Canberra Hospital and Health Services
OperationalProcedure
Dhulwa Mental Health Unit (DMHU) – Use of Therapy Spaces
Contents
Contents
Purpose
Alerts
Scope
Section 1 – Responsibility for Therapy Spaces
1.1 On-ward Therapy Spaces
1.2 Off-ward Therapy Spaces
1.3 Orientation to therapy spaces
1.4 Staff facilitating an activity
Section 2 – Accounting for Tools, Equipment and Materials
2.1 Counts of Tools, Equipment and Materials
2.2 Missing Tools, Equipment or Materials
2.3 Weekly Audits
2.4 Damaged, broken or work tools, materials or equipment
Section 3 – Consumer Access and Use of Therapy Spaces
3.1 Approval for Consumer Access to Therapy Spaces
3.2 Risk Assessment
3.3 Safety and Security
3.4 Unsupervised Access to Therapy Spaces
3.5 Documentation
Section 4 – Booking Therapy Spaces
4.1 On-ward Therapy Group Rooms
4.2 Off-ward Therapy Spaces
4.3 Computer devices
Implementation
Related Policies, Procedures, Guidelines and Legislation
Legislation
Definition of Terms
Search Terms
Purpose
The purpose of this procedure is to provide all staff working in Dhulwa Mental Health Unit (DMHU) with the necessary information about:
- Responsibilities for therapy spaces
- Use of storage spaces
- Accounting for tools, equipment and materials
- Consumer access to and use of therapy spaces, and
- Booking therapy spaces.
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Alerts
This procedure should be read in conjunction with the Mental Health Act 2015, the Mental Health (Secure Facilities) Act 2016, the DMHU Control of Tools, Equipment and Materials Procedure and the DMHU Consumer Access to Electronic Devices Procedure.
All staff involved in an activity must be familiar with the location of the fixed duress alarm(s) in the space they are using before taking consumers into the space (see Justice Health Services Duress and Emergency Response Procedurefor more information).
Only staff who have received the relevant orientation and induction to a therapy space, including how items may be used and are to be safely managed in the space, will have access to tools, equipment and materials (including sporting and music resources).
Staff wishing to access the space and tools, equipment and materials for use with consumers will need to liaise with the relevant manager of the space (see below) about their training.
Information about the use of equipment, tools and materials in each therapy space is available from the respective therapy space manual, located in the therapy space, generally on the door. In some circumstances posters on display in the room may also be used as an easy reference for example, hand washing in the ADL Kitchen.
Staff facilitating an activity are responsible for completing the Session Inventory Form, located in the Session Inventory Formbooklet stored in each therapy space, before and at the conclusion of the activity.
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Scope
This procedure applies to:
- All staff working in DMHU, and
- All DMHU therapy spaces, including the:
- Activities of Daily Living (ADL) Kitchen
- Barbeque Area
- Basketball Court
- Computer Room
- Dining rooms
- Group Activity rooms
- Gymnasium
- Multi-Faith Room
- Multipurpose Room
- Sensory Modulation Room
- Vocational Workshop, and
- Walking track.
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Section 1 – Responsibility for Therapy Spaces
1.1 On-ward Therapy Spaces
Nursing staff on each unit are responsible for managing the on-ward therapy spaces (see definition of terms). All enquiries about the use of these spaces and associated equipment should be directed to the Nurse in Charge (NIC).
1.2 Off-ward Therapy Spaces
Allocated staff are responsible for managing each of the following off-ward therapy spaces:
1.2.1 Activities of Daily Living Kitchen
- The Occupational Therapist (OT)is responsible for managing for the ADL Kitchen.
- The OT and Allied Health Assistant (AHA) have overall responsibility for ensuringthe maintenance and cleaning of equipment and thecompletion and monitoring of documentation e.g. Session Inventory Form, of the ADL Kitchen and for the purchase of appropriate equipment.
1.2.2 Barbeques
- The Facility Managerhas overall responsibility for the maintenance, cleaning of the barbeque areaand for the purchase of appropriate equipment.
- Cleaning of the barbeques is scheduled for every Monday and additional cleaning can be arranged on request, through the Facility Manger.
- Staff facilitating a barbeque are responsible for ordering all stores required.
Note: Any tools or equipment taken from the ADL kitchen for a barbeque, must be recorded on the kitchen Session Inventory Form.
1.2.3 Basketball Court
The Facility Managerhas responsibility for the maintenance of the basketball court.All enquiries about the basketball court should be directed to the Facility Manager.
Staff facilitating an activity have responsibility for equipment and the use of the basketball court during an activity.
1.2.4 Computer Room and DMHU owned laptops, iPads, iPods and computers
The Therapy Manager has management responsibility for the Computer Room and DMHU owned laptops, iPads, iPods and computers available for consumer use. All enquiries about the use of these resources should be directed to the Therapy Manager. The Therapy Manager will manage the DMHU iTunes account.
Alert: It is essential that all access to the computer room must follow section 4.1 Access to DMHU Computer Room in the DMHU Consumer Access to Electronic Devices Procedure.
1.2.5 Gymnasium
The Exercise Physiologist(EP) is responsible for managing the gymnasium (gym). All enquiries about the use of the gym and associated equipment should be directed to the EP (or Therapy Manager in absence of EP).
- The EP and AHA have overall responsibility for ensuring the maintenance and cleaning of equipment and the completion and monitoring of documentation (e.g. Session Inventory Checklist), in the gym and for the purchase of appropriate equipment.
1.2.6 Multi-Faith Room
- The Allied Health Team is responsible for managing the Multi-Faith Room. All enquiries about the use of the Multi-Faith Room and associated equipment should be directed to the Therapy Manager or delegate.
1.2.7Multipurpose Activities Room
- The Art Therapist is responsible for managing the Multipurpose Activity Room and the purchase and replenishment of equipment and materials for art therapy purposes. All enquiries about the use of the Multipurpose Activity Room and associated equipment should be directed to the Art Therapist.
- Where the room is used for activities other than Art, the facilitator of that activity is responsible for the management of equipment or materials.
- Staff should inform the Art Therapist as art materials become depleted.
- Sharps are to be kept in the locked knife box in the Multipurpose Storeroom. Staff may access these with approval from the Therapy Manager, Art Therapist or OT.
- Only the tools required for the activity should be removed from the Multipurpose Storeroom.
1.2.8 Sensory Modulation Room
- The OT is responsible for managing the Sensory Modulation Room.
- The OT and AHA have overall responsibility forensuring the maintenance, cleaning and monitoring of the sensory modulation room and for the purchase of appropriate equipment.
1.2.9 Vocational Training Room
- The OT is responsible for managing the Vocational Training Room. All enquiries about the use of the Vocational Training Room and associated equipment should be directed to the OT (or Therapy Manager in the absence of the OT).
1.2.10 Walking Track
- The Facility Manageris responsible for managing the walking track maintenance and upkeep. All enquiries about the maintenance and upkeep of the Walking Track should be directed to the Facility Manager.
1.3 Orientation to therapy spaces
The staff member(s) with responsibility for each therapy space are available to orientate staff to the space, its manual and associated equipment. Staff seeking orientation should approach the relevant staff member(s) for orientation.
1.4 Staff facilitating an activity
Staff facilitating an activity will:
- Conduct the session in accordance with the therapy space manual located on the back of the door
- Use the Session Inventory Checklist to record all tools and materials to be used during an activity at the commencement of the activity and at the conclusion of the activity, before consumers have left the therapy space (see DMHU Control ofEquipment and Materials Procedure for further information)
- Ensure all items used during the activity are returned to their respective locations, (e.g. locked cupboards, ADL kitchen)
- Ensure the space is left tidy and clean, (i.e. paint brushes are cleaned, the barbeque is cleaned)
- Ensure any required cleaning and hygiene guidelines, specified in the therapy space manual, have been followed
- Ensure any keys borrowed from a Therapy Manager are returned
- Advise security control (on ext 79600) before takingconsumers to off-ward activities. This is to ensure that security turns on the relevant Closed Circuit Television (CCTV) cameras in the area during the activity, and
- Advise security control (on ext 79600) when the activity has concluded, so that security can turn off the relevant cameras at the conclusion of the activity.
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Section 2 – Accounting for Tools, Equipment and Materials
Unless otherwise stipulated in this procedure, the following requirements apply to the use and storage of equipment in therapy spaces.
2.1 Counts of Tools, Equipment and Materials
- At the beginning and end of each activity, staff responsible for supervising the activity must conduct a count of all tools, equipment and materials to be used, using the Session Inventory Check Form contained in the session inventory check form audit booklet, located in the therapy space (see therapy space manual and DMHU Control ofEquipment and Materials Procedure for further information). The count at the end of the activity must occur before consumers leave the room.
2.2 Missing Tools, Equipment or Materials
- If any tools, equipment or materials are missing, search procedures should commence, as outlined in section four of the DMHU Control of Equipment and Materials Procedure (see DMHU Search Procedure for more information).
2.3 Weekly Audits
- Staff with overall responsibility for a therapy space will conduct a weekly audit of all tools and materials in the therapy space using the respective therapy space audit checklist, containedin the therapy space audit booklet, located in the therapy space.
- The Unit Management Team (UMT) will audit Inventory Formsto monitor compliance.
- The Therapy Manager will table an audit report of inventory forms at the monthly DMHU Security and Facility meeting.
2.4 Damaged, broken or work tools, materials or equipment
- The staff member responsible for the therapy space will replace any damaged, broken or worn out tools, materials or equipment.
- Before new tools, materials or equipment are taken into the therapy space they must be engraved with the appropriate identification (see therapy space manual andDMHU Use of Tools and Material Procedure for more information).
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Section 3 –ConsumerAccess and Use of Therapy Spaces
3.1 Approval for Consumer Access to Therapy Spaces
Access to off-ward therapy spaces requires approval of the MDT, based on the consumer’s Security Classification and Leave Entitlement (SCALE) (see DMHU Consumer Leave Management Procedure for more information) and must be documented in the consumer’s Treatment, Placement, Restrictions, Implementation, Monitoring and Review(TPRIM) Plan (see DMHU Clinical Risk Assessment and Management Procedure for more information).
Access to outdoor therapy spaces (see definition of terms) is contingent on approval for ground leave as indicated by the consumer’s SCALE rating. This may be escorted, supervised, or unescorted (see DMHU Consumer Leave Management Procedure for more information).
3.2 Risk Assessment
Access to specific activities and facilities is based on relevant risk assessments. These include:
3.2.1 Activities of Daily Living Kitchen and Barbeque Areas
The OT will conduct relevant risk assessments and document the outcome in the consumer’s electronic clinical file (ECR). Assessments may include the safe use of sharps, fire equipment, and use of tools or implements.
3.2.2 Consumer Computer Room andDMHU owned laptop, iPad, IPod or Computer
Consumers will require MDT approval before having access to the computer room and a DMHU owned laptop, iPad iPod or computer to use for therapeutic activities.Access to a DMHU owned laptop, iPad iPod or computer may be given with or without supervision, based on the consumer’s SCALE and MDT approval (see DMHU Consumer Access to Electronic Devices Procedure for more information).
3.2.3 Gymnasium
TheEP will conduct physical and medical risk assessments using the Dhulwa Gym Pre-Screening Tool and the Physical Assessment Form: Dhulwa Gym available on the DMHU forms folder. These will be scanned into the consumer’s ECR.
3.2.4 Multipurpose Room
The facilitator of an activity conducted in the Multipurpose Room will ensure that consumers have any appropriate risk assessments, e.g. when using tools that may pose a risk.
3.2.5 Vocational Workshop
The facilitator of an activity conducted in the Vocational Workshop will ensure that consumers have any appropriate risk assessments, e.g. when using tools that may pose a risk.
3.3 Safety and Security
Notwithstanding the above risk assessments, dynamic clinical factors may govern the decision to approve participation on a given occasion (i.e., leave, mental state, Dynamic Appraisal and Situational Risk (DASA) score, TPRIM updates and group mix). Dynamic factors will be assessed by the staff member facilitating the activity on each occasion prior to providing access to the therapy space. A final decision on access will be determined by the NIC and/or Therapy Manager.
Prior to commencing an activity, staff responsible for supervising the activity should:
- Be aware of the consumer’sTPRIM Plan and SCALE rating (see Consumer Leave Management Procedure for more information) and current mental state of each consumer considered for an activity
- Check the space for any hazards, e.g.,prohibited and restricted items and items requiring approval (see DMHU Prohibited and Restricted Items for more information)
- When facilitating activities in the grounds, collect a Talk Radio Network (TRN) radio from the staff station to facilitate contact with security or another staff member in the event that staff require further assistance to manage a medical or security incident, and
- Note the ratio of staff to consumers required, as indicated by their SCALE and minuted in the TPRIM.
3.4 Unsupervised Access to Therapy Spaces
Unsupervised access may be granted to a therapy space, .e.g. the walking track, depending on the consumer’s SCALE and recommendation of the MDT.
3.5 Documentation
At the conclusion of each activity, a member of staff involved in the activity should record a clinical note in the ECR of each consumer who was involved in the activity and for any consumer who declined to participate in the activity. This note should include information about the consumer’s mental state, participation level and anything else of relevance.
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Section 4 – Booking Therapy Spaces
4.1 On-ward Therapy Group Rooms
Activities and programs scheduled in the on-ward group activity rooms will be documented on the Lomandra and Cassia Unit timetables, located on the staff station noticeboard and consumer noticeboards.
If there is no activity scheduled in a room, it can be used and accessed as needed (i.e. as a quiet space, for play station, etc), with the prior approval of the NIC.
4.2 Off-ward Therapy Spaces
Activities and programs scheduled in each therapy space will be documented on the relevant therapy space timetable, located on the door of the space and on the consumer noticeboard.
If there is no activity scheduled in the space, a member of staff may use the space with a consumer after first seeking approval from the staff member responsible for the space or Therapy Manager.
4.3 Computer devices
Bookings for all consumer computer devices can be made via the Computer Room Diary
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Implementation
The contents of this procedure will be communicated through training provided to DMHU staff and other relevant teams where the procedure applies. New staff will be familiarised with the procedure on their induction.
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Related Policies, Procedures, Guidelines and Legislation
Policies
ACT Health Work Health and Safety Policy
ACT Health Work Health and Safety Management System
ACT Health Incident Management Policy
ACT Health Waste Management Policy
ACT Health Electrical Safety Policy
DMHU Search Policy
Procedures
ACT Health Incident Management Procedure
ACT Health Significant Incident Procedure
CHHS Mobile Electrical Equipment including Clinical Equipment
MHJHADS Director on Call Roles and Responsibilities Procedure
MHJHADS Significant Incidents Reporting Procedure
Justice Health Services Duress and Emergency Response Procedure
DMHU Control of Tools, Equipment and Materials Procedure
DMHU Referral, Admission and Transfer of Care Procedure
DMHU Search Procedure
DMHU Consumer Access to Electronic Devices Procedure
DMHU Prohibited and Restricted Items and Items Requiring Approval for more information
DMHU Clinical Risk Assessment and Management Procedure
DMHU Leave Procedure
Frameworks
DMHU Security Procedural Framework
ACT Health Waste Management Plan
Standards
- Australian Charter of Healthcare Rights
- National Standards for Mental Health Services 2010
- National Safety and Quality Health Service Standards 2012
- Australian and New Zealand Food Standards Code
Legislation
- Mental Health Act 2015
- Mental Health (Secure Facilities) Act 2016
- Children and Young People Act 2008
- Public Advocate Act 2005
- Human Rights Act 2004
- Carers Recognition Act 2010
- Health Records (Privacy & Access) Act 1997
- Guardianship and Management of Property Act 1991
- Crimes Act 1900
- Privacy Act 1988
- Discrimination Act 1991
- Work Health and Safety Act 2011
- Corrections Management Act 2007
- Official Visitor Act 2012
- Territory Records Act 2002
- Working with Vulnerable People (Background Checking) Act 2011
- Health Act 1993
- Workplace Privacy Act 2011
- Security Industry Act 2003
- Court Procedures Act 2004
- Electrical Safety Act 1971
- Food Act 2001
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