Enhanced Care Procedure
|Next review: 31/10/2022|
|Standard Operating Procedure|
|Approved By: Chief Nurse|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
Enhanced Care Procedure
- Definition of Enhanced Care
- Aims and Process for Enhanced Care
- Roles and Responsibilities
- Audit and Monitoring Compliance
Leeds Teaching Hospital Trust (LTHT) is committed to ensuring high standards and safe care for all patients, staff and relatives. We will ensure the safety and dignity of patients and the safety of staff are priorities when anticipating or managing potentially violent and aggressive situations (NICE 2015). LTHT uses Enhanced Care to achieve some of these aims. Enhanced Care systematically risk assesses a patient’s psychological and behavioural needs. Enhanced Care assessments can be undertaken on any adult patient that triggers initial screening criteria on the Nursing Specialist assessment (NSA). Assessments are particularly salient for patients who have been assessed as being potentially at risk of harm to themselves or others. The outcome of the risk assessment identifies the additional levels of observation, supervision and interventions a patient may require. This supervision maybe undertaken by a range of workers according to individual patient needs. The level of supervision a patient requires will be reviewed weekly or sooner if patient needs or location changes.
The Enhanced Care Procedure provides a systematic process to risk assess individual patient’s psychological well-being. It then identifies the additional supervision and support they may require to keep them safe. The aim is to ensure that patients are cared for in a safe and dignified environment pertinent to their needs. This procedure standardises the delivery of Enhanced Care to ensure that patients are cared for in a safe environment. Through identifying that patients have the correct level of support for their needs the procedure aims to ensure that staff, relatives, carers and visitors can work and visit in a safe environment.
This procedure is for all LTHT staff (registered, unregistered and ancillary) who are assessing, supporting or caring for patients who require Enhanced Care. There may also be occasions when patient risk assessments indicate the requirement of additional agency staff (security or mental health specialists for example) to keep patient’s safe. These staff should be made aware of their role in context of this procedure.
Enhanced Care is an integral part of a therapeutic care plan, to ensure the sensitive monitoring of the patient’s behaviour and mental state. It helps to identify factors that may escalate or reduce challenging behaviours. Enhanced Care focusses on using the least restrictive means to maintain safety. The process of Enhanced Care ensures that there is a system of monitoring in place applicable to patients’ needs and responsive to alterations in risk, and must be both safe and supportive. Enhanced Care aims to increase the patient’s safety and where required that of carers, visitors and staff.
For many patients Enhanced Care is often only required for a temporary period. Irrespective of the cause, they require safety, compassion, understanding and appropriate treatment. Patients must be engaged in a positive therapeutic relationship with staff, both during and after this increased period of need. Levels of observation may have an impact on standard staffing and skill mix numbers and will require extra controls, reporting and additional staffing.
- To provide guidance on the risk assessment processes and subsequent management and provision of Enhanced Care to patients based on their individual needs.
- To enable the identification of the appropriate level of supervision and the type of worker required to deliver Enhanced Care.
- To provide a resource to support activity intervention related to Enhanced Care.
This guideline provides practical information and guidance for staff to carry out effective Enhanced Care whilst maintaining the patient’s dignity.
LTHT is committed to improving standards of care by delivery of a service that is of the highest quality possible. This includes ensuring there is a system of monitoring in place applicable to patients’ needs and responsive to alterations in risk. This guidance supports ward staff in ensuring that patients requiring Enhanced Care have the appropriate level of care, supervision and observation available to them, provided by a suitable member of staff of staff with the right knowledge and skills to competently care for and or supervise the patient(s).
Enhanced Care should never interfere or compromise any planned treatment or therapy for a patient.
4.2 Common Reasons Why Patients Need Enhanced Care.
- Calling out and disturbing other patients
- Mild Confusion / agitation
- Confused and wandering
- Risk of pulling out indwelling devices
- Agitation / anxiety
- Impaired cognition / Reduced insight / Hallucinations
- Attempts or intension to self-harm
- Risk to self or others
- Violent behaviour
- Immediate risk of absconding
- Withdrawn / uncommunicative
4.3 Impact of Enhanced Care
Enhanced Care is a form of restraint, which can impact on the human rights, privacy and dignity of a person. The Mental Capacity Act (2005) states that whether or not the person is resisting, if their freedom of movement is being restricted (such as during Enhanced Care) then they are being restrained. The key purpose of Enhanced Care is to ensure safe and positive engagements during a temporary period of distress when the patient’s presentation may risk harm to themselves or others.
When any level of Enhanced Care is being provided to those patients who lack capacity, a Restraint / Restrictive Intervention Care Plan Bundle (LTH2487) must be completed in conjunction with the Enhanced Care risk assessment.
NICE (2015) guidance is clear that patients should consent to, and be involved ‘in all decisions about their care and treatment, and (healthcare providers) develop care and risk management plans jointly with them. If a patient is unable or unwilling to participate, offer them the opportunity to review and revise the plans as soon as they are able or willing and, if they agree, involve their carer’ (NICE 2015 section 1.1.6). Within LTHT consent and patient (and/or relative and carer) involvement will be documented in the LTHT Enhanced Care Risk Assessment tool (LTH0326). Use of Enhanced Care Procedure ensures that interventions are proportionate to an assessed risk of harm whilst maximising the dignity and rights of the patient.
Mental Health Act (MHA)
Patients who are or may need to be subject to MHA Section may require an RMN if to provide enhanced care if deemed to be high risk. This should be assessed on a case by case basis and should take place with the patient’s responsible clinician or relevant psychiatry team. For further information, see LTHT MHA Use of Compulsory Powers
LTHT MHA Use of Compulsory Powers
Mental Capacity Act (MCA)
If a patient is assessed to be lacking capacity to make a decision about treatment, they can be treated in their best interests under the MCA.
Patients can be stopped from leaving the ward against medical advice and a worker can be assigned to support the patient, if on balance is in their best interests. Again ensuring the Restraint / Restrictive Intervention Care Plan Bundle (LTH2487) is completed.
The use of medium and high risk Enhanced Care could be considered a form of restraint, and when used for patients who lack capacity the level of observation should be documented as being the least restrictive, and used only for the time period necessary. Enhanced Care can be provided under the MCA for those who lack capacity for short term only; if it is felt that the Enhanced Care will have to continue for a prolonged period application for Deprivation of Liberties Safeguards (DOLS) will need to be considered. The MCA/MHA Team or the Adult Safeguarding Team will be able to advise further on the appropriateness of a referral Ext (65011/66964). For further information on MCA see MCA Intranet site or our MCA Procedures
Deprivation of Liberties Safeguards (DOLS)
When patients have been requiring Enhanced Care for a prolonged time, (i.e. for several days) or it has been for a shorter period but they are strongly objecting; it is necessary to apply for an urgent and a standard DOLS assessment by fully completing the DoLS FORM1, please refer to the LTHT DOLS Standard Operating Procedures. Further information can be gained through contacting the MCA/MHA Team or Adult Safeguarding Team follow guidance on the DoLS Intranet site
4.4 Identification of risk and the required level of supervision
Patients are identified as being potentially in need of Enhanced Care through triggering assessments of domains of care within the Nursing Specialist Assessment (NSA). Patients can also be identified at pre-admission or during admission through professional judgment for example during the “Safety Huddle”. If a patient is assessed as not requiring Enhanced Care, they will be reassessed for triggers through reassessment of the patient’s’ needs using the NSA or earlier if their condition or location changes.
A risk assessment is undertaken using the LTHT Enhanced Care Risk Assessment tool (LTH0326). The tool will guide the registered nurse to assess the level of risk that the patient has to potential harm and will direct them to describing the level of supervision that the patient needs and the type of worker that the patient required to undertake the supervision
If this support cannot be deployed through normal ward allocation of staff and there is a requirement for additional staff this must be discussed with the Matron or the Clinical Site Manager (out of hours). The Matron or CSM will then confirm the assessment of risk and level of supervision and type of worker required and will source staff either from the CSU or approve shifts to be filled via temporary staffing processes. Where 1:1 uninterrupted bedwatch security supervision (CROMA) is required the bookings for these shifts will be through the Facilities Hub via the CARPs system. The name and pin number of security personnel will be recorded within the CARPs log (see Appendix 2).
All patients who are having Enhanced Care either 1 to 1 or cohort, will require reassessing every 24 hours for this requirement or earlier if the patient’s condition dictates or their location changes.
4.5 Level of Support
The registered nurse must determine the level of support and supervision a patient may require by completing the Enhanced Care Risk Assessment Tool (LTH0326) and appropriate care planning documentation (Table 1).
Table 1: Types of enhanced support observations
There may be patients who require assessment for their psychological needs (in addition to physiological assessment) to ensure they receive the most appropriate level of Enhanced Care. This assessment and referral to appropriate teams and services should be done on an individual basis. In hours there are liaison psychiatric services. Out of hours the Liaison Psychiatric Specialist Practitioners are available to assess patients and advise ward teams. Assessments can be undertaken on existing patients (who may have deteriorated psychologically and are a risk to themselves or others) or newly admitted patients who need to be assessed overnight.
The phrases intermittent observation, Uninterrupted observation (within eye sight) and enhanced observation (arm’s length) have been adopted for use within LTHT based on commonality and agreed best practice within NICE (NG 10) and Leeds and York Partnership NHS Foundation Trust (LYPNFT) procedures (2012).
The nurse in charge must discuss with the Matron or Clinical Site Manager (CSM) (out of hours) whether the ward can manage to care for the patient using their existing resources or if additional staff are required. This must be approved by the Matron or CSM out of hours via the Eroster system. The registered nurse must ensure that the ward team are aware of the level of support required. It is recognised that undertaking 1:1 supervision requires significant attention and concentration. Where possible ward teams should provide workers undertaking supervision with regular opportunities for rest periods, whilst ensuring that the patient requiring 1:1 supervision is supervised at all times.
Ideally no individual should provide Enhanced Care for any longer than 4 hours. At that point another health care professional must take over providing the 1:1 care or Cohort supervision. Staff providing Enhanced care should sign, date and time when they provided the Enhanced Care in the Enhanced Care Activity Log (LTH0315).
However; it is recognised that changing the person who is providing 1:1 care too frequently may be detrimental to those patients who require consistency. Inconsistency and frequent change can often exacerbate challenging behaviour especially for those patients living with dementia or other cognitive impairments.
In these circumstances a clinical judgement should be made regularly throughout the course of the day and documented in the Enhanced Care Activity Log (LTH0315), with rationale as to why the same health care professional is providing care that exceeds 4 hours.
Please note Bedwatch security (CROMA) is exempt from this rule as they are an external agency whose staff are contacted to work 12 hour shifts. However; ward teams should provide workers undertaking supervision with opportunities for rest and meal break periods, whilst ensuring that the patient requiring 1:1 supervision is supervised at all times.
Low Risk (Green): Intermittent observation
This means that the patient must be observed at specific intervals agreed by the Nurse-in-Charge and where possible agreed in collaboration with the patient/carers /family as appropriate. This level of support is indicated where the assessed risk is higher than normal ward observation (but there is not an acute or overt risk of harm to self or others) and the patient is deemed safe between checks or has capacity to summon support where necessary.
It is anticipated that low risk will only be used for a limited period of time. The timeframes decided by the team must be specified and clearly recorded, as well as realistic and achievable for the staff involved.
Medium Risk (Amber) : Constant observation (to be within eye sight)
The patient must be visible and under constant, uninterrupted supervision of the observer. Within line of sight should place staff close enough to respond immediately should an incident occur or be likely to occur. There may be occasions for some degree of privacy (e.g. use of bathroom/toilet/when visitors present) but then patient must be within eyesight of a member of staff or responsible carer at all times
A regular summary of the patient’s condition, care and treatment must be entered on the appropriate care plan. This must include changes in mental health, physical, psychological and social behaviour, pertinent development and significant events. This level may include cohorting patients to provide efficient but effective observation and supervision. Social inclusion is an essential part of this observation. The staff member who is delivering cohort observation should facilitate conversation and activity within the group wherever possible.
Environmental factors should be considered to maintain patient safety, (e.g. including removing equipment/instruments that may be used to cause harm to self or others, positioning of furniture to reduce falls, consideration of noise/lighting levels).
High Risk (Red): Enhanced observation (at arm’s length)
The patient must be subject to close proximity, constant, uninterrupted observation. Actual distance or proximity must be determined by an assessment of the patient’s condition. There may be occasions when patients who have acute mental health problems or maybe at risk of harm to themselves or others are assessed as requiring constant uninterrupted supervision (24 hours a day). This may include the need for keeping bathroom and lavatory doors ajar or unlocked to allow for constant uninterrupted supervision when they are used. In these circumstances the gender of the supervising personnel must be reviewed to ensure they are appropriate for the patient. Registered staff must ensure they clearly handover and document assessed risks and appropriate actions to supervising personnel. This will include if bathroom/lavatory doors are to be kept unlocked or if patients are to be accompanied at all times. Following further patient assessment, the patient may be allowed some degree of privacy (e.g. use of bathroom/lavatory), though this must be clearly stated in the care plan. This level of Enhanced Care is one to one care.
4.6 Identification of Appropriate Worker to Deliver Enhanced Care
The risk assessment and patients’ mental health needs will be an indicator of the type of workers and the skill set required to provide appropriate level of Enhanced Care.
Registered Nurse-Mental Health (RMN):
A RMN may be indicated if a patient :
- Requires a MHA section
- Is expressing suicidal intention.
- Has extremely challenging behaviour towards others.
The primary role of the RMN is to monitor the mental state of the patient and to identify any deterioration in the patient’s mental state. The RMN will engage in meaningful activity during their shift with the patient and continually assess level of engagement, mood and risk during these activities. Risk assessments are also an essential element of the RMN role in order to determine the safety risk of the patient to themselves, staff and or visitors. These assessments are communicated to the multidisciplinary team via documentation and verbal handovers, to ensure the plan of care is up to date and relevant to the patient’s needs. The RNM will also provide physical nursing care within their competence e.g. personal cares, hydration and nutrition, physical observation and documentation. An RMN should only be used for the provision of 1:1 care and not for cohorting.
Registered Nurse (Adult) RGN:
A RGN would be required to care for the acutely physically unwell patient who are:
- Requiring personnel care
- Pulling at lines, tubes that may result in significant harm.
The role of the RGN whilst providing Enhanced Care is to keep the patient safe from harm and to identify any deterioration in the patient’s condition. The RGN will be responsible for monitoring the physical health of the patient, ensuring good hydration and nutrition, observing for symptoms of delirium and adapting nursing care as required. The RGN will maintain the safety of the patient during their shift and escalate any concerns to the nurse in charge and the medical team.
A CSW would be required to care for physically unwell patients or dependant patients that are:
- Requiring personnel care
The role of the CSW whilst providing enhanced care is to keep the patient safe from harm. The CSW would be expected to provide personal and physical care to the patient within their competence. The CSW will be responsible for undertaking physical observations, ensuring good hydration and nutrition, observing for symptoms of delirium and recording and reporting to supervisory registered nursing staff. The CSW will maintain the safety of the patient during their shift and escalate any concerns to the registered nurse allocated to the patient.
Security Bedwatch ( CROMA)
Security Bedwatch staff provide security to the patient and where required the carers, visitors and or staff. These staff should only be used where there is a high risk of violent or aggressive behaviour, where the patient is a risk to themselves and or others within the ward environment or where there is a high risk of the patient absconding whilst under DoLs or Mental Health Act Section. Bedwatch security must not be used to sit with patients who are a high falls risk or in isolation with patients in a high risk mental state; in these cases the Bedwatch staff may cover care delivery by a CSW with mental health experience or a RMN. The therapeutic, personal and nursing care will not be provided by this staff group.
Security/ Police/Prison Guards
These staff may be required to support ward staff to ensure protection of the patient, carers, visitors and staff. The therapeutic enhanced, personal and nursing care will not be provided by these staff groups.
All staff who are looking after a patient who is receiving Enhanced Care must receive a handover which will summarise the patient’s needs and safety requirements for that shift. This should be given by either the nurse in charge or the registered nurse looking after the patient in question. It is not appropriate for unregistered staff or Bedwatch security personnel to provide this handover information. Where external staff (bank/agency/bedwatch) is used to provide Enhanced Care, the handover from the nurse in charge should include an outline of the expectations of that member of staff. They should be referred to the ‘Enhanced Care Activity Log’ (LTH0315) which suggests some interactive activities that the worker can undertake to provide therapeutic Enhanced Care during the supervision.
The worker will complete the activity log noting the effect of the intervention on the patient as this will support further activity planning. If the worker looking after the patient has any concerns with regards the patient or their ability to provide Enhanced Care they must escalate this to the nurse in charge. If a worker is providing Enhanced Care to a cohorted group of patients, they must not leave the bay without being relieved by another staff member of staff, who must remain in that bay until they themselves are relieved.
4.7 Reviewing Patient’s Level of Risk
All patients who are receiving Enhanced Care either 1 to 1 or cohort, will require reassessing weekly or earlier if the patient’s condition or location changes. Where it is assessed that a patient requires continuation of the Enhanced Care which cannot be met out of the normal ward allocation, the requirement must be re-confirmed with the Matron or the Clinical Site Manager (out of hours) every 24 hours, who will either source staff from elsewhere within the CSU or approve external temporary staffing resources. Block booking of bedwatch or bank/agency staff should be avoided unless prior written approval is provided by the Matron. Should a patient be assessed as no longer requiring Enhanced Care and staffing has been sourced from outside the normal ward allocation, the Matron or CSM must be informed to allow resources to be redeployed appropriately.
Matrons will be responsible for providing support to wards where patients are receiving Enhanced Care, ensuring that the risk assessments are properly completed and that the level of Enhanced Care identified is appropriate. Matrons will be required to visit the wards within their clinical areas once a shift to discuss the wards Enhanced Care requirements. Where Matrons/CSM are unable to secure the correct worker to provide supervision for a patient they will escalate this to the responsible Head of Nursing.
4.8 Incidents whilst Executing Duties
Despite all interventions there is the potential that patient accidents and/or incidents may occur. All incidents should be reported on Datix with relevant staff writing statements if indicated. A Datix must be completed in the instance that restraint is used in response to an emergency / incident that puts people at risk and is not part of the planned response to the patient’s needs, any use of restraint that leads to any physical harm (even minor harm), and any use of emergency rapid tranquilisation that is not part of the documented plan of care. All staff (LTHT/bank/Agency/supply) involved in any incident should be given an opportunity to discuss what happened in the form of debrief. Debrief maybe by ward Sisters or Charge Nurses or more senior staff depending on the incident. Non-LTHT employees should inform their supervisors/managers to ensure they also receive any supportive follow up.
The Chief Executive has overall responsibility and accountability for ensuring that the Trust meets its obligations in respect of maintaining appropriate standards of care and safety for both patients and staff.
The Chief Executive delegates the responsibility for monitoring and compliance to the Chief Nurse and Chief Medical Officer.
The Chief Nurse is responsible for ensuring that procedures relating to Enhanced Care are developed, maintained, and communicated throughout the organisation and in co-ordination with other relevant organisations and stakeholders.
Director of Nursing (Operations)
The Director of Nursing (Operations) is the responsible officer for strategic operational management relating to Enhanced Care. They (or their deputies) will be a primary communication channel within and external to CSU and executive team.
Heads of Nursing
The Heads of Nursing are responsible for ensuring that the principles surrounding Enhanced Care are effectively communicated within their CSU and that staff are aware of their responsibilities.
The Heads of Nursing are responsible for ensuring that the contents of this document are communicated and implemented within their areas of responsibility. The Heads of Nursing have responsibility for monitoring that Enhanced Care assessments are being conducted correctly on patients and that workers are deployed to keep patients safe.
Matrons are responsible for ensuring that effective processes are followed to facilitate effective and detailed assessments of Enhanced Care in their designated area of responsibility. They are responsible for providing additional deployment of staff. Matrons are responsible for ensuring that designated Enhanced Care audits are undertaken, reviewed and reported at governance meetings.
Ward Sister/Charge Nurse
It is the Ward Sister or Charge Nurse’s responsibility to ensure that their staff are made aware of the Trust procedure for Enhanced Care. That these processes are included as part of induction of all staff that may be involved in care of patients. They will ensure that all staff members understand what is required to undertake and facilitate Enhanced Care assessments.
The Allocated Nurse
The allocated nurse undertaking the Enhanced Care risk assessment must ensure that all important/appropriate information is communicated to all staff members coming onto shift. This ensures that the patients receive the care that they require and that all relevant care plans are included.
All staff regardless of grade and including students and trainees that are coming onto shift into a ward or department have a responsibility to ensure they are aware of Enhanced Care and what it means for the patients they are allocated to care for.
Audit of compliance to the procedure will be undertaken annually.
In addition measures such as learning from investigations, incident reports, claims and complaints will provide themes relating to incident trends and transferable lessons.
This procedure will be reviewed three yearly. It may be revised in the interim depending on new or changes to existing technologies.
|Target patient group:|
|Target professional group(s):||All Secondary Healthcare Professionals
National Institute for Clinical Excellence (NG10) (2015) Violence and aggression: Short term management in mental health, health and community settings NICE
Leeds and York Partnership NHS Foundation Trust (2012) Procedure for the Observation and Engagement of People Using the services of Leeds and York Partnership NHS Foundation Trust October
LHP version 2.0
Equity and Diversity
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