self harm, life threatening behaviour- overdose, bruising, minor fractures, suicidal tendencies
2.Risk to Others: threats of violence, actual harm to others, damage to property, violent behaviour or aggressive tendencies
3.Risk to Environment: Fire setting behaviour, deliberate minor damage to equipment or surroundings
4.Risk –Vulnerability/Exploitation: Child protection concerns,
Date
Time:
Name of Health Professional(s) undertaking risk assessment:
Signature of Health Professional(s):
Details / Rationale :
(Clinical need, previous history,)
Level of
Supervision
Required:
General
Special
General
Special
General
Special
General
Special
Review Section:
(Please state risk assessment review date)
Additional Comments:
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