If Being Read As a Paper Copy, Please Refer to Trust Intranet to Ensure This Is the Current

Therapeutic Restraint Policy (Restrictive Interventions) of Adults Under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS) and Procedure for DOLS Authorisation

If being read as a paper copy, please refer to Trust intranet to ensure this is the current version

Document Reference: / LGT/MCA003
Version: / 1
Date Effective: / 27th May 2014
Author: / Paul Hodson – Adult Safeguarding Manager
Responsible Director: / Joy Ellery - Director of Knowledge, Governance and Communications
Consultation: / Lewisham & Greenwich NHS Trust staff.
Adult and Children & Young People Safeguarding Committee.
Bexley, Greenwich and Lewisham Local Authorities
Approved By and Date: / Adult & Children & Young People Safeguarding Committee - 06/05/2014
Ratified By and Date: / 27th May 2014, Integrated Governance Committee
Target Audience: / All Staff
Equality Impact Assessment: / High Positive Impact
Review Date: / 06/05/2015

Lewisham and Greenwich NHS Trust Page 1 of 28

Therapeutic Restraint Policy (Restrictive Interventions) of Adults Under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS) and Procedure for DOLS Authorisation

Review and Amendment Log

Version / Date / Author / Type of change / Summary of Change(s)
1 / 06/05/2014 / Paul Hodson / Updated to reflect changes since integration / This replaces the LHT document: Therapeutic Restraint Policy (restrictive interventions) of Adults under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS) and procedure for DOLS authorisation – version 1, 19/04/11and the SLHT document – Safeguarding Adults Policy – including Guidance onDeprivation of Liberty and Restraints – version 3 May 2012

Dissemination Plan

Audience / Method / Paper or Electronic / Responsible Staff Member
All staff / Trust intranet / Electronic / Paul Hodson, Adult Safeguarding Manager

Lewisham and Greenwich NHS Trust Page 1 of 28

Therapeutic Restraint Policy (Restrictive Interventions) of Adults Under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS) and Procedure for DOLS Authorisation

Contents

1.Introduction

1.1Policy Description

2.Purpose and Scope

3.Definitions

3.1The Human Rights Act 1998

3.2Mental Capacity Act 2005 – Deprivation of Liberty Safeguards 2007

4.Roles and Responsibilities

4.1The Chief Executive and Trust Board

4.2The Executive Director / Lead for Adult Safeguarding

4.3Directorate Management Teams

4.4Ward, Clinic, and Service Managers/Leads

4.5All Staff

5.Principles of Restraint

5.1 What Is Restraint and Restrictive Interventions?

5.2 Types of Restraint (Restrictive Interventions)

5.2.1 Physical Restraint

5.2.2 Therapeutic Holding / Intervention

5.2.3 Barriers Preventing Freedom Of Movement

5.2.4 Medical Restraint

5.2.5 Medication and Chemical Sedation / Restraint

5.2.6 Psychological Restraint

5.3Legal Context

5.4Mental Capacity Act 2005

5.5Deprivation of Liberty And Restraint – The Law

5.6 Deprivation of Liberty (DOLS)

5.6.1 'The Acid Test' for the authorisation of the DOLS...... 15

5.6.2 Urgent and Standard DOLS...... 16

5.6.3 Consideration of alternatives...... 17

5.6.4 The DOLS (Standard Authorisation) process...... 17

5.6.5 The responsibilities of the Managing Authority following the authorisation of

DOLS 18

5.6.6 If a DOLS application is declined19

5.6.7 CQC notification 19

5.6.8 Death of an individual subject to a DOLS19

6.Training

7.Monitoring Compliance

8.References

9.Associated Documents

Appendix 1: Equality Impact Assessment

Appendix 2: Screening Tool3

Appendix 3:Contact Numbers6

Lewisham and Greenwich NHS Trust Page 1 of 28

Therapeutic Restraint Policy (Restrictive Interventions) of Adults Under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS) and Procedure for DOLS Authorisation

1.Introduction

Managing challenging behaviour within a Healthcare Trust are complex as the behaviours exhibited by people have various causes and therefore need a varied response to manage appropriately. Policies and procedures will not cover all eventualities and can only act as a guide of good practice. Common sense will need to be applied to each individual situation when applying the principles within this policy.

Some of the main underlying causes of challenging behaviours can be:

Mental health issues – as described under the Mental Health Act
Medical conditions e.g. delirium
Dementia
Lack of mental capacity
Volatile personality
Upsetting situations
Substance misuse
Socially unacceptable response to stress (rather than volatile personality)

Whilst on Lewisham & Greenwich NHS Trust premisesa range of people may present with challenging behaviours including visitors, patient and staff. This policy and the Managing Challenging Behaviour in Older Adults with Dementia Procedure offerssupport to staff in the management of patients with challenging behaviour. Each policy should be read together to ensure a broad understanding, and ensure the right policy is utilised in each situation.

The principles and guidance within this policy must be followed by all staff and services in Lewisham & Greenwich NHS Trust.

1.1Policy Description

The Mental Capacity Act (2005) provides a statutory framework for acting on behalf of individuals aged 16 years and over who lack the mental capacity to make certain decisions for themselves. It introduced a number of measures to protect individuals and seeks to ensure that every person is given the chance to make decisions for themselves.

Since the commencement of the Mental Capacity Act the government has added a new provision, the Deprivation of Liberty Safeguards (DOLS), which was introduced through the Mental Health Act 2007 in order to comply with the European Court of Human Rights judgement in the HL v UK case in 2004. (This case is commonly referred to as the ‘Bournewood’ judgement).

The Deprivation of Liberty Safeguards were introduced to provide a proper legal process and suitable protection in those circumstances where deprivation of liberty appears to be unavoidable, in a person’s best interests. They apply to people who lack capacity to decide about their care or treatment, and who are deprived of their liberty in order to protect them from harm, but are not covered by the Mental Health Act 1983. The safeguards are applicable to people in, acute and independent hospitals hospital, or Care Homes that are registered under Care Standards Act 2000.The new safeguards become a statutory obligation from 1 April 2009.

This policy provides guidance to staff for the safe use of restraint (restrictive interventions - physical and chemical) under the Mental Capacity Act when caring for adult patients. It is written to ensure all staff work within the law and in the best interest of the people they are providing treatment and care for. The policy sets out a framework for staff to follow in certain situations where they are required to restrain a patient to enable care and treatment to be delivered effectively. The policy relates to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DOLS).

No one should be deprived of their liberty unless authorised to do so unless they are detained under the Mental Health Act 1983 or are being detained under criminal law.

This policy sets out actions and procedures regarding restraint that can be undertaken which comply with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS).

The Trust will ensure that restraint (restrictive interventions)is used:

As infrequently as possible,
Thatit is used in the best interest of the patient,
And when used, everything possible is done to prevent injury or harm and maintain the patient’s sense of dignity.

It is recognised that adults and those who are at risk may sometimes require the use of restrictive interventions to ensure they remain safe and receive appropriate treatment andcare. Restraint may be justifiably used in some cases in the following circumstances:

The individual is displaying behaviour that is putting themselves or others at risk of harm
The individual is displaying behaviour that is putting others at risk of harm
The individual is requiring treatment by a legal order, i.e. Mental Health Act 1983
The individual is requiring urgent life-saving treatment.
The individual needs to be maintained in a secure setting.

“Lets talk about restraint – rights risks and responsibility” (2008)RCN

Other relevant policies/guidance include:

Lewisham & Greenwich NHS Trust Safeguarding Adults at Risk Policy

Bed rail assessment forms

DOH Deprivation of Liberty Safeguards ‘A guide for hospitals and care homes 2009’
Lewisham’s multi-agency guidance on Mental Capacity Act, Deprivation of Liberty Safeguard procedures April 2011.

2.Purpose and Scope

This policy is intended to:

Set out a framework of good practice, recognising the need to ensure that all legal, ethical and professional issues, including the Deprivation of Liberty Safeguards for adults and the Human Rights Act 1998, have been taken into consideration.
Ensure restraint or restriction will only be used as a last resort or in exceptional circumstances and will be used in proportion to the situation
Provide guidance for managers and staff.
Help all involved act appropriately in a safe and legal manner, thus ensuring effective responses to the assessment, care and treatment of patients.

The policy applies to all:

Staff employed by the Trust, working on Trust premises.
Staff employed by the Trust, working in people’s homes, or in other organisation’s premises.
All sites and services within Lewisham & Greenwich NHS Trust.

This guidance is not intended to be a comprehensive manual covering all situations and methods; instead it is a set of principles and key references which will help staff to develop practices in their workplace, in conjunction with other members of the multidisciplinary team using the Mental Capacity Act, Deprivation of Liberty Safeguards and guidance papers on restraint / restriction.

This policy does not relate to the routine use of sedation within anaesthetics and critical care.

The use of restrictive intervention in the vast majority of cases will apply to individuals wholack capacity to consent to treatment or care and where restraint is used in their best interest toprotect them from harm.

3.Definitions

3.1The Human Rights Act 1998

The Human Rights Act sets out the principles regarding the protection of adults from abuse by public authorities or people working for these organisations. Article 5 of the Act relates to the rights of people to be safe and staff have a duty to ensure that patients have their care needs assessed appropriately and their safety is maintained through person centred care.

3.2Mental Capacity Act 2005 – Deprivation of Liberty Safeguards 2007

The Mental Capacity Act 2005 (MCA) provides a statutory framework for acting on behalf of individuals who lack the mental capacity to make certain decisions for themselves. It introduced a number of measures to protect individuals and seeks to ensure that every person is given the chance to make decisions for themselves.

Since the commencement of the Mental Capacity Act (MCA) the government has added a new provision, the Deprivation of Liberty Safeguards (DOLS), which was introduced to comply with the European Court of Human Rights judgement made in 2004 (The Bournewood judgement).

DOLS was introduced to provide a proper legal process and suitable protection in those circumstances where deprivation of liberty appears to be unavoidable, in a person’s best interests. They apply to people who lack capacity to decide about their care or treatment, and who are deprived of their liberty in order to protect them from harm, but are not covered by the Mental Health Act 1983. The safeguards are applicable to people in acute and independent hospitals or care homes that are registered under the Care Standards Act 2000.

Before providing care or treatment, healthcare staff must decide on whether the patient in question has the mental capacity to consent to the care or treatment that is thought to be in his/her best interest in accordance with the Mental Capacity Act 2005 guidelines.

In making a decision whether to use restraint on a patient who lacks capacity to consent to treatment or care, a risk assessment should be undertaken considering the risks of using restraint and the possible harm the patient is likely to suffer if some form of restraint is not used.

It is not possible to remove all risk and so a proportionate response is needed when the risk of harm does arise.

Proportionate response means using the least intrusive type and minimum amount of restraint to achieve a specific outcome in the best interest of the patient who lacks capacity.

Healthcare professionals should consider less restrictive options before using restraint. Where possible they should consult others involved in the person’s care in deciding what actions would be best employed in protecting the patient.

Any action intended to restrain a person who lacks capacity will not attract protection from liability unless the following two conditions are met:

The person taking the action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity
The amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm.

4.Roles and Responsibilities

4.1The Chief Executive and Trust Board

The Chief Executive and Trust Board will ensure:

The overall implementation, monitoring and effectiveness of the policy
The allocation of resources to provide compliance with the policy
That managers are aware of their responsibilities and implement the policy.

4.2The Executive Director / Lead for Adult Safeguarding

The Executive Director / Lead for Adult Safeguarding:

Has the delegated authority from the Chief Executive for the operation of this policy

Ensures that the Trust Board is advised of the effectiveness of this policy and of any shortfalls in meeting the standards set.

4.3Directorate Management Teams

These teams will ensure:

The policy is distributed within their Service Directorate and adhered to.
Staff receive appropriate training
Resources are provided to comply with this policy.

4.4Ward, Clinic, and Service Managers/Leads

These managers/leads will ensure:

This policy and the accompanying procedures are fully implemented and adhered to in their area and that all staff are aware of its contents and their duties
In all wards/areas where the use of physical or medication restraint is foreseeable there should be access to Basic Life Support (BLS) equipment for patients within 3 minutes (NICE, 2005)
All staff undertake relevant training e.g. understanding legislation, regulation and relevant policy, therapeutic holding or restrictive physical intervention as appropriate to their area of work.

4.5All Staff

All Trust staff are:

To be aware of this policy and its content
To apply the principles of this policy as required.

5.Principles of Restraint

People are entitled to be cared for in the least restrictive way possible and care planning should always consider if there are other, less restrictive options available. In exceptional circumstances it may not be possible to care for someone other than imposing a regime which may amount to a deprivation of a person’s liberty.

All Trust staff will ensure that patients are cared for in a safe and dignified manner. Where restraint is required in the best interest of the patient, it is used in compliance with the law and principles of the Mental Capacity Act 2005 and the Human Rights Act 1998.

The Trust is committed to providing a safe environment for its patients, staff and others, as well as recognising their rights and needs and respecting the dignity of individuals for whom it provides care. Therefore when using restraint, a balance must be achieved between minimising risk of harm to patients and others, and maintaining dignity, personal freedom and choice.

In accordance with the Mental Capacity Act 2005, staff must only use restraint as a last resort, when all other strategies have failed. Staff must ensure that the restrictive intervention is:

Proportionate to the harm that could occur if the restraint was not used,
The least restrictive option,
In the patient’s best interest,
Only used for the shortest period possible.

Before using any form of restrictive patient intervention, staff will risk assess each situation on an individual basis which considers:

The environment
The patient’s behaviour
The patient’s underlying condition and treatment
The patient’s mental capacity
Duty of Care
Likelihood of harm to the person or other people

The assessment must be recorded in the patient’s records.

All events requiring restraint to be used in an emergency will be recorded as a clinical incident and must be reported to the multi-disciplinary team and matron with a clear plan for future occurrences where possible.

The use of this restraint policy in the care of vulnerable adults will be referenced and referred to in the safeguarding adults training which is mandatory for all clinical staff.

5.1What Is Restraint and Restrictive Interventions?

According to established international definitions, included within Showing restraint: challenging the use of restraint in care homes (Counsel and Care UK, 2002), restraint is defined as ‘the intentional restriction of a person’s voluntary movement or behaviour’. In this context ‘behaviour’ means planned or purposeful actions, rather than unconscious, accidental or reflex actions.

Let’s talk about restraint – rights risk and responsibility (2002). RCN

Guidance on restraint can also be found by referring to codes of practice relating to particular Acts of Parliament including:

Human Rights Act 1998
Mental Capacity Act 2005
Deprivation of Liberty Safeguards ‘code of practice’ 2007

It is recognised that in exercising our duty of care in ensuring the safety of individuals within the Trust, decisions on the use of restraint methods may have be applied to patients in urgent and emergency situations. Sometimes these decisions may have to be made quickly and without consultation with colleagues and relatives. Staff must ensure detailed documentation of actions and reasons for the restraint are recorded in the patient’s records.

If restraint may be required over a longer term, other than a one off emergency response or if restraint is considered to be required periodically due to the individual’s condition then the member of staff must refer to the procedures within this policy, to gain appropriate authorisation for the ongoing restraint / restriction.