Temporarily locking ward doors*
This care bundle describes seven actions to ensure the best clinical outcome for patients who have been affected by locking the doors on an OPERATIONALLY OPEN WARD. Care must be delivered in a safe and positive manner to ensure safe decision making and environmental controls for behaviourally disturbed wards. Each described intervention will be required to be delivered, however these do not need to be completely sequentially.
*The same interventions would be used for any decision to lock any other doors which are routinely open (gardens/bathrooms etc.)
Aim:
Support the Patient in developing coping strategies before the use of locking doors.
What to do:
Preplanning to include plan of care and other supporting care documentation such as person centred care plans, Positive Behavioural Support plans, Safety plans, SAFEWARDS and risk assessments, alongside information following previous incidents to ensure locking ward doors is not the first approach for managing challenging behaviour.
Consider bed placement, staff and patient mix and environmental factors in ward allocation on admission.
Consider physical causes such as delirium, medication induced confusion, or use of illicit substances.
Review and update risk assessment.
Aim:
Ensure timely and accurate record keeping. Develop robust systems for the temporary locking of ward doors and aftercare.
What to do
Ensure all staff who will lock the ward doors have completed MCA and MHA training and support available from L&D training staff.
Ensure all staff involved in the use of locking ward doors have access to supervision and any learning needs are addressed.
Clear documentation on PARIS of rationale for the use of locking ward doors and actions following its commencement.
Explain and document rationale to patient.
Explain and document rationale to all informal patients also on the ward including capacity to consent to remain under changed circumstances.
Update and review the clinical documentation regularly including the care plan and risk assessment.
DATIX to be completed for all incidents involving locking ward doors.
Review and update risk assessment.
Aim:
Safe management of locking doors on Open Wards which is trauma informed and prioritises the patient. experience.
What to do:
Put signage on both sides of main door to ward to inform patients, carers and visitors.
Complete care plan for patient whose presentation is causing temporarily locked doors.
- Why locking door manages risk.
- Why decision to lock the door is least restrictive option.
- Strategies aimed at pre-venting behaviour escalating.
- Active strategies to unlock door
- The indicators that risk has reduced to allow doors to be unlocked.
Inform bleep holder to inform gatekeepers to assess capacity to agree to being admitted to locked ward.
Refer to complex case panel.
Inform Day area/HUB/OT of locked status to allow for “drop in” activities to be accessed.
Assess capacity of all informal patients to agree to remain.
Complete capacity assessment on PARIS.
Review and update risk assessment.
Aim:
Foster a multi-disciplinary approach to care planning for Locking ward Doors to manage challenging. behaviour.
What to do:
Team to review locked doors decision continuously using criteria in care plan.
Formal discussion each handover to be documented using criteria in care plan.
Clinical review within 24 hours including Nursing staff and medical team to review care plan, current management plan and future plans to manage risk including alternatives to Locking ward doors.
Feedback from clinical review to be included in care plan and risk assessment.
Discuss the locking of ward doors in the next MDT ward round/Clinical team review for the patient.
Formulation of risks to assess the continued need for Ward doors to remain locked and explore possible alternatives.
Assess effectiveness of current care plan – consider onward referral.
Ongoing review of management and routine treatment and any possible interactions.
Aim:
Develop a robust system that ensures that the patient’s psychological and emotion wellbeing is monitored.
What to do:
MD Team to include in next (and subsequent) MDT reviews, active measures to assess and promote:
- Psychological and emotional impact of locked door
- Protection of Family and private life (article 8)
- Capacity to consent to remain informal for all informal patients.
Formulate active plans for off ward activity.
Liaise with Hub/OT Day area for ward based activity.
Consider level of support required by staff/patient following any incident for psychological impact and physical injuries.
Consider discharge and Home treatment, and transfer options for informal patients adversely affected by locked door regime.
Aim:
Foster a multi-disciplinary approach to care planning for Opening ward doors after managing challenging behaviour.
What to do:
Clinical review within 24 hours, including Nursing staff and medical staff to review care plan and future plan including alternatives.
Feedback from clinical review to be included in care plan and risk assessment.
Discuss the use of locking door in next MDT ward round/Clinical team review for the patient.
Assess effectiveness of current care plan – consider diagnosis.
Ongoing review of current care plan and routine treatment and any possible onward referral.
Aim:
Support the patient and carer(s) following locking Ward doors and support all involved to develop understanding of why doors were locked.
What to do:
Staff to carry out immediate post-incident debrief as described in P&PS Training.
Review incident that led to Doors being locked with the patient, carer and/or advocate and signpost to additional support.
Review the positive behavioural support plan, advanced directives and other clinical documentation.
Ensure witnesses are given the opportunity to reflect on their experience of the incident.
Feedback from debriefs to be included in care plan and risk assessment.
Ensure all staff involved have access to supervision.
Identify training needs.