Document name:
Management of Aggression and
Violence: Personal Safety and Violence
Reduction policy, procedures and
guidance
Document type:
Clinical Policy
Staff group to whom it applies:
All staff within the Trust
Distribution:
Trust wide
How to access:
Intranet and Internet
Issue date:
September 2015
Version:
Version 4;
updated in response to safety alert
NHS/PSA/W/2015/011, Jan 2016
Next review:
September 2017
Approved by:
Executive Management Team
Developed by:
Managing Aggression and Violence
Network
Director leads:
Director of Nursing Clinical Governance
and Safety
Contact for advice:
Mark Kidder
Network Leader Managing Aggression
and Violence
01924 327064
Mark.kidder@swyt.nhs.uk
1
Contents
1
Introduction ................................................................................................... .3
2
Purpose ............................................................................................................3
3
Duties ................................................................................................................4
4
Definitions ........................................................................................................6
5
Development of Policy ....................................................................................7
6
Review and revision arrangements including version control .....................7
7
Dissemination and implementation ................................................................8
8
Monitoring Compliance.................................................................................. .9
9
Guidance ........................................................................................................ 10
9.1 Legal issues .................................................................................................... 10
9.2 Ethical issues .................................................................................................. 12
9.3 Mental Capacity Act (MCA) 2005 ..................................................................... 12
9.4 Human Rights Act (1998) ................................................................................ 13
9.5 Public health model ......................................................................................... 13
9.6 Primary prevention .......................................................................................... 14
9.7 Secondary interventions .................................................................................. 16
9.8 Tertiary interventions ....................................................................................... 17
9.9 Restraint .......................................................................................................... 18
9.10 Mechanical restraint ......................................................................................... 22
9.11 Restraint in order to administer treatment ....................................................... 23
9.12 Taking blood without consent .......................................................................... 23
9.13 Rapid tranquillisation ....................................................................................... 23
9.14 Seclusion ......................................................................................................... 23
9.15 Setting incident thresholds for frequent challenging behaviour ....................... 23
9.16 Arrangements for ensuring the safety of lone workers .................................... 23
9.17 Weapons ......................................................................................................... 24
9.18 Situations in which Police involvement may be requested .............................. 24
9.19 Training ........................................................................................................... 25
10 Procedures .................................................................................................... 26
10.1 De-Escalation techniques ................................................................................ 26
10.2 Restraint General principles ............................................................................ 26
10.3 Restraint Procedure………………………………………………… …….....………27
10.4 Post incident support and learning .................................................................. 28
10.5 Evaluation and review ..................................................................................... 29
10.6 Specialist advice .............................................................................................. 29
11 References ..................................................................................................... 29
12 Association documentation ......................................................................... 30
Appendix A What MAV course should I attend ....................................................... 32
Appendix B Equality Impact Assessment Tool ....................................................... 33
Appendix C Version Control Sheet ......................................................................... 35
2
1. INTRODUCTION
This policy supports a consistent and positive approach to the management of
aggression and violence within South West Yorkshire Partnership NHS
Foundation Trust (SWYPFT). While recognising incidents of violence may occur
within the course of clinical work, it aims to support staff in effectively managing
such incidents safely and effectively. Another key aim of this policy, and its
associated procedures and guidance, is reducing the number and severity of
incidents of aggression and violence through shaping practice and addressing
environmental factors which may contribute to these episodes. It also aims to
reduce the frequency of the use of restrictive physical interventions.
2.
PURPOSE
2.1 Purpose of the policy

Provides guidance on how situations can be
minimises the risk to users of the service.

Promote safety of staff

Identify best practice

Set the standards across the organisation

Support training packages in place

Ensure safeguards in place to
aggression

Reduce the use of physical intervention in the organisation

Safe use of restrictive physical intervention as last resort
2.2
Rationale for development
dealt with in a way that
manage episodes of violence and
The Trust aims to balance the rights and responsibilities of people using its
services with those of employees, with a clear approach to therapeutic risk
taking. It also aims to support staff, by ensuring that working environments are
as safe and pleasant to work in as possible.
This document outlines how these aims will be addressed and indicates the
Trust’s responsibilities and those of its staff.
Risks from aggression and violence are assessed by use of the Trust’s
recognised risk assessments (clinical and non clinical) in order to develop safe
and supportive systems including the development of personal safety
precautions and the development of appropriate skills by its employees.
2.3
Objectives and intended outcome of the policy
To provide the Trust and Trust staff with a framework to effectively reduce and
manage the risk from aggression and violence.
The objectives are to:

Support the reduction of violence and aggression by identifying causes and
by utilising proactive approaches to reducing incidents;
3

Reduce the use of restrictive physical intervention

Clarify responsibilities in relation to Managing Aggression and Violence
within the Trust as well as the remit and scope of roles;

Outline / describe the Trust’s commitment to training and risk continuum
Appendix A);

Ensure SWYPFT employees are aware of and can access Managing
Aggression and Violence specialist advice.
3.
DUTIES
The Chief Executive has overall responsibility for the implementation of this
policy.
The Director of Nursing, Clinical Governance and Safety has lead
responsibility for the management of aggression and violence, and is the
identified board member for increasing the use of recovery-based approaches
including, where appropriate, positive behavioural support planning, and
reducing restrictive interventions, reporting regularly to the Trust board on
performance.
The Network Leader for the Management of Aggression and Violence is
responsible for managing and maintaining a network of Personal Safety
Specialist Advisors and Trainers. The Network Leader will ensure that network
staff supports the Business Delivery Units and support services, in identifying
training and development needs with reference to current legislation and best
practice. The Network Leader will assist the Trust in reviewing incidents and
recommend appropriate action.
The Personal Safety Specialist Advisers are responsible for supporting the
development and maintenance of a strategic approach to personal safety
throughout the Trust. They will support and advise the Business Delivery Units
in providing safe and effective care in line with current policy and best practice.
The Specialist Advisers also deliver the training for SWYPFT alongside the MAV
trainers.
The Service Managers will ensure :

Staff are aware of and familiar with this and related policies;

Incidents of aggression and violence are managed to ensure the immediate
safety of those involved;

Liaison with clinical teams, managers, Specialist Advisors, and the police
as necessary

All incidents of aggression and violence are reported factually in clinical
records and entered on to the Incident Management Database (DATIX) or
via DATIXWEB;

Incidents of violence are investigated in line with the Incident Reporting
and Management (including Serious Untoward Incidents) Policy and
Procedures;

Learning from reviews are brought to the attention of the relevant
Business Delivery Unit or sub group, the Trust Group responsible for
4
managing aggression and violence and Personal Safety and Aggression
Management Specialist Advisers or relevant other Specialist Advisers for
further analysis and for sharing more widely across the Trust;

Appropriate clinical risk assessments are undertaken and clinical risk
assessment tools relating to aggression, violence and personal safety are
used; suitable management plans are devised to prevent and manage such
incidents. The information will be communicated via multi disciplinary team
meetings and Care Programme Approach (CPA) meetings;

The generic risk assessment for personal safety contained in the Health
and Safety Risk assessment folder is completed. A risk management plan
and local procedures should be developed to minimise the risk of violence
to staff, service users and the public. These will be evaluated at least
annually. Personal safety risk assessment

Staff are made aware of the risks within the work place and their personal
responsibilities at local and Trust induction. They should also receive
information, instruction and education to enable them to work safely;

All staff attend their mandatory training and updates appropriate to their
area of work commensurate with the level of potential risk, identified with
reference Appendix 1;

Staff trained in physical skills (breakaway/disengagement or team work)
attend refresher updates in accordance with training needs analysis

Employees with disabilities, ongoing health conditions, or pregnant
employees and nursing mothers who may need to work in identified risk
areas have a separate risk assessment as appropriate. It may be
appropriate to consult with occupational health staff;

All those affected by violent/aggressive situations are to be offered
appropriate post incident support, including follow up support, which may
include prosecution of an offender through liaison with the Local Security
Management Specialists (LSMSs).
All Employees should:

Employees are responsible for taking reasonable care of their own safety
and the safety of others who are affected by their acts or omissions;

Comply with this policy;

Be familiar with related policies and procedures;

Access regular training and updates;

Follow any advice, systems, procedures or education introduced in order to
reduce or eliminate risks identified.

Share information with colleagues to minimise aggression; Support
colleagues managing potentially aggressive situations;

If required, deploy RPI
experience

Seek ongoing support, supervision and advice;
appropriate to their skills, knowledge and
5

Adhere to the principles of good practice and principles of the use of only
justifiable, appropriate reasonable and proportionate force when deploying
RPI;

Ensure that incidents of aggression and violence are reported factually in
the service users clinical record (RIO) and on DATIXWEB are completed in
accordance with Incident reporting and management (including Serious
Untoward Incidents) Policy and Procedures;

Be responsible for their own safety by sharing with managers any issue
that need to be taken into account by their involvement in managing
aggression and violence, e.g. pregnancy, underlying health conditions, etc.
and contact Occupational Health if necessary.
4.
DEFINITIONS
Workplace Violence
Any incident where staff are abused, threatened or assaulted in circumstances
related to their work, involving an explicit or implicit challenge to their safety, well
being or health.
Physical assault
The intentional application of force to the person of another, without lawful
justification, resulting in physical injury or personal discomfort. (NHS Protect)
Non physical assault
The use of inappropriate words or behaviour causing distress and /or
constituting harassment. (NHS Protect)
De-escalation
The use of techniques (including verbal and non-verbal communication skills)
aimed at defusing anger and averting aggression.
Challenging Behaviour
Behaviour can be described as challenging when it is of such intensity,
frequency or duration as to threaten the quality of life and/or the physical safety
of the individual or others and is likely to lead to responses that are reactive,
aversive or result in exclusion. (Emerson 2011)
Restrictive Intervention
Deliberate acts on the part of other person(s) that restrict an individual’s
movements, liberty and/or freedom to act independently in order to take control
of a dangerous situation where there is a real possibility of harm to the person or
others if no action is undertaken, end or reduce significantly the danger to
person and others, and contain or limit the patient’s freedom for no longer than
is necessary.Restrictive practices refer to physical, mechanical and chemical
interventions. (Positive and Proactive Care: reducing the need for restrictive
interventions, 2014)
6
Physical Restraint
Any direct physical contact where the intention is to prevent, restrict or subdue
movement of the body (or part of the body) of another person.” Mental Health
Act Code of Practice (2015)
Prone Restraint
The use of restraint in a face down or chest down position. Incidents of restraint
that involve a service user being placed face down or chest down for any period
(even if briefly prior to being turned over), should be defined as prone restraint.
Similarly if a service user falls or places themselves in a face down or chest
down position during a restrictive intervention, this should be defined as prone
restraint.
5.
DEVELOPMENT OF THE POLICY
5.1 Identification of stakeholders
The stakeholders for this policy are: the Executive Management Team (EMT),
Trust Board, Managing Aggression and Violence Trust Action Group
(MAVTAG), Health and Safety Trust Action Group (H&S TAG) Business
Delivery Units, service users, carers, police and SWYPFT staff involved in the
consultation, approval and implementation of the policy
5.2 Responsibility for document development
This policy has been developed by the MAV Network Leader and the Personal
Safety and Aggression Management Specialist Advisers supported by the
MAVTAG.
5.3
Equality impact assessment
The organisation aims to design and implement services, policies and measures
that meet the diverse needs of the service, population and workforce, ensuring
that none are placed at a disadvantage over others. The Equality Impact
Assessment tool is designed to help consider the needs and assess the impact
of policies and is contained in Appendix B.
5.4 Consultation process
Consultation via the MAVTAG, (which is made up of BDU representatives,
safeguarding leads, equality and diversity leads and service user
representatives ) Health & Safety TAG, Business Delivery Units, Managers,
Policies and Procedures group before approval via the Executive Management
Team (EMT).
5.5 Policy approval process
The policy has been considered / reviewed / commended by the Managing
Aggression and Violence Trust Action Group and has been agreed as an
organisation-wide policy by the EMT.
5.6 Ratification process
The EMT is responsible for ratifying the contents of the policy and any
expenditure associated with implementing control factors against violence and
aggression across the Trust.
7
6
REVIEW AND REVISION ARRANGEMENTS INCLUDING VERSION
CONTROL
6.1 Process for reviewing the policy
This document will be reviewed bi-annually or more frequently if national policy
or guideline changes are required to be considered (whichever occurs first),
primarily by the organisation-wide MAV TAG following which it will be subject to
re-ratification.
6.2 Version control
This document is version 4 (Appendix C)
7 DISSEMINATION AND IMPLEMENTATION
7.1 Dissemination of the policy
Once approved, the Integrated Governance Manager will be responsible for
ensuring the updated version is added to the document store on the intranet and
is included in the staff brief.
The Integrated Governance Manager is responsible for ensuring the document
being replaced is removed from the document store and that electronic and
paper copies, clearly marked with version details, are retained as a corporate
record.
If local teams down load and keep a paper version of procedural documents, the
manager must identify someone within the team who is responsible for updating
the paper version when a policy change is communicated
All managing aggression and violence training will refer to the current version of
this policy
7.2 Implementation of the policy
Directors and Business Delivery Units
The responsibility to ensure compliance with this Policy rests with the Chief
Executive who delegates the operational requirements to each director of a
service or Business Delivery Units appropriate to their span of control, who
ensure that staff understand and are aware of their responsibilities with regard to
this policy.
Managers
Ensure all staff, including temporary, agency and locum staff, are aware of this
policy, complies with it and carry out their responsibilities identified within it,
including attendance on training.
Ensure the initiation, development and approval of local procedures that support
this policy and dissemination of these procedures to their relevant staff.
Plan and resource measures to facilitate effectiveness of this policy
Employees
Employees must ensure they are aware of this policy and work within it, as well
as any local procedures within their workplaces.
Volunteers, External Contractors and Visitors/Members of the Public
8
Managers have an important role in ensuring that visitors to Trust premises or
their areas of responsibility, whilst undertaking work or visiting patients, have
minimum potential to be exposed to aggression or violence.
It is the responsibility of the person in charge of an area to make external
contractors, volunteers , students vistors and members of the public aware of
the safety and security of the area and are expected to comply with the
instructions given in order to minimise risk of exposure to aggressive or violent
situations.
Occupational Health
As well as providing support through pre-employment health screening,
Occupational Health provides assessments of individuals’ ongoing fitness to
work, or attend training, liaising with Specialist Advisers or managers where
necessary.
Staff who have concerns about health issues and their ability to perform physical
interventions and/or MAV training should contact Occupational Health for
advice.
They also provide a post incident or/and a confidential health counselling
service, when staff need further advice, support or information.
8
MONITORING COMPLIANCE
8.1 Responsibilities
The Executive Management Team (EMT) is responsible for the overall
management of incidents within the Trust where Trust-wide incident reports and
individual Serious Untoward Incidents are reviewed and through individual
Director accountabilities Risk Management Strategy.
Business Delivery Units monitor incidents and commission investigations
within operational services which includes:

Managing issues in relation to incident management, reporting and
recording, including inputting on the Datix system.’

Receiving quarterly reports about incident, complaints, claims and legal
issues, analysing trends and identifying learning to be shared both across
services and with other care groups.

Receiving information pertaining to “learning from incidents” within the care
group, in other care groups and from specialist advisers and
commissioning work to address the identified risk issues.
Incidents of clinical aggression and violence are reviewed and monitored
through the Management of Violence and Aggression Trust Action Group
(MAVTAG) and through the Health and Safety Trust Action Group. The TAGs
ensure reporting occurs from all service areas, analyses the incidents looking for
trends, develops work streams to act on those trends. They monitor training
uptake and evaluation of training.
Risk assessments for the prevention and clinical management of violence and
aggression and, timescales for review of risk assessments and how action plans
are developed as a result of risk assessments are reviewed and formally audited
through RiO.
9
Arrangements for the making sure lone workers are safe is by the Head of Health,
Safety & Security and the Health & Safety Manager providing reports to the
SWYPFT Clinical Governance & Clinical Safety Group and
Health and Safety Trust Action Group detailing all incidents/accidents and
identifying trends and exceptions.
The Clinical Governance and Clinical Safety Committee are responsible for the
scrutiny of this process.
8.2 Standards/key performance indicators

The Trust reports to NHS Protect Violence Against Staff (VAS) and figures
are benchmarked against other organisations.

Key performance indicators for physical violence against staff by patient
and physical violence against patient by patient, restraint, individuals
secluded, and aggression management training are collected monthly or
quartly as required on the Compliance Data Capture forms and available
on the performance dashboards on the Trust intranet.

Key performance indicators for physical violence against staff by patient
and physical violence against patient by patient, use of seclusion and use
of restraint are collected quarterly for the High Level Summary –
Compliance and reported to the Trust board.

Audit priorities including managing aggression and violence audits are
monitored by the Clinical Audit and Practice Evaluation Group and
approved by the Clinical Governance and Safety Committee.

Training performance is recorded on the Trust iintranet site. The level of
compliance is mandated by the Trust Board and information is collected at
Trust, BDU and individual staff levels
9 GUIDANCE
Managing aggression and violence
The intention of this guidance is to give staff an understanding of the broad
spectrum of issues relating to the management of aggression and violence.
This guidance supports the training and specialist advice provision available
from the South West Yorkshire Partnership NHS Foundation Trust (SWYPFT),
Management of Aggression and Violence (MAV) Network.
This guidance covers a range of interventions which may be considered for the
safe and therapeutic management of people, whose behaviour may present a
particular risk to themselves or to others, including staff
This guidance applies to all service users, whether or not they are detained
under the Mental Health Act (1983 amended 2007). It also accepts that carers,
relatives, staff and others may be the source of disturbed or aggressive
behaviour .
9.1LEGAL ISSUES
Staff need to be aware of the legal and ethical issues which are pertinent in the
management of aggression and violence. The management of aggression and
violence training courses consider both non physical techniques and physical
10
techniques to manage an aggressive episode and, whether staff are working
alone or as part of a team.
The physical management of aggression and violence may result in a restriction
of the liberty (e.g. in relation to restraint) and autonomy of the person and may
be unlawful, Criminal charges such as false imprisonment and assault & battery
may arise from the unlawful use of restrictive physical interventions (RPI’s) .
The management of aggression and violence must therefore always be justified
in law.
Lawful Defence and Reasonable Force
To enable the application of force and/or the restriction of liberty of a person to
be recognised as legitimate there are two criteria which must be satisfied:
A legitimate reason to use force or restrict liberty must exist
The force and / or restriction used must be Justifiable, Appropriate, Reasonable
and Proportionate.
Reasonable Force
Definition: “The force used should be no more than was necessary to
accomplish the object for which it is allowed (so that retaliation, revenge and
punishment are not permitted). Secondly, the reaction must be in proportion to
the harm which is threatened in both degree and duration” (Dimond B., Legal
Aspects of Nursing 2011)
The action will be judged with consideration to the facts as the individual
perceived them to be at the time, even if he or she later realises it was wrong or
unreasonable i.e. If you have an honestly held belief that you or another are in
imminent danger, then you may use such force that is necessary to avert that
danger.
Other Legitimate Defences
Exercise of statutory powers and duties. These mainly come from the
authority to use force under the Mental Health Act (1983).
Self Defence. The law imposes duty on a potential victim to retreat and escape
and it is only when there is no opportunity to disengage that self-defence is likely
to be considered legitimate.
To Prevent a Breach of the Peace. This is defined as a situation where “harm
is done or likely to be done to a person or in his presence, to his property: or
harm is feared through an affray, riot, assault or other disturbance”.
To Prevent a Crime. Section 3 of the Criminal Law Act 1967 states that “A
person may use such force as is reasonable in the circumstances in the
prevention of a crime or in effecting or assisting in the lawful arrest of offenders
or of persons unlawfully at large”
This provision applies to both informal and detained patients enables staff to use
reasonable force to restrain or breakaway from a person in self defence of
others or to protect property.
11
9.2 ETHICAL ISSUES
There are ethical issues which are implicit in all decision making, the issues
which require particular consideration in this context are:

Obligations and duties;

Avoiding harm;

Assessing the consequences of action;

Autonomy and rights;

Best interests;

Values and beliefs.
Duty of Care
Staff working in a care environment have a duty of care towards the people they
are supporting. Duty of care has been defined as the ‘obligation placed on an
individual requiring that they exercise a reasonable standard of care while doing
something (or possibly omitting to do something) that could forseeably harm
others’.
9.3 MENTAL CAPACITY ACT (MCA) 2005
The MCA came fully into force on 1 October 2007. It is designed to protect
people who lack the capacity to take decisions for themselves.
There are 5 Key Principles of the MCA (2005) these are:

A person is assumed to have capacity;

People must be helped to make decisions;

Unwise decisions do not necessarily mean lack of capacity;

Decisions on behalf of a person who lacks capacity must be taken in the
person’s best interests;

Decisions must entail the least possible restriction of freedom.
The MCA defines restraint and gives criteria that need to be met for restraint to
legally occur, they are:

The person lacks capacity and it will be in the person’s best interests and;

It is reasonable to believe that it is necessary to restrain the person to
prevent harm to them and;

Any restraint is a proportionate response to the likelihood of the person
suffering harm and the seriousness of that harm.
Best Interests:
The term ‘best interests’ is used in care provision and for the purposes of this
document it refers to:
12
‘Any action taken to preserve the life, or health, or well being. Patients ‘best
interest’ include medical as well as wider welfare considerations including:
dressing, washing, assisting with the consumption of food and drink’.
In the assessing of best interest discussions should include where possible, the
service user, family, friends, health professionals carers and advocate.
Considerations should include; ethical and religious issues, any previously
stated preferences and beliefs and information should be shared to inform the
whole team.
It should be recorded why any treatment / care is in the service users best
interest and the process used to reach the decision..
Staff should consider:

Which action would best promote the persons autonomy;

Who would benefit from the outcome;

What would the least invasive approach or is a reversible approach
available;

Does everyone agree with the planned outcome
The Mental Capacity Act Deprivation of Liberty Safeguards (DoLS)
‘The Mental Capacity Act Deprivation of Liberty safeguards were introduced into
the Mental Capacity Act 2005 through the Mental Health Act 2007 The
safeguards provide a framework for considering the deprivation of liberty for
people who lack the capacity to consent to treatment or care in either a hospital
or care home that, in their own best interests, can only be provided in
circumstances that amount to a deprivation of liberty’
9.4 HUMAN RIGHTS ACT (1998)
Any use of restrictive interventions must be compliant with the Human Rights
Act 1998 (HRA), which gives effect in the UK to certain rights and freedoms
guaranteed under the European Convention on Human Rights (ECHR).

No restrictive intervention should be used unless it is medically necessary to
do so in all the circumstances of the case. Action that is not medically
necessary may well breach a patient’s rights under article 3, which prohibits
inhuman or degradingtreatment. ‘Inhuman or degrading treatment does
not have to be deliberate’

Article 8 of the ECHR protects the right to respect for private and family life.

Restrictive intervention that does not meet the minimum level of severity for
article 3 may nevertheless breach a patient’s article 8 rights if it has a
sufficiently adverse effect on the patient’s private life, including their moral
and physical integrity.

Restrictions that alone, or in combination, deprive a patient of their liberty
without lawful authority will breach article 5 of the ECHR (the right to
liberty).
9.5 PUBLIC HEALTH MODEL
13
The model of violence reduction in the Mental Health Act Code of Practice
(2015) sees prevention as having three dimensions: primary, secondary and
tertiary. The focus is on proactive, preventative measures.
Primary Prevention is the action to prevent violence before it occurs and it is a
proactive strategy. E.g. risk management, provision of a therapeutic
environment
Secondary Prevention is the action taken when violence is perceived to be
imminent and is a reactive strategy.
Tertiary Prevention is the action taken when violence is occurring and
provides opportunity for learning for the future.
9.6 PRIMARY PREVENTION
Prevention
Prevention of aggression and violence is best achieved through effective
systems of organisational, environmental and clinical risk assessment and
14
management. Such risk assessment and risk management approaches should
also promote therapeutic engagement and collaboration with service users.
Fostering and Developing Positive Relationships
The principles of establishing positive relationships and clear communication
with other organisations, service users, and carers must be a priority.
Developing positive relationships can reduce the potential for aggression and
violence and consequently the need to deploy RPI’s.
Staff must try to develop sound trusting therapeutic relationships with service
users so that they can learn to recognise potential danger signs. Staff should
understand when to intervene to prevent harm from occurring. Continuity of
staffing is an important factor both in the development of professional skills and
consistency in managing service users.
Services and staff should demonstrate and encourage respect for racial and
cultural diversity, and recognise the need for privacy and dignity. These are
essential values that are asserted in policy, educational material, training and
practice initiatives related to the safe and therapeutic management of service
users.
Staff should also recognise that, due to the nature of their contact with service
users, they may experience disturbed behaviour as intermittent, while fellow
service users or carers experience it as persistent.
Particular care needs to be taken to ensure that negative and stigmatising
judgements about certain behaviours, diagnoses or personal characteristics do
not obscure a rigorous assessment of the degree of risk or the potential
benefits of appropriate treatment to people in severe distress.
Providing Information
Service users should have access to information about the following in a
suitable format:

Which staff are on duty, including any assigned to support them personally

Why they have been admitted (and if detained, the reason for detention, the
powers used and their extent, and rights of appeal);

What their rights are with regard to consent to treatments, complaints
procedures, and access to independent help and advocacy and

What may happen if they pose a danger to themselves or others .
This information needs to be provided at admission, repeated as necessary and
recorded in the clinical record..
Other Strategies
In addition to individual care plans incorporating positive behaviour support
which are fundamental to the appropriate management of challenging
behaviour, problems may be minimised by considering the environments and
identifying and managing problem areas. Among such general measures are:

Engaging service users and keeping them fully informed of what is
happening and why;
15

Giving each service user a defined personal space for the safe keeping of
possessions;

Organising the unit on in patient areas, to provide, for example, quiet rooms,
recreation rooms, single sex areas, visitors' rooms and access to fresh air;

Ensuring service users are able to make telephone calls in private, wherever
possible;

Involving service users in identifying their own trigger factors, early warning
signs of disturbed or violent behaviour and the management of these;

Providing appropriate activities for all service users, including exercise areas
and encouraging service users to take part in appropriate activities

Managing the skill mix of staff and responding to changes in clinical
environment

Consistent application and monitoring of any individual programme (care
plan) ;

Ensuring that service users' concerns are dealt with quickly and fairly.
Safe Place of Work
To establish a safe place of work and to encourage a pro-security safety culture;
risk assessment and risk management plans need to be formulated and
implemented .
In exploring preventive methods staff should be aware of some possible factors
which may contribute to challenging behaviour. Such as:

Boredom and lack of environmental stimulation;

Too much stimulation, overheating, noise and general disruption;

Overcrowding, lack of access to external space;

Personal frustrations associated with being contained within a restricted
environment; antagonism, aggression or provocation on the part of others;
Influence of alcohol or substance abuse;

An unsuitable mix of service users
9.7 SECONDARY INTERVENTIONS
Risk assessment
Thorough evidence-based clinical risk assessment and management is an
essential and on-going element of good care planning, and effective and safe
practice. The key principle is that all service users will have a risk assessment
completed and documented, where necessary leading to the development of a
documented risk management plan Clinical risk assessment, management and
training policy
Cues to aggression
Warning signs or cues often precede acts of aggression . The more observant
you are the more likely you are to pick up on these cues. The earlier the subtle
signs are identified the more options may be available to de-escalate the
situation.
16
Cues to aggression vary from person to person, one of the most indicative is a
change in behaviour that varies from the individuals ‘norm’. The following list,
which is not exhaustive, may help to indicate that a service user is at increased
risk of becoming aggressive .
Cues identified that are known to an individuals aggression precede a known
persons violence should be included in their care plans and risk management
plans;

Tense / angry facial expressions;

Increased prolonged restlessness, pacing, body tension;

Increased breathing, muscle twitching and dilated pupils;

Increased volume of speech;

Refusal to communicate, withdrawal, irritability;

Prolonged eye contact;

Thought processes unclear, poor concentration;

Delusions or hallucinations with violent content;

Threats or gesture;

Reporting anger or violent feelings.
Use of Electronic Alarms and Call Systems
These systems are usually ward / unit based and designed to call for assistance
and or to activate in the case of an emergency.
Managers should ensure that there are enough units for all staff who require one
and everyone is instructed in there use and what to expect as a response.
A local protocol giving staff guidance on what to do in the event of an alarm
being activated such as identifying specific individuals to attend incidents or the
formation of a response team should be in place and all staff aware of.
More guidance is a available from Operational Guidance for the Pinpoint Alarm
System http://nww.swyt.nhs.uk/docs/Documents/1016.doc
9.8 TERTIARY INTERVENTIONS
Tertiary interventions may be required when violence is occurring; the main
purpose of this section and the techniques are to effectively manage the incident
and to enable learning from incidents to take place.
Individuals in need of care and treatment may, as a consequence of their
presentation , present particular risks to themselves or others. Such risks are
usually associated with behaviours that challenge
Staff should also be aware of other risks , such as self-neglect or sexual
vulnerability.
The primary focus for managing people who may present with disturbed or
violent behaviour (or both) should be the establishment of a culture which
focuses on early recognition, prevention and de-escalation of potential
17
aggression, using a wide range of techniques to minimise the risk of its
occurrence;
Ensure that the techniques and methods used to restrict a service user:

are proportionate to the risk and potential seriousness of harm

are the least restrictive option to meet the need

are used for no longer than necessary

take account of the service user’s preferences, if known and it is possible to
do so

take account of the service user’s physical health, degree of frailty and
developmental age..
9.9 RESTRAINT
Interventions such as restraint, seclusion, or rapid tranquilisation should only be
considered if de-escalation and other strategies have failed to manage the
individual . Where such interventions are necessary, clinical need and the
safety of the service users and others is the primary consideration.
Any interventions employed to manage disturbed behaviour must be seen as
Justifiable, Appropriate, Reasonable and Proportionate, taking into account the
risks posed by the behaviour or potential behaviour.
The choice of appropriate restrictive intervention will depend on various factors,
but should be guided by:

The duty to protect other service users, visitors and staff; and

Service user preference, if known;

The clinical needs of the service user;

The needs of other people affected by the disturbed behaviour;

The availability of resources within the environment of care;

The justification for physical responses.
Physical responses, , are no substitute for identifying and addressing the
problem before it reaches a crisis.
The Managing Aggression and Violence Network is available to support staff
and the specialist advisors can provide support with any aspect of the MAV.
Safety of Others (When Staff Member is on Their Own)
A dilemma occurs for staff when faced with a situation, where an aggressor may
be inflicting injury on themselves or another. It is important that the staff member
does not lose regard for their own safety. The desire to protect a vulnerable
individual is understood, staff must:

Always judge their ability to manage the intervention in a way that produces
best outcome;

Summon assistance if they cannot manage the intervention;
18

Unless exceptional circumstances exist, not attempt to restrain the individual
on their own.
Restraint (Mental Health Act 1983 - Code of Practice revised 2015)
Restraint may take many forms. It may be both verbal and physical and may
vary in degrees from an instruction to seclusion.
The purpose of restraint as a response to immediate risk is:

take immediate control of a dangerous situation where there is a real
possibility of harm to the person or others if no action is undertaken, and

end or reduce significantly the danger to the patient or others.
The most common reasons for restraint are:
The most common reasons for needing to consider the use of restrictive
interventions are:

physical assault by the patient

dangerous, threatening or destructive behaviour

self-harm or risk of physical injury by accident

extreme and prolonged over-activity that is likely to lead to physical
exhaustion, or

attempts to escape or abscond (where the patient is detained under the
Act or deprived of their liberty under the MCA).
Any restraint used should:

be used for no longer than necessary to prevent harm to the person or to
others

be a proportionate response to that harm, and

be the least restrictive option

use least restrictive level of hold
Using Physical Interventions (Restraint) as Part of a Team Approach
Physical intervention describes a conscious or reactive decision by a person or
persons to assist, support, hold or restrain another person.
This will be either a:

Pre-arranged intervention (Planned). This should be documented in the
service user’s positive behaviour support plan or individual care-plan. The
procedure should be reviewed regularly by the multi-disciplinary team and
where possible, include the views of the service user or,

A reactive response (Unplanned). This will always depend on all the
circumstance of the situation. Following a reactive response a review should
take place to determine what if anything can be done to prevent the
intervention becoming necessary in the future. If a positive behaviour support
plan is not already in place then one should be started.
19
Restrictive Interventions

No restrictive intervention should be carried out unless it is medically
necessary to do so. Action that is not medically necessary may breach the
patient’s human rights under article 3, which prohibits inhuman or degrading
treatment. It may also breach their article 8 rights to a private and family life
or article 5 rights to liberty.

Any individual who may exhibit behaviours which may present a risk to
themselves or other people should have a full risk assessment of their
potential and their needs. This should be incorporated into a positive
behaviour support plan / care plan.

All individuals should be evaluated to identify any physical or psychological
risks and any religious, cultural or gender issues that may require restraint
techniques to be modified. These may include:

Musculoskeletal problems that limit joint movement, decrease bone
strength, cause deformity or cause pain. This includes limb loss and
the presence of prosthetics (false limbs) or orthotics (splints).

Neuromuscular problems that may include high muscle tone, low
muscle tone, ataxia or athetosis.

Cardiovascular problems such as angina, heart conditions,
hypertension or hypotension and history of heart attack. This should
include presence of blood disorders that affect clotting.

Respiratory disease such as asthma, chronic obstructive pulmonary
disease or any condition affecting the patient’s breathing.

Pregnancy or post-partum.

Altered sensory systems that affect pain or touch sensation,
positioning the body in space, hearing or speech.

Previous psychological trauma that may have resulted from abuse or
assault.

Use of drugs and/or alcohol
If physical or psychological risk factors are identified consideration should be
given to contacting the MAV team for specialist advice.

Any individual who presents with behaviours that are challenging must have
a behaviour support plan that covers:

what is usual for them ,

what triggers unwanted behaviours,

what the behaviours are,
20

the desired outcomes for the individual and how they should be
managed at primary, secondary and tertiary levels.
This should be produced in collaboration with the individual , their family, carers
and advocate.
All restrictive interventions must be applied using principles and methods taught
on the trust training syllabus, by staff that are competent to do so.

Due regard must be taken of the risks to life and health identified as part of
the training.

Restrictive interventions should be used in a way that minimises any risk to
the patient’s health and safety and that causes the minimum interference to
their autonomy, privacy and dignity, while being sufficient to protect the
patient and other people. The patient’s freedom should be contained or
limited for no longer than is necessary.

Unless there are cogent reasons for doing so, staff must not cause
deliberate pain to a patient in an attempt to force compliance with their
instructions(for example, to mitigate an immediate risk to life).

In areas where restrictive interventions occur there must be access to life
support equipment as described in the trust resuscitation policy.

In exceptional circumstances when staff are unable to safely manage a
violent situation using the techniques and facilities that are available to
them, the assistance of the police may be requested. In these cases staff
remain responsible for the health and safety of the individual .

The emotional and psychological wellbeing of patients must be properly
managed. This should be done by involving the patient in the planning of
restrictive interventions whenever possible, reassuring them and explaining
what is happening during the restrictive intervention and post-incident
counselling as soon after the incident as is appropriate.

Individuals should be medically assessed following physical restraint. If staff
are concerned and no doctor is immediately available arrangements should
be made to transfer the patient to A&E.

All instances of restrictive interventions must be fully recorded in the
patient’s clinical record and on the trust incident system. Records must
include an account of:

The lead up to the intervention

How staff attempted to de-escalate the incident

A detailed description of the restrictive intervention, including all
positions and holds used, which staff were involved and what they
21
were doing, the length of the restrictive intervention and the conditions
under which it was discontinued.

The post-incident counselling offered to the patient

Any changes made to the positive behaviour support plan.

Staff involved in the incident should be involved in a post-incident review
which analyses the effectiveness of the de-escalation and the intervention.

All staff working in clinical areas must undertake training around the
management of aggression and violence that has been identified as
appropriate to their role and work area. (see Trust mandatory training)
9.10
MECHANICAL RESTRAINT

Mechanical restraint is a form of restrictive intervention that refers to the
use of a device to prevent, restrict or subdue movement of a person’s
body, or part of the body, for the primary purpose of behavioural control

Mechanical restraints are not routinely used within the Trust for any of our
service users except in extraordinary and/or urgent situations, and then
only for the shortest possible time and when all other less restrictive
options have been considered/exhausted by the team and senior
managers.

The use of any mechanical restraint must be based on a comprehensive
risk assessment by the RC and MDT and a care plan and safeguards
need to be in place to protect the service user and others, which are
regularly reviewed. Those using mechanical restraints must be trained
and experienced in their use.

The use of mechanical restraints is usually limited to patients identified as
requiring this level of intervention when off the ward. These will be
patients most likely subject to Ministry of Justice overview. The use of
mechanical restraints will be included in the risk management and
associated care plans for the patient.

The use of mechanical restraints in other situations is subject to an MDT
meeting, consisting of the patient’s Responsible Clinician, the nurse in
charge of the ward, the patient’s named nurse, any other clinician
significantly involved in the patient’s care, an IMHA, an IMCA if applicable
and if possible. The decision must be communicated to the relevant
General Manager and the BDU director or the Director of Nursing in their
absence.

This plan should detail the circumstances which might warrant
mechanical restraint, the type of device to be applied, how continued
attempts should be made to de-escalate the situation and any special
22
measures that are required to reduce the likelihood of physical or
emotional trauma resulting.

Where the care plan allows the nurse in charge to authorise the use of
mechanical restraint, the patient’s Responsible Clinician or on call
consultant should be informed immediately.

When mechanical restraint is used to manage violent behaviour rather
than as a security measure, the patient must remain under continuous
observation throughout, be reviewed by a registered nurse every 15
minutes and be examined by a doctor after one hour and at four hourly
intervals. Reviews should ensure that the individual is as comfortable as
possible and should include a full evaluation of the patient’s physical and
mental health condition.

Reviews should be undertaken more frequently if requested by nursing
staff.

At all times the MHA Code of Practice and the MAV Specialist Advisor
should be referred to when considering and using mechanical restraint.

The application and use of materials or equipment (which may include
prescribed therapeutic aids) such as belts, helmets, clothing, straps,
cuffs, splints and specialised equipment, which are designed to
specifically restrict the free movement of an individual but must be
considered as a restrictive practice as described in the MCA (2005) and
the necessary safeguards for use of mechanical restraints must be
applied.
9.11
RESTRAINT IN ORDER TO ADMINISTER TREATMENT
Restraint can also be used in order to administer medication (or other forms of
treatment) , where there is legal authority1 to treat the individual without
consent. It should not be used unless there is such legal authority.
The use of restraint to administer treatment in non-emergency circumstances
should be properly documented in the service user’s notes, along with the
justification for it.
It should, where possible follow the restraint procedure and be care planned.
Medication should never be used to as a substitute for adequate staffing. Other
than in exceptional circumstances, the management of behaviour by medication
should only be used after careful consideration, and as part of a treatment plan.
9.12
TAKING BLOOD WITHOUT CONSENT
The CQC issued guidance on the taking of blood under the Mental Health Act as
a treatment “ancillary” to treatment with medications such as clozapine and
1
Legal Authority refers to either consent as in the case of a person with capacity or that they are detained
Mental Health Act (1983). Those who lack capacity and are not detained MHA would require the
decision of a MDT, may be an IMCA involved and possibly Court of Protection involvement depending
on the gravity of the decision
23
lithium and agreed that it could be enforced for detained service users who do
not consent to blood testing. The degree of resistance and its origins (e.g.
religious objections) to the blood sampling should be taken into consideration.
Any other blood testing without consent should only occur after consideration of
the criteria that need to be met for restraint to legally occur under the Mental
Capacity Act

The person lacks capacity and it will be in the person’s best interests and;

It is reasonable to believe that it is necessary to restrain the person to
prevent harm to them and:

Any restraint is a proportionate response to the likelihood of the person
suffering harm and the seriousness of that harm
Advice should be sought from the MAV team where it is anticipated that
resistance and restraint might occur.
9.13
RAPID TRANQUILLISATION
The Rapid Tranquilisation Policy should be consulted.
9.14
SECLUSION
The Seclusion Policy should be consulted
9.15 SETTING INCIDENT THRESHOLDS FOR FREQUENT CHALLENGING
BEHAVIOUR
In some clinical situations staff may find it difficult to know when to record
certain events or behaviours as an incident. For example, if an individual service
user has a frequent pattern of behaviour such as self harming, verbal
aggression or challenging behaviour, which could be seen as the usual
presentation of their condition.
It is impossible to give a definitive guide for recording these incidents, but a
process is suggested in the Incident reporting and management (including
Serious Untoward Incidents) Policy and Procedures;
9.16 ARRANGEMENTS
WORKERS
FOR
ENSURING
THE
SAFETY
OF
LONE
The trust must ensure that they have adequate arrangements in place to asses
risk to their staff. A risk assessment is carried out to identify the risks to workers
and any others who may be affected by their work. Proper conduct of the
assessment must identify how the risks arise and how they impact on those
affected. This information is needed to make decisions on how to manage those
risks so that the decisions are made in an informed, rational and structured
manner and that the action taken is proportionate. Arrangements also need to
be put in place to monitor and review the findings. Lone Working Policy
9.17 WEAPONS
24

Throughout this document, the term ‘weapon’ means any object that could
be used to threaten or injure another person. 2

This guidance does not cover guns, other firearms or similar weapons
(including replicas). All incidents involving firearms should be immediately
reported to the police in line with locally agreed protocols

It is essential that managers develop strategies for managing difficult situations.

The Trust has a policy on searching patients and their property to promote a
safe and secure environment. This should be applied with caution if there is
a reasonable suspicion that the service user is carrying a weapon and there
is an risk to the service user, staff or others.

If a weapon is used or threatened Staff should attempt to isolate the individual .

Occasionally people may use a weapon during an act of violence. Staff
should not attempt to disarm the person.

Service users or visitors will be isolated where possible and a 999 call made to
the Police and a call for assistance made.

Consider the use of barriers, space and knowledge of the environment such
as keeping access to exits to maintain personal safety. If safe attempt to
maintain dialogue with the potential assailant, with the aim of getting the
assailant to stop threatening with the weapon, whilst maintaining a safe
distance.

Where life is threatened, do as the person demands, try persuasion and try
to get help.

If this is not possible then staff should use any justifiable, appropriate
reasonable and proportionate measures to defend themselves and others in
order to escape and call for assistance.
9.18 SITUATIONS IN WHICH POLICE INVOLVEMENT MAY BE
REQUESTED
Police involvement may be requested in relation to:

Preventing a breach of the peace on Trust premises;

Assisting in an incident when staff and or patients are threatened and staff
are unable to safely manage or contain the situation;

In response to risks to individuals or the public identified in the course of
assessment and treatment;

Evidence or suspicion of
environment.
illegal drugs or weapons into the ward
It is acknowledged that once the police have been summoned to an incident,
they will assume operational control and staff should do as directed by officers.
Staff remain responsible for the patient’s health & safety.
2
NHS Counter Fraud and Security Management Service. (2006).Offensive weapons NHS Security
Management Service guidance. NHS CFSMS
25
If the police have been called to an incident, the nurse in charge of the ward
should provide an orientation of the ward, brief description of circumstances
leading up to the incident, the type of weapon, where patient is located and how
the patient is currently presenting. Any known medical conditions, drugs and
alcohol.
(See Violence, Abuse, Harassment and Aggression at Work Policy Violence,
Abuse, Harassment and Aggression at Work Policy)
9.19
TRAINING
The Trust provides training for staff to ensure they can fulfil their responsibilities
under the policy and take measures to protect themselves, service users and
members of the public from aggression or violence at work. All staff must attend
managing aggression and violence training where it has been identified as being
mandatory.
Staff can obtain details of the types of training available, training dates / venues
and course information via the SWYPFT Learning & Development Portfolio or the
Managing aggression and violence network. Tel: 01924 327064
Training needs are prioritised according to risk (Appendix A). The level of training
required by staff is determined by their post and area of work. This information is
reflected on ESR as a competence requirement of each post and ESR reporting
arrangements will reflect this.
Staff will be introduced to this policy at initial work-based Induction training and are
made aware of their departmental procedures on the control of aggression
/personal safety and violence.
The Trust provides bespoke training for staff who works in areas where they
may be exposed to aggression or violence, or may need to become involved in
the restraint of service users. This includes recognising anger, potential
aggression, antecedents and risk factors of disturbed or violent behaviour and
how to monitor their own verbal and non-verbal behaviour. Training includes
methods of anticipating, de-escalating or coping with disturbed/violent
behaviour.
Where staff have been unable to access training prior to commencing work ,
managers, as an interim measure, must ensure that systems are in place to
ensure that recognition, prevention and de-escalation of aggression and
violence awareness forms part of the ward/unit induction programme and is
underpinned by a robust risk assessment. This should make clear what the staff
member’s response and role should be when faced with incidents involving
aggression and violence. These principles should also be applied to bank,
agency and all staff unfamiliar to the ward/unit.
All staff who undertake training in the management of aggression and violence
and physical interventions training should attend .refreshers at intervals
commensurate with their post and area of work.
10
PROCEDURES
26
10.1
De-Escalation techniques

The response to aggression would depend on whether the aggression was
directed toward the staff member on a one to one basis (i.e. lone working or
isolated) or whether the aggression was in an environment where assistance
could be summoned if required.

One staff member should lead the response – unless they are alone with
potential aggressor where they may have to consider exiting.

That staff member should consider which de-escalation techniques are
appropriate.

Appropriate de-escalation techniques should have been identified through
risk assessment and care planning.

The staff member should give clear explanations and instructions to the
service user regarding what they intend to do, and relevant options.

Separate agitated service users from others (using quiet areas of the ward,
bedrooms, comfort rooms, gardens or other available spaces) to aid deescalation, ensuring that staff do not become isolated.

Use a designated area or room to reduce emotional arousal or agitation and
support the service user to become calm. In services where seclusion is
practised, do not routinely use the seclusion room for this purpose because
the service user may perceive this as threatening.

The staff member who coordinates the response should attempt to clarify
the issue and attempt collaborative problem solving.
This will involve:

Establishing rapport and emphasising the need for mutual co-operation.

Negotiating realistic options.

Asking open questions.

Ensuring that non-verbal and verbal responses indicate concern and
attentiveness.

Using empathic and non-judgemental listening.

Paying attention to the non-verbal communication of the service user.

Paying attention to staffs own non-verbal communication, respecting
personal space and avoiding confrontational eye contact.

Adopting a non-threatening but safe stance, safe distance, side on.

Appearing to be calm and in control. (It is difficult to be calm due to the
effect of adrenaline although an appearance of calm gives some
reassurance to the agitated person).
10.2 Restraint General principles

Is an emergency response or there seems to be a real possibility that
significant harm would occur if no intervention is made;

One staff member should coordinate response to the incident;
27

Move others not involved;

Approach and ask individual to stop the behaviour or comply with a request;

Give explanations of possible outcomes;

Any initial attempt to restrain aggressive behaviour should, as far as the
situation will allow, be non-physical;

A balanced judgement should be made between the need to promote
autonomy and the duty to protect individuals from likely harm;

The specific needs of service users with sensory impairments should be
taken into account - approaches to deaf and hearing impaired service users
should be made within their visual field (not from behind) and gestures used
to engage them in calm communication;
10.3 Restraint Procedure

Assistance should be sought by call system or verbally;

Where possible only staff trained on the MAV Teamwork course should be
involved in restraint;

Staff not trained on the MAV Teamwork course should not be placed on
response teams or participate in prearranged physical interventions, unless
in an emergency ;

Large numbers of staff acting in a uncoordinated way can be counter
productive. Organise a well briefed team of staff (The team approach
demonstrated in MAV training);

Make a visual check for weapons;

Once committed, act decisively;

Patients should not be deliberately restrained in a way that impacts on their
airway breathing or circulation. The mouth and/or nose should never be
covered and there should be no pressure to the neck region, rib cage and/or
abdomen.

Unless there are cogent reasons for doing so, there must be no planned or
intentional restraint of a person in a prone position on any surface, not just
the floor.

Therefore, wherever possible, restraining service users on the floor should
be avoided. If, however, the floor is used, then this should be for the shortest
period of time and for the central reason of gaining control of a highly risky or
dangerous situation.

In exceptional situations where the service user needs to be placed in the
prone position, this should be for the shortest possible period of time.

Do not routinely use manual restraint for more than 10 minutes.

Consider rapid tranquillisation or seclusion as alternatives to prolonged
manual restraint (longer than 10 minutes).
28

During restraint against active resistance or if a restraint ends up on the
floor, one team member should be responsible for protecting and supporting
the head and neck;

All team members should take responsibility for ensuring the health and
wellbeing of the service user during restraint;

Don’t be distracted from your allocated task as part of the team;

Ensure that airway and breathing are not compromised;

Monitor vital signs, for signs of distress and the physical and psychological
health of person.

Monitor vital signs using the Early Warning Score or EWS (appendix 1
Cardiopulmonary Resuscitation Policy) and associated documentation and
follow the guidance.

If vital cannot be monitored, e.g. service user refusal, the reasons why they
could not be monitored should be recorded in the clinical record

End restraint as soon as it is safe to do so.
10.4 Post incident support and learning
After using a restrictive intervention, and when the risks of harm have been
contained, conduct an immediate post-incident review, including a nurse and a
doctor, to identify and address physical harm to service users or staff, ongoing
risks and the emotional impact on service users and staff, including witnesses.
Discuss the incident with service users, witnesses and staff involved only after
they have recovered their composure and aim to:

acknowledge the emotional responses to the incident and assess whether
there is a need for emotional support for any trauma experienced

promote relaxation and feelings of safety

support a return to normal patterns of activity

ensure that everyone involved in the service user's care, including their
carers, has been informed of the event, if the service user agrees. Ensure
that the necessary documentation has been completed. Ensure that the
service user involved has the opportunity to discuss the incident in a
supportive environment with a member of staff or or carer.

Offer the service user the opportunity to write their perspective of the event in
the notes.
A Post Incident Review should:

evaluate the physical and emotional impact on everyone involved, including
witnesses

help service users and staff to identify what led to the incident and what
could have been done differently

determine whether alternatives, including less restrictive interventions, were
discussed
29

determine whether service barriers or constraints make it difficult to avoid
the same course of actions in future

recommend changes to the service’s philosophy, policies, care
environment, treatment approaches, staff education and training, if
appropriate

avoid a similar incident happening in future, if possible.
Further learning for staff can be gained through individual clinical supervision or
group supervision sessions. The MAV Network is available for advice on any
technical details of the management of violence and aggression or if the review
highlights any issues regarding the use of RPI.
Any staff member involved in an aggressive or violent incident can access
appropriate support and further counselling if necessary through the Staff
Counselling Services, Occupational Health Service or Pastoral Care
10.5 Evaluation and review
A key part of the evaluation and analysis process is the role of information
obtained from the DATIX system.
The Trust will use the DATIX system to monitor and analyse aggressive and or
violent incidents including “near misses”. This will highlight concerns and emerging
trends, which will enable Business Delivery Units and managers to evaluate
procedures and practices to be changed, where necessary, to improve the
environment for staff and service users.
The MAVTAG and the Health and Safety Trust Action Group also monitor
incidents of violence and aggression
Procedures developed by managers will be reviewed regularly to ensure they
remain relevant to the prevailing circumstances. They will also be reviewed in
the light of information received about incidents, new published guidelines and
the principles of good practice.
10.6 Specialist advice
The MAV Team is available to offer training, advice and support to all services
and staff across all BDU’s based on national best practice guidance. Contact the
team
11


REFERENCES
A Positive and Proactive Workforce: a guide to workforce development for
commissioners and employers seeking to minimise the use of restrictive
practices in social care and health. Skills for Health and Skills for
Care.(2014)
http://www.skillsforhealth.org.uk/component/docman/doc_download/2423-apositive-andproactive-workforce.html
British Institute of Learning Disabilities (2014) Code of Practice
forminimising the use and reduction of physical interventions:planning,
developing and delivering training (4th Edition)
http://www.bild.org.uk/our-services/books/positive-behaviour-support/bildcode-of-practice/
30

British Institute of Learning Disabilities (2013) Framework for Reducing
Restrictive Practices
http://www.bild.org.uk/our-services/books/positive-behavioursupport/framework-for-reducing-restrictive/

British Institute of Learning Disabilities (2014) A human risghts perspective
on reducing restrictive practices in intellectual disability and autism.
http://www.bild.org.uk/our-services/books/positive-behaviour-support/ahuman-rights-perspective/

Department of Health. (2015). Mental Health Act 1983 Code of Practice.
London. TSO
https://www.gov.uk/government/uploads/system/uploads/attachment_data/f
ile/396918/Code_of_Practice.pdf

Meeting Needs and Reducing Distress: guidance on the prevention and
management of clinically related challenging behaviour in NHS settings.
Department of Health, NHS Protect. (2013).
http://www.nhsbsa.nhs.uk/Documents/SecurityManagement/Meeting_need
s_and_reducing_distress.pdf

NHS SMS (2003) A professional Approach to Managing Security in the
NHS. London, NHS SMS.
http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/sms_strategy.
pdf

NHS Security Management Service (2005) ‘Not Alone’ A Guide for the
Better Protection of Lone Workers in the NHS. London NHS SMS
http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/Lone_Working
_Guidance_final.pdf

NHS Counter Fraud and Security Management Service. (2006).Offensive
weapons: NHS Security Management Service guidance. NHS CFSMS
http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/offensive_wea
pons.pdf

NHS Security Management Service (2005) Promoting Safer and
Therapeutic Services - Implementing the National Syllabus in Mental
Health and Learning Disability Services, NHS Security Management
Service.
http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/psts_impleme
nting_syllabus.pdf

NHS Security Management Service (2007) Tackling Violence Against Staff.
Explanatory notes for reporting procedures by Secretary of state Directions
in November 2003 (updated March 2007) London, NHS SMS.
http://www.nhsbsa.nhs.uk/SecurityManagement/Documents/Tackling_viole
nce_against_staff_2007.pdf

Positive and Proactive Care: reducing the need for restrictive
interventions.Department of Health. (2014).
https://www.gov.uk/government/publications/positive-and-proactive-carereducing-restrictive-interventions
31

Royal College of Nursing (2007) Lets talk about restraint rights risks and
responsibility
http://www.rcn.org.uk/__data/assets/pdf_file/0007/157723/003208.pdf

Violence and Aggression: Short-term management in mental health, health
and community settings. Updated edition. NICE Guideline NG10 (2015)
http://www.nice.org.uk/guidance/cg25/resources/cg25-violence-fullguideline
12 ASSOCIATED DOCUMENTATION

Clinical risk assessment, management and training policy

Care Programme Approach
http://nww.swyt.nhs.uk/cpa/Pages/default.aspx

Health, Safety, Security and Environment home page
http://nww.swyt.nhs.uk/health-safety/Pages/default.aspx

Investigating and analysing incidents, complaints and claims to learn from
experience http://nww.swyt.nhs.uk/docs/Documents/776.doc

Mandatory training home page http://nww.swyt.nhs.uk/learningdevelopment/Pages/Mandatory-training.aspx

Managing aggression and violence (MAV) home page
http://nww.swyt.nhs.uk/mav/Pages/default.aspx

Occupational health home page
http://nww.swyt.nhs.uk/wellbeing/occupational-health/Pages/default.aspx

Policy for Lone Working
http://nww.swyt.nhs.uk/Policies/documents/228.doc

Protocol for the Prevention of Abuse of Vulnerable Adults
http://nww.swyt.nhs.uk/Policies/documents/417.doc

Patient safety home page http://nww.swyt.nhs.uk/incidentreporting/Pages/Contact-the-team.aspx

Seclusion policy http://nww.swyt.nhs.uk/docs/Documents/396.docx

Staff consultancy and counselling service home page
http://nww.swyt.nhs.uk/wellbeing/staff-counselling/Pages/default.aspx
32
APPENDIX A
What MAV course should I attend?
Aggression Management Teamwork – 4 day initial course and 2 day
annual update
Staff who work with service users on a clinical basis in areas where restraint has
been deemed necessary, require this training. For example clinical staff working
inWorking Age Adult, Forensic and Older Peoples inpatient areas.
Aggression Management Teamwork -Caring Approaches to Aroused
Situations (CAAS) Learning Disability 4 day initial course and 2 day annual
update
Staff who work with service users on a clinical basis in areas where restraint has
been deemed necessary, require this training. For example clinical staff working
in inpatient areas. Specifically designed for staff working in Learning Disability
service and accredited by the British Institute for Learning Disabilities (BILD)
Aggression Management De-escalation and Breakaway (Clinical) – 1 Day –
(2 Year Refresher).
Staff who are not required to restrain but may be exposed to risk in which they
may need to breakaway. For example community based clinical staff, lone
workers, allied Health Professionals.
Aggression Management Personal Safety and Breakaway (non clinical) –
½ Day – (2 Year Refresher)
Staff who enter into service user areas or deal with the public but do not have a
direct clinical relationship with service users, require this training. For example
porters, domestics, ward clerks, receptionists. It includes training on the
responsibilities of staff to ensure they keep themselves safe, do not cause risk
to others and inform the lead nurse/ head of department of any incidents.
Aggression Management Personal Safety Awareness (E-learning) (3 Year
Refresher)
Staff who rarely service user areas or deal with the public, require this training.
For example office or administrative staff. It includes causes of anger and how
to manage work based conflict.
33
Appendix B
Equality Impact Assessment Tool
Equality Impact
Assessment Questions:
Evidence based Answers & Actions:
1
Name of the policy that you
are Equality Impact Assessing
MAV policy
2
Describe the overall aim of
your policy and context?
Who will benefit from this
policy?
This policy is to support a consistent and positive
approach to the management of aggression and
violence within South West Yorkshire Partnership NHS
Foundation Trust (SWYPFT). It aims to support staff to
effectively manage incidents with the aim of reducing
the number and severity of incidents of aggression and
violence to a minimum
All staff
3
Who is the overall lead for this
assessment?
Director of Nursing Compliance and Innovation
4
Who else was involved in
conducting this assessment?
Network Leader Managing Aggression and Violence
5
Have you involved and
consulted service users,
carers, and staff in developing
this policy?
Members of the MAV TAG and Health and safety TAG
were consulted. Key clinicians and Managers and
were asked to comment. Though service users are
represented on the above groups the policy will be
reviewed by a service user and carer group.
What did you find out and how
have you used this
information?
6
What equality data have you
used to inform this equality
impact assessment?
N/A
7
What does this data say?
N/A
8
Have you considered the
potential for unlawful direct or
indirect discrimination in
relation to this policy?
Yes
34
9
Taking into account the
information gathered.
Does this policy affect one
group less or more favourably
than another on the basis of:
Where Negative impact has been identified please
explain what action you will take to mitigate this.
If no action is to be taken please explain your
reasoning.
YES
10
NO
Race
N
Disability
Y
Gender
N
Age
N
Sexual Orientation
N
Religion or Belief
N
Transgender
N
What measures are you
implementing or already have in
place to ensure that this policy:

promotes equality of
opportunity,

promotes good relations
between different equality
groups,

eliminates harassment
and discrimination
On Teamwork Clinical 2 courses
a level of physical ability is
required. Occupational health will
make a functional assessment of
individuals and a judgement
made as to whether the condition
is permanent or temporary. The
MAV Team will attempt to make
reasonable adaptations to
physical techniques. If no
adaptations can be made the
individuals manager and
Occupational Health will be
informed
This policy is a standing item for discussion at the MAVTAG
where issues can be identified and acted upon.
11
Have you developed an Action
Plan arising from this
assessment?
If yes, then please attach any
plans at the back of this template
N/A
12
Who will approve this
assessment and when will you
publish this assessment.
Executive Management Team
When revised policy is approved by Trust Board
35
Version Control Sheet
This sheet should provide a history of previous versions of the policy and
changes made
Version
Date
Author
Status
Comment / changes
1
6th October
2008
Mark
Kidder
Final
New Policy
2
7th October
2010
Mark
Kidder
Final
Revision - Addition of Restraint
Monitoring Form
Equality Impact Assessment
Conversion to Business
Delivery Units
Update of training risk
continuum and addition of E –
learning package.
3
1st October
2012
MAV tag
Final
Synthesised with BBDU
4
Sept 15
MAV Tag
Final
Revision in relation to
Department of Health. (2015).
Mental Health Act 1983 Code of
Practice.
Meeting Needs and Reducing
Distress: guidance on the
prevention and management of
clinically related challenging
behaviour in NHS settings.
Department of Health, NHS
Protect. (2013).
Positive and Proactive Care:
reducing the need for restrictive
interventions.Department of
Health. (2014).
Violence and Aggression:
Short-term management in
mental health, health and
community settings. Updated
edition. NICE Guideline NG10
(2015)
British Institute of Learning
Disabilities Code of Practice
forminimising the use and
reduction of physical
interventions:planning,
developing and delivering
training (2014)
A Positive and Proactive
36
Workforce: a guide to workforce
development for commissioners
and employers seeking to
minimise the use of restrictive
practices in social care and
health. Skills for Health and
Skills for Care.(2014)
These include guidance to the
use of prone restraint and high
level holds.
The use of mechanical restraint
Use of individual support plans
37