ADMISSION, TRANSFER AND DISCHARGE POLICY

FOR INPATIENT SERVICES

Quality & Clinical Effectiveness Manager

Author:
Policy Review Group
Sponsor/Executive: Director of Nursing and Quality
Clinical Effectiveness, Audit & Research
Responsible committee:
Group – May 2019
Ratified by: Quality and Compliance Executive
Consultation & Approval: Developed by working group with
(Committee/Groups which signed off the representatives form directorates and other
policy, including date) interested parties
This document replaces: Version 5
Date ratified: 26 June 2019
Date issued: 4 July 2019
Review date: June 2021
Version: Version 5.1
Policy Number: CL03
To support the process of admission, transfer
Purpose of the Policy:
and discharge for inpatient services
If developed in partnership with
another agency, ratification details N/A
of the relevant agency
Policy in-line with national
guidelines:

Signed on behalf of the Trust: …………………………………………………..

Tracy Dowling, Chief Executive

Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789
 Version Control Page

Version Date Author(s) Comments

1.0 January Wendy Llaneza Discharge Guidance initially developed by
2008 Ann Hiles Ann Hiles, later expanded into Admission,
Discharge & Transfer Policy in line with
NHSLA standards.
Policy ratified by Quality & Healthcare
Governance Committee
2.0 May 2010 Wendy Llaneza Policy updated to reflect new CQC and
NHSLA standards, national guidance and
Trust governance structures, and SUI
recommendations, in particular:
• list of definitions (section 3)
• duties and responsibilities (section 5)
• list of information required in
accordance with the CQC standards
on transfer/discharge (section 7.3)
• documentation completed on
discharge (section 12.1, 12.2 and
12.4)
• guidance related to lost contacts/DNAs
(section 14.1 and 14.2)
• guidance regarding 7-day follow-up
(section 16)
• monitoring arrangements (section 25)
• revised Discharge Notification Form v2
(Appendix 4)
2.1 May 2011 Wendy Llaneza Reviewed. Minor amendments made to
Mick Simpson sections 5.7, 7.3, 12.1, 14.1 and 16.2.
3.0 March Wendy Llaneza Full review of the policy. Key changes
2015 Policy Review include:
Group
• new Trust governance structure
• the new clinical/operational structures
• simplifying and clarifying standards of
practice, processes and procedures,
being mindful of evidence-based good
practice standards
• definitions and criteria on key
performance indicators – CRHT
gatekeeping, 7 day follow up and
Delayed Transfers of Care
• revised checklists – admission,
standards of admission documentation
for doctors, discharge, discharge
notification form

Page 2 of 58
Version Date Author(s) Comments
4.0 April 2018 Neil Winstone, Full review of policy, key changes include:
Associate
Director and • Updated to reflect OPAC physical
policy review health wards
group • Inclusion of Care of pregnant
women plus a check list
• Strengthening of the suicide
prevention section with reference to
the Trust’s Zero Suicide strategy
• Updating of mental health act
guidance
• Updating of the Think family
approach to child and family
welfare and safeguarding
• Alignment the involving of carers
including sharing information with
the carers Policy so that there is
consistent message across
relevant policies

5.0 May 2019 Anna Tuke Review of policy to ensure consistency

(Associate with the Confidentiality policy
director of
Involvement and Review of section 22 with Orna Clarke
Partnerships
5.1 September Neil Winstone 6. Additional text regarding supervision of
2019 CPFT learners added. Agreed with Trust
Executive, governance committees,
Directorates and Learning and
Development
Policy Circulation Information

Notification of policy release:

All recipients;
Staff Notice Board;
Intranet;
Key words to be used in DtGP
search.

CQC Standards

Page 3 of 58
 CONTENTS
SECTION Page

OVERARCHING POLICY STATEMENT ....................................................................................7

1 Introduction ......................................................................................................................7

2 Purpose .............................................................................................................................7

3 Scope ................................................................................................................................7

4 Definitions.........................................................................................................................7

5 Over-arching Principles of Good Practice ......................................................................9

6 Duties and Responsibilities .............................................................................................9

7 Staff development ..........................................................................................................12

8 National Key Performance Indicators (KPIs) ................................................................12

9 Monitoring Compliance..................................................................................................12

10 Other Associated Trust Polices ....................................................................................13

ADMISSION INTO INPATIENT SERVICES ..............................................................................14

11 Context ............................................................................................................................14

12 General Principles ..........................................................................................................14

13 Accessing Inpatient Services ........................................................................................14

14 Gatekeeping by CRHT (Adult & Specialist and OPMH wards) ....................................15

15 Admission of pregnant women .....................................................................................15

16 Admission of a Young Person to an Acute Ward .........................................................16

17 Admission of a Child or Parent of a Child Subject to a Child Protection Plan ...........16

18 Infection Control.............................................................................................................16

19 Information Requirements for Admission and Transfers of Care ...............................17

20 Care Coordination, Primary Nursing and role of ward manager on physical

health wards ...................................................................................................................17

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SECTION Page

21 Admission Process ........................................................................................................17

22 Consent to admission care and treatment ...................................................................17

23 ‘Think Family’ and the Safeguarding of Children .........................................................18

24 Information to Patients and/or Family/Carers ..............................................................19

25 Information Sharing and Confidentiality.......................................................................20

26 Record Keeping ..............................................................................................................20

27 Child Visiting ..................................................................................................................20

28 Single Sex Accommodation/Privacy and Dignity .........................................................20

TRANSFERS ............................................................................................................................20

29 Transfers between Trust Services ................................................................................20

30 Transfers into CPFT from another Hospital .................................................................21

31 Transfers from CPFT to another Hospital.....................................................................21

32 Out of Hours Transfer Arrangements ...........................................................................22

DISCHARGE FROM AN INPATIENT SERVICE .......................................................................22

33 General Principles ..........................................................................................................22

34 Discharge Planning ........................................................................................................23

35 Discharge against Medical Advice ................................................................................23

36 Transport ........................................................................................................................24

37 Communication and Information Requirements ..........................................................24

38 Medication on Discharge ...............................................................................................25

39 Infection Control Considerations ..................................................................................25

40 Follow Up Arrangements for patients on inpatient wards ...........................................26

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SECTION Page

DISCHARGE FROM AN INPATIENT SERVICE ……

41 Suicide Prevention .........................................................................................................27

42 Carer Needs ....................................................................................................................28

43 Carers’ Assessment .......................................................................................................31

44 Mental Health Legislation and Legal Requirements ....................................................32

45 Delayed Transfers of Care (DTOC) ................................................................................32

46 Monitoring Compliance..................................................................................................33

47 Links to Other Documents .............................................................................................33

48 References ......................................................................................................................33

49 Acknowledgements ........................................................................................................35

APPENDICES

APPENDIX 1 Admissions Checklist .....................................................................................36

APPENDIX 2 Minimum Standards for Admission Documentation by Medical

Staff ................................................................................................................39

APPENDIX 3 Discharge Checklist .......................................................................................43

APPENDIX 4 Discharge from Inpatient Care Notification Form ........................................45

APPENDIX 5 Discharge from Inpatient Care Against Medical Advice Form ....................47

APPENDIX 6 OPAC Physical Health Wards Admission Checklist ....................................49

APPENDIX 7 OPAC Physical Health Wads Discharge Checklist ......................................51

APPENDIX 8 Care of the Pregnant Patient .........................................................................53

Appendix 9 Think Family …………….………………………………….……….........51

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OVERARCHING POLICY STATEMENT

1 Introduction

Cambridgeshire & Peterborough NHS Foundation Trust (hereafter referred to as ‘CPFT’

or ‘the Trust’) is committed to providing safe and effective services that reflect the
needs of the people it serves and meets the national standards of quality and safety.

The admission, transfer and discharge of patients are significant stages of the care
process, and an integral component of the Care Programme Approach (CPA). The
Trust recognises that an effective admission, discharge and transfer process enables
patients to move forward towards greater independence in the communities in which
they live, in line with the philosophy of recovery.

2 Purpose

This policy sets out the key steps that must be taken to ensure that the admission,
transfer and discharge process is carried out in a safe and effective manner.

This policy aims to ensure that all Trust staff involved in the provision of health and
social care are working together towards an effective coordinated service that meets
the individual needs of patients, as well as those of their relative/carer(s).

This policy must be used in conjunction with other relevant Trust policies and guidance
listed in Section 9.

3 Scope

This policy applies to all patients who come under our care and all staff in the following
inpatient services:
• Adult & Specialist Directorate
• Older People and Adult Community Directorate
• Children, Young people and Families Directorate

4 Definitions

A Patient is a person who receives services provided by the Trust. For the remainder
of this document, the term ‘patient’ will be used to refer to people who use our
services.

The Care Programme Approach (CPA) is the process used by providers of mental
health care to coordinate the care, treatment and support for people who have mental
health needs (CQC 2010).

Care Planning describes, in an easy accessible way, the services’, care and support
being provided to the patient and where appropriate the carer/family. It should be
discussed and negotiated with the patient to ensure they are in agreement with all
proposed plans of care.

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A Care Coordinator is a health or social care practitioner who is responsible for
coordinating the care of a patient.

A Key worker/Primary nurse/allocated nurse is a nurse who is responsible for the

planning, implementation, and evaluation of the nursing care of one or more patients for
the duration of an inpatient stay.

The Carers Trust definition of a carer is as follows. ‘You are a carer if you provide
help and support, unpaid to a family member, friend or neighbour who would otherwise
not be able to manage without this support.

The person you care for may have physical or learning disability, dementia or mental
health problems or they may misuse drugs or alcohol. What ever their illness they are
dependent on your care.

The person may live with you or elsewhere, they may be an adult or a child, but if they
rely on you for support, then you are entitled to support as a carer.

Anybody can be a carer. Carers come from all walks of life, all cultures, and can be
any age. You may be a mother, father, wife, husband, parent, partner, friend, uncle,
niece, colleague or neighbour. No matter what your relationship, if the person you care
for can not manage without your support then you are a carer.’

Advance Decisions – Advance Decisions are governed by the Mental Capacity Act
(MCA) 2005 and relate to refusals of specified treatment, if specific circumstances arise
in the future at a time when the person no longer has mental capacity. Advance
Decisions are sometimes also known as ‘advance directive’, ‘advance refusal’ or ‘living
will’. However, the statutory term is “Advance Decision”. A valid Advance Decision,
which is applicable to the circumstances which arise, is legally binding in the same way
as a contemporaneous refusal by a person with capacity, with the exception of
treatment of mental disorder in people who are detained under the MHA 1983.
Professionals may be legally liable if they administer treatment that a service user has
refused in a valid and applicable advance decision.

Advance Statement – is a general statement of a person’s wishes and views. People

who understand the implications of their choices can state in advance how they wish to
be treated if they suffer loss of mental capacity. It can reflect their religious beliefs or
other beliefs that they have and allows the person to state how they would like to be
treated should they not be able to communicate their wishes in the future.

Admission refers to the formal acceptance of a patient into a service. Within the
context of this document, this refers to the admission of a patient into an inpatient unit.

Transfer refers to the movement of patients between care settings and care providers,
both internally (i.e. between Trust services) and externally (i.e. between a Trust
service and another agency).

Discharge is the point at which a patient’s inpatient stay comes to an end.

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5 Over-arching Principles of Good Practice

This policy should be implemented in conjunction with the Care Planning Policy,
Clinical Risk Assessment Policy, and the Trust Access Policy.
All staff should work within a framework of integrated multidisciplinary and multi-agency
team working to effectively manage all aspects of the process.

The engagement and active participation of the patient and their relative/carer(s) as
equal partners in the process are central to the delivery of care.

A robust and comprehensive assessment and management of risks covering all

relevant aspects of the patient’s care and treatment should be made, repeated at
regular intervals where necessary, particularly during the patient’s discharge planning
process, and recorded clearly and accurately in a timely manner. In the absence of
patient consent the views of carers, relatives can and should be sort to ensure potential
crucial information contributes to the over all assessment.

The patient and their relative/carer(s)/friends etc. with the patient’s consent, are given
relevant, appropriate and adequate information at every stage of their journey through
the care pathway. This is essential to ensure that carers’ needs are met so that they
can give the best possible support to their relative or friend. If consent hasn’t been
given it is essential to communicate this to carers reassuring them that this doesn’t
prevent them discussing with clinical staff their concerns about their relative or friend.
Regular communication with carers is essential regardless whether consent has or
hasn’t been given.

6 Duties and Responsibilities

Chief Executive and Trust Board

Responsibility for compliance with this policy is vested in the Trust Board, delegated to
the Chief Executive and in turn delegated to relevant staff across the Trust, to ensure
that there are appropriate systems and processes in place to facilitate an effective
discharge.

Executive Directors
The Director of Nursing and Quality, the Medical Director and the Chief Operating
Officer have joint overarching responsibility for the implementation of this policy and for
ensuring that appropriate processes are in place for the admission, transfer and
discharge of patients within the Trust. This responsibility is delegated to Clinical
Directors and managers within the Clinical Directorates.

Quality, Safety and Governance Committee (QS&G)

The Quality, Safety and Governance Committee (QS&G) is responsible for the
ratification of this policy.

The Quality and Compliance Executive (formally the Clinical Governance and Patient
Safety Group, CGPSG), which reports to QS&G, has overarching responsibility for the
development, approval, monitoring and review of this policy. Other relevant subgroups
and working groups within the Trust will form part of the consultation process as
appropriate in line with the Trust’s governance framework.

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Directorate Managers
This includes the Clinical Directors, Associate Directors of Operations, General
Managers, Directorate Heads of Nursing, Ward Managers and Modern Matrons within
the clinical services who are responsible for the correct and consistent implementation
and monitoring compliance with this policy within their respective service areas.

The Consultant Psychiatrist / Consultant Geriatrician or other medical lead

The responsibility for the overall treatment plan of a patient lies with the Consultant
Psychiatrist, working with the multidisciplinary team (see 6.6). As part of this
responsibility, the Consultant Psychiatrist must ensure that:
• the correct admission and discharge medication is prescribed the Discharge
Notification Form (DNF) is completed and sent to the GP within 24 hours of
discharge, and a copy given to the patient and/or their cares/family
• the Discharge Summary is completed and a copy sent to the GP within 7 days
• the patient’s ICD10 diagnosis is made, recorded in the appropriate
documentation and coded in a timely manner

Multidisciplinary team (MDT)

The multidisciplinary team consists of professionals, practitioners and all staff involved
in the provision of treatment and care to the patient, and as such is responsible for
ensuring that:

• a comprehensive assessment of the patient’s strengths, needs, and relevant

risks is carried out
• the patient and/or relative/carer(s) are given every opportunity to actively
participate in the admission, transfer and discharge process
• the patient and/or their relative/carer(s)/other significant people with the consent
of the patient are given relevant, appropriate and adequate information and
explanations where required
• an agreed plan of care is in place prior to the planned discharge of the patient
from Trust inpatient services
• good and effective communication is maintained with all members of the
multidisciplinary team, and in particular liaising closely with the care coordinator
as required
• all interventions and assessments are undertaken, including pre-discharge
assessments, in a timely manner as required, and reporting the outcomes in the
appropriate format
• an effective formulation of the care and treatment plan is in place, including the
discharge plan
• ensure good communication with other services involved
• all information relevant to the patient’s care is recorded in accordance with the
Clinical Record Keeping Policy

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The Care Coordinator (Mental Health services only)
The care coordinator has the overall responsibility for coordinating all aspects of the
care and treatment of the patient at all stages of their journey through the care pathway
(for services that are not covered by the CPA, these responsibilities are synonymous
with the responsibilities of the named nurse). This includes:

• ensuring that all relevant information are available and easily accessible by other
members of the multidisciplinary team in a timely manner
• where known, alert relevant other services and practitioners about any issues
related to safeguarding adults/children or MAPPA, particularly those that may
impact on safe and effective discharge planning
• ensuring that any identified relative/carer(s) are well informed with regards to
issues related to the admission, transfer and discharge process, including
treatment and care options and including interim or intermediate placements.
• ensuring that all practitioners and agencies, including non-statutory or and
voluntary agencies, involved in the planning and preparation of the patient’s
transfer/discharge are aware of the plan of care and transfer/discharge
arrangements.
• ensuring that appropriate follow up arrangements are made within the required
timescales in line with this policy.

The Named / Primary Nurse/ Ward Manager or deputy

The named / primary nurse / or allocated nurse on shift is responsible for coordinating
the patient’s care within the inpatient setting. In some instances, the named / primary
nurse may also be the care coordinator whilst the patient remains in hospital. Other
key responsibilities include:

• working closely with the community care coordinator, where applicable, in

relation to all aspects of the patient’s care.
• ensuring the correct and timely completion of the necessary agreed
documentation, including checklists, and Discharge Notification Form, and that
all relevant individuals are provided with copies thereof.
• coordinating all necessary arrangements, including time and date of
transfer/discharge, transport, accommodation, property and valuables, etc., and
ensuring that these are communicated to all relevant individuals involved in the
patient’s discharge plan.
• medication concordance issues

The Pharmacy team

As part of the healthcare team, the pharmacist and pharmacy technicians are key
players in medication management both as a source of medicines information and
practical guidance for staff, patients and their relative/carer(s) in the preparation for
discharge. In addition the pharmacy team will

• advise on ongoing medication issues including the need for compliance aids
• dispense any required medicines
• check the discharge medication prescription chart for accuracy and
appropriateness, amending if necessary

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Supervisors and Assessors of learners
CPFT provides training to learners from a range of disciplines. Regulatory bodies (such
as the NMC or HCPC), and the Trust require that registered staff who undertake the
supervision and assessment of student learners have the proficiency, skill and
knowledge to facilitate the education for learners. They will, within the scope of their
responsibilities, ensure that learners have completed agreed relevant placement
training and are able to demonstrate the understanding of the theory prior to the
practicing of the skill.

7 Staff development

Relevant training in the form of induction and team based coaching will be provided in
conjunction with training around the Care Planning Policy, Clinical Record Keeping
Policy and clinical risk assessment and management procedures. In addition, service
managers will provide the necessary guidance and support for the correct and
consistent application of this policy.

8 National Key Performance Indicators (KPIs)

The processes set out in this policy include three mandatory national KPIs that the
Trust submits to NHSi1. This policy sets out the definitions and exemptions from the
perspective of clinical practice and operational procedures. More detailed definitions
and exemptions that support the collation and analysis of data are set out in the KPI
handbook which can be accessed via this link:
http://nww.intranet.cpft.nhs.uk/Corporate/BusinessInformation/glossary/Pages/default.a
spx.

The relevant KPIs are:

• CRHT gate keeping

• CPA 7-day follow up
• Delayed transfers of care

9 Monitoring Compliance

The main responsibility for monitoring the implementation of this policy lies with the
senior managers through team/care review meetings and supervision.

Monitoring of key aspects of the care process, including the assessment, risk
assessment, care planning, review and discharge process is done through the Quality
& safety assurance tool (QSAT) review process and record keeping audits.

1 NHSi is an executive non-departmental public body of the Department of Health. Its main purpose is to
protect and promote the interests of patients by ensuring the whole sector works for their benefit. It has a
specific role on monitoring the performance of NHS Foundation Trusts, by ensuring that:
• independent NHS foundation Trusts are well-led so that they can provide quality care on a
sustainable basis
• essential services are maintained if a provider gets into serious difficulties
• the NHS payment system promotes quality and efficiency
• procurement, choice and competition operate in the best interests of patients
.
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Specific monitoring requirements to meet the risk management standards (NHS
Litigation Authority) for the discharge process are set out in Section 46 of this policy.

Additional monitoring arrangements will be agreed on a risk-based approach and may

include formal Trust audits or service evaluations.

There are also specific Key Performance Indicators (KPIs) related to the
implementation of this policy which will be reported upon as part of the Trust’s
integrated quality and performance dashboard.

10 Other Associated Trust Polices

The following are key policies and guidelines that should be considered in conjunction
with this policy. Please see the policy site on the Trust intranet to check that the current
policies are being referred to.

• The Care Planning Policy

• Carer Policy
• Child Visiting Policy
• Choice Policy
• Clinical Risk Assessment Policy
• Clinical Record Keeping Policy
• Confidentiality Policy
• RiO Consent to Share Information SOP
• Consent Policy
• Medicines Policy and associated MM SOPs
• RiO SOP for Discharge
• Service Access Policy
• Admission of a Young Person to an Acute Ward 2018
• Transfer of Patients between Adult Mental Health (AMH) & Older People Mental
Health (OPMH) Services Criteria
• Falls Prevention and Management Policy
• Infection Control Policy
• Serious Incident (SI) Policy and Procedure
• Safeguarding Children Policy
• Eliminating Mixed Sex Accommodation Policy
• Protocol for Driving and Psychiatric Disorders
• Relevant Mental Health Act Policies
• CPFT Zero Suicide Strategy
• Physical Assessment of Inpatients Policy
• Leave of Absence from Hospital (AWOL) Policy
• Transfer: CAMHS to Adult Mental Health Services Protocol
• General Protocol for Protecting and Using Personal Information within
Cambridgeshire and Peterborough

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ADMISSION INTO INPATIENT SERVICES

11 Context

Being admitted to hospital is a significant and often stressful event for the patient and
their family/carer(s). It is therefore important to remember that first impressions are
often those that the patient or family/carer remembers the most. With this in mind, it is
essential that staff are friendly, confident and professional; and offer reassurance,
explanation and information as appropriate.

Every effort will have been made to support the person to remain in the community.
The needs of the patient and their family will be central to the admission process.

It is essential that as appropriate, discharge arrangements are commenced/identified

prior to admission. Care co-ordination is essential to support this process and will
continue throughout the period of admission.

12 General Principles

Admissions into inpatient services should be based on the following principles:

• People will be admitted to an appropriate environment consistent with their

mental health, physical health and safety needs.
• The person and/or their family/carer(s) are fully involved in the process and are
given adequate, appropriate and timely information.
• Where other agencies or professionals are involved in the person’s care, their
involvement is sought as appropriate
• The professional who has primary responsibility of the person’s care is
responsible for ensuring that all information required is handed over to the
receiving team prior to admission.
• People are treated in the least restrictive environment which is consistent with
their clinical and safety needs.

13 Accessing Inpatient Services

Each individual service will have their own criteria and process for accessing their
services. Refer to the relevant service operational policies, protocols and procedures
and the Trust Access Policy for further guidance.

First Response Service

The First Response Service provides urgent 24-hour access, seven days a week, 365
days a year, to mental health care, advice, support and treatment for people
experiencing a mental health crisis. This includes access to the “sanctuary” which is an
out of hours “safe place” for those in crisis and referral to other primary and secondary
services. It is available to anyone who lives in Cambridgeshire who feel they need
urgent mental health care. This includes service users, carers, family and friends.
Anyone can refer to FRS via 111 Option 2.

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Psychiatric Liaison (psychiatric liaison for acute medical services)
This pathway provides specialist mental health assessment advice and intervention to
people in acute hospitals.

14 Gatekeeping by CRHT (Adult & Specialist and OPMH wards)

The Department of Health (DH) requires that all admissions into adult acute psychiatric
inpatient wards for patients aged 16-65 are gate kept by the Crisis Resolution and
Home Treatment (CRHT). An admission is deemed to have been gate kept if the
CRHT team has assessed the person before admission and they were involved in the
decision-making process that resulted in admission (DH, 2011)2.

Exceptions to the CRHT gatekeeping requirement are listed below:

• Patients transferred from another NHS hospital for psychiatric treatment

• Internal transfers between wards in the Trust for psychiatric treatment
• Patients on leave under Section 17a of the Mental Health Act (MHA)
• Patients who are planned admissions to a Detox bed
• Patients under a Ministry of Defence (MoD) contract
• Planned admissions for psychiatric care from specialist units such as eating
disorder units

For patients who are brought in under the MHA, including Section 136 (Place of Safety)
and CTO recall or revocation, the CRHT must be involved in the decision to admit them
into a ward.

In situations where a patient from another area presents locally and requires
emergency admission, the home area should be contacted and ask to find a bed in their
area, this include sourcing a private bed if no NHS one is available. Where the home
area has exhausted all options and no bed is available then, in the best interest of the
patient which should be paramount, a local CPFT bed (if available) should be used. A
clear plan of transfer back to the home trust should be agreed with the expectation that
the patient will be returned to their home area within 48 hours of admission. All
information regarding the patient and admission should be recorded on RiO

15 Admission of Pregnant Women

Although relatively unusual pregnant woman admitted because of their mental health
needs are at greater than those of the average population due to their increased
physical health needs, and for some limitations in the use of medication to manage
their mental health condition. There is also a clear need for the involvement of outside
agencies to manage the pregnancy using a multi disciplinary approach Appendix 8
provides a check list to be used when a pregnant woman is admitted

2This official definition and exceptions are taken from the Technical Guidance for the 2012/13 Operating
Framework published by the Department of Health on 22 December 2011.
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16 Admission of a Young Person to an Acute Ward

As a principle young people aged 16 years old and under will NOT be admitted into an
adult acute ward. If it is not possible to identify an appropriate adolescent unit then if
necessary, a young person of 16 or 17 years old may be admitted on to an adult
psychiatric ward.

When considering the possible admission of a young person to an adult inpatient ward
the decision must be reached to ensure the safety and wellbeing of the young person
and that the risks associated with such admission are identified and managed
with the appropriate safeguards in place to promote the safety and welfare of the young
person.

Any admission of an under 18 into an adult acute ward is requires an IMR Serious
Incident (SI) and will be reported in accordance with the Trust’s incident reporting
procedures. Refer to the Serious Incident (SI) Policy and Procedure for guidance.

Please refer to the Trust policy ‘Admission of a Young Person to an Acute Ward 2018’
for further guidance.

17 Admission of a Child or Parent of a Child Subject to a Child Protection Plan

Promoting children’s well-being and safeguarding them from harm crucially depends
upon effective information sharing, collaboration and understanding between agencies
and professionals There must therefore be effective channels of communication
between all agencies including care coordinators, GPs, Health Visitors, School Nurses,
Children’s Social Care and any other relevant agencies of any planned or unplanned
attendance, admission and discharge of a child or parent of a child who is subject to a
Child Protection Plan.

Further advice and guidance around this issue can be obtained from the Safeguarding
Children Team within the Trust. Please also refer to the Safeguarding Children Policy
and the Guidance document for effective joint working for Safeguarding Children who
have a Parent or Carer with Mental Health Problems for further guidance.

18 Infection Control

Patients with acute diarrhoea and/or vomiting should not be admitted to the Trust.
Please inform and take advice from the Infection Prevention and Control (IPaC) Modern
Matron if you are asked to accept a patient with these symptoms.

Patients admitted to OPAC Physical health wards from acute Trust or other institution
must be isolated in a side room until a negative MRSA screen is obtained, (unless a
negative screen has been obtained within the last 7 days).

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19 Information Requirements for Admission and Transfers of Care

Good clinical practice requires specific information to be available to the receiving

service to ensure that the needs of the person are met safely and that there is no delay
to the assessment of needs.
Effective communication between the community team and inpatient unit is essential.
This will include and up-to-date assessment, care plan, and risk assessment.

20 Care Coordination, Primary Nursing and role of ward manager on physical

health wards

A primary nurse who will be responsible for the coordination of the patient’s care and
treatment whilst in hospital will be identified within 24 hours of admission.

It is good practice to consider the individual needs of the patient (e.g., age, gender and
ethnicity) when allocating a primary nurse.

When patients are admitted into a ward from a Trust community team, contact should
continue by that team during their period of admission. Where applicable
communication will be maintained between the care coordinator and the primary nurse
regarding progress and steps towards discharge, including attendance at relevant
review meetings, to ensure continuity of care.

21 Admission Process

The standard Admission Checklist (Appendix 1) sets out the necessary steps and
procedures that need to be carried out during the admission process.

The Minimum Standards for Admission Assessment Documentation by Medical Staff is

set out in Appendix 2.

22 Consent to admission care and treatment

Psychiatric inpatient wards – Following the ‘Cheshire West’ supreme court ruling
(2014), patients who lack capacity to consent to their admission, care and treatment
cannot be admitted to psychiatric wards as informal patients. Staff must assess [1]all
inpatients capacity to consent to the admission care and treatment within 24 hours and
record the outcome on the dedicated RiO form (IP capacity to consent to care &
treatment form, under the ‘Consent’ tab). Patients who lack capacity and who are not
already detained under the MHA are deprived of their liberty (acid test – see MCA/DoLS
policy and procedures). An urgent Deprivation of Liberty safeguards (DoLS)
authorisation and a standard DoLS application must be put in place. Patients who lack
capacity to consent to their admission care & treatment and object - do not meet the
DoLS criteria. In those cases, consideration for a MHA Assessment should be
given.(See MCA/DoLS policy and procedures).

Physical Health wards – a valid consent should be obtained from patient at the point of
admission (see Consent to Examination and Treatment policy). As part of the
discussion, if the nurse suspects that the patient may lack capacity to consent to their
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admission, care and treatment, a full capacity assessment should be carried out and
recorded on the Trust capacity assessment form. A copy of the capacity assessment
must be filed in the patient’s manual health records. If the patient lacks capacity a best
interest assessment should follow. For patients who are subject to a regime which
amounts to a deprivation of their liberty (see acid test – see DoLS policy) an urgent
Deprivation of Liberty safeguards (DoLS) authorisation and a standard DoLS
application must be in place. (See MCA/DoLS policy and procedures).

A person's capacity to consent can change and should be regularly reviewed when
circumstances change, or as part of the care planning reviews.

A physical health assessment must be carried out within 24 hours of admission, or

sooner if deemed necessary. When declined by the patient, a note of this must be
made in the electronic clinical record. Please refer to the Physical Assessment of
Inpatients Policy for further guidance.

The risk assessment must be reviewed and updated within 24 hours of admission to
ascertain whether this is still relevant and accurate within the context of the inpatient
setting, and an initial plan of care developed.

Medicines reconciliation must be carried out in accordance with the requirements and
timescales set out in the Medicines Policy.

23 ‘Think Family’ and the Safeguarding of Children

On admission the ward need to establish whether the service user/patient has carer
responsibilities (either part time or full time), or is living with children under age of 18
years. If this is the case, staff need to explain that as a Trust we promote a ‘Think
Family’ approach. The purpose of this is to provide support and an assessment of what
the family needs might be, and that arrangements are in place ready for discharge

As a minimum the ward need to obtain details of the children including

• DOB
• Address
• Nature of relationship of parental responsibility
• Whether they are already receiving support through Early Help Assessment or
Children’s Social Care.
o If so then the ward should liaise with those professionals with consent.
o If no services are currently in place, assessment around the level of need
for the child/ young person should be completed by staff

There are a number of tools available to assist with that assessment including the
Keeping Children Safe risk assessment tool. Staff using RiO need to complete the
electronic form. Staff using other systems need to complete the template and attach in
the patient record (Appendix 9). It is essential for staff to ensure that a responsible
adult is identified to care for children whilst their parent/ carer is in hospital.
It is important for staff to reassure service users that in the majority of circumstances,
information will only shared with their consent This includes accessing services to
support parents and carers whose health needs may mean they need extra help for a
time.

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However, in rare circumstances if staff are made aware that any child/young person is
at risk of significant harm, the law requires staff to share information with other agencies
in order to keep children safe, even if the parent doesn’t consent. In those cases staff
would generally explain to the service user what information is being shared and the
reasons for this decision.

Support and advice and further guidance around record keeping when safeguarding
children, should be accessed via
• the safeguarding children team 01733 777961, or
• [email protected]
• the NHS app
• the CPFT safeguarding children’s satchel on PC desktops
• or the Safeguarding children ‘User Guide’ (attached)
Links to other policies
• Safeguarding children policy
• Child Visiting Policy

On admission the carer record should be completed

24 Information to Patients and/or Family/Carers

As part of the admission process, an assessment must be made of the person’s

capacity, or competence in the case of children or young people, to understand, retain
information and make informed decisions about their care. Refer to the Consent Policy
for further guidance.

The clinician must use their judgement to determine how much information to give and
at what stage of the admission this is given.

Patients and families should be provided with relevant verbal and written/electronic
information (leaflets etc.). Ward teams will need to record what has been provided and
what more needs to be given.

As a minimum, the patient and/or their family/carer(s), with the patient’s consent,
should be given information about the ward through a ward information leaflet if
available, and an accompanying explanation of significant points if required.

Patients admitted under the Mental Health Act (MHA) or Mental Capacity Act must be
given information about their rights under the Act. Please refer to the relevant Mental
Health Act policies for further guidance.

Draw up Implement and an individualised care plan within 24 hours.

It is important that staff understand that even where consent has not been given, they
should still attempt to gather information from families and friends, especially in regard
to risk information. Confidentiality is not broken by listening, and does not stop staff
gathering information.

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25 Information Sharing and Confidentiality

Staff need to take into account the principles and procedures around information
sharing must be explained to the patient or their family/carer(s). They also need to take
into account the principle and policies around working with carers and families. Whilst
this is normally straight forward, staff can face complex dilemmas. In such cases they
should seek guidance from senior staff including the Team ‘Carers lead’. Refer to the
Confidentiality Policy and RiO Consent to Share Information Standard Operating
Procedure (SOP) for further guidance.

Information about the admission will be shared with other relevant practitioners and
agencies, subject to consent from the patient in accordance with the policies and
standards around information sharing as defined in the relevant Trust and multi-agency
policies to ensure that appropriate and relevant information is shared in an appropriate
and timely manner.

26 Record Keeping

All admission documentation must be completed in accordance with the relevant Trust
policies and procedures.

Refer to the Clinical Record Keeping Policy for further guidance.

27 Child Visiting

Patients who come into hospital have the right to maintain contact with and be visited
by anyone they wish to see, subject to carefully limited exceptions. This applies equally
to all patients, including those who are formally detained under the Mental Health Act.

The child’s interests must remain paramount and take precedence over the interests of
the adults involved when decisions are made about whether visits are appropriate.

Refer to the Child Visiting Policy for further guidance.

28 Single Sex Accommodation/Privacy and Dignity

The patient’s safety, privacy and dignity will be paramount throughout their stay in the
least restrictive environment. Refer to the Trust’s Eliminating Mixed Sex
Accommodation Policy for further guidance

TRANSFERS

29 Transfers between Trust Services

It is important to ensure that when assessing the need and appropriateness of a

transfer to another service, the views of all members of the multidisciplinary team, those
of the patient and their relative/carer(s) and any other individuals involved in their care
are fully considered and documented.,

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Where a transfer to another ward or another service within the Trust is necessary, the
transferring team must

• Provide a comprehensive verbal and written handover. Identify the clinician who
will be responsible for the patient’s plan of care in the new/receiving team.
• Agree the patient’s plan of care with the receiving team prior to the transfer,
including responsibility for identified interventions/actions.
• The receiving ward team must review the care plan including risk plan and level
of observations to check that they are appropriate to their ward.

The patient and/or their relative/carer(s) will be given information about the reason for
referral, the team/service they have been referred to, their plan of care and such other
relevant information as required. This will be recorded in the patient’s progress notes.

An inventory must be made of any valuables handed in for safekeeping or properties

brought in by the patient prior to the transfer, signed by a member of staff from the
transferring and receiving service and the patient or family/carer.

Patients will be escorted where appropriate when being transferred to another service.
The nature of the escort will depend on clinical need and identified risks.

For patients detained under the Mental Health Act, staff must comply with the MHA
legal requirements as outlined in the Transfer under the Mental Health Act SOP.

The transferring team is responsible for ensuring that the transfer is documented in the
patient’s records in accordance with the Trust’s record keeping procedures.

The receiving ward is responsible for updating care plans and other documentation to
reflect the change of environment and team

30 Transfers into CPFT from another Hospital

Transfers from an acute Trust must have a consultant to consultant (or nominated
medical/nursing representatives) dialogue and agreement before a transfer takes place,
which is recorded in the case notes. This is to ensure the patient is medically fit and
any ongoing physical health care needs are able to be met by the receiving ward.

A transfer will be treated as a new admission and the same procedures apply.

The transfer of patients detained under the MHA to CPFT from another hospital
manager’s jurisdiction must be done in compliance with the MHA legal requirements as
outlined in the Transfer under the Mental Health Act SOP.

31 Transfers from CPFT to another Hospital

Where a transfer is necessary, the named nurse or nominated deputy should discuss
the reasons with the patient and/or their relative/carer(s) in terms that they understand.

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Where a transfer to a ward outside the Trust (i.e. acute Trust) is necessary, a
comprehensive handover must take place verbally and in writing along with a transfer
letter and other applicable documents.

The transfer of patients detained under the MHA from CPFT to another hospital
manager’s jurisdiction must be done in compliance with the MHA legal requirements as
outlined in the Transfer under the Mental Health Act SoP.

32 Out of Hours Transfer Arrangements

Where possible, transfer of patients should happen during normal office hours.
However, transfer of patients out of hours is sometimes necessary. Any out of hours
transfer should pay special consideration of safe escort arrangements, prior risk
assessment and adequate documentation to accompany the transfer.

DISCHARGE FROM AN INPATIENT SERVICE

33 General Principles

All discharge and aftercare arrangements must be made in a manner which ensures a
safe and smooth transition from an inpatient stay in hospital to returning home or to a
community-based treatment/care including residential or nursing care home

Planning for discharge should commence as soon as possible following admission.

This should be done with the full involvement of the patient and/or their family/carer(s),
where appropriate and in collaboration with all professionals and other agencies
involved in their care.

Patients on mental health wards will not be discharged without the agreement of the
Consultant Psychiatrist, and for detained patients the Responsible Clinician (RC) having
responsibility for that patient, or his/her deputy.

Patients on OPAC physical health wards will be deemed fit for discharge by a doctor.
Thereafter actual discharge will be agreed by the MDT lead

Patients and/or carer must be given an estimated date of discharge.

The procedure for discharge will be facilitated by the named nurse/practitioner, in

collaboration with the community mental health care coordinator or for physical health
patient with the District Nurse/speciality team.

Carers’ needs will be taken into account throughout the discharge process and will be
involved whenever possible.

The Discharge Checklist (Appendix 3) must be completed, dated and signed off by a
designated member of the care team.

The Discharge Notification Form (Appendix 4) or relevant documentation on physical

health wards, must be completed and sent to the GP (General Practitioner) and the

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community team within 24 hours, with a copy given to the patient. The Discharge
Summary must be completed and sent to the GP within 7 days of discharge.

CPFT is contracted to supply 7 days of medication at discharge. Patients at risk of

taking an overdose may be prescribed less than 7 days, the exact amount to be
decided by risk assessment. In these situations, it is good practice for the ward to
speak to the GP about the appropriate quantities to be prescribed for future
prescriptions in primary care. In some circumstances, it may be appropriate to supply
more than 7 days supply on discharge. This must be decided on an individual basis or,
in the case of adult acute assessment units, between 7 and 14 days may be supplied in
line with their local procedure.

34 Discharge Planning

Every patient will have a meeting where discharge is discussed prior to a planned
discharge. They should be invited to attend whenever possible and appropriate, and
be given advance notice verbally.
The patient should be informed that a relative/carer and/or an advocate may
accompany them, and the relevant individuals invited with the consent of the patient.
The named nurse and the community care coordinator should attend or where
appropriate be appropriately represented. When not in attendance, communication
between the inpatient unit and the care coordinator will take place prior to discharge.

If the discharge involves arrangements for a social care funded package of care, then
the package should be discussed at the earliest opportunity with the relevant Social
Care Lead. Specific procedures will vary across Cambridgeshire and Peterborough
services, and between different client groups. This policy should be used in
conjunction with the relevant local procedures.

As far as possible suitable days, dates and time for discharge should be discussed and
agreed with all concerned.

Arrangements for the follow up should be agreed in the meeting discussion/agreeing

discharge plans, including who/which team is responsible for the follow up.

Service users entitled to statutory after-care under s117 must have their needs
assessed and clarified as part of the Care Programme Approach (CPA) process. After-
care planning should start as soon as possible after admission and should be service
user focused. As part of the discharge planning, a S117 must be organised and
aftercare arrangement agrees with the patient their carer and relevant professionals.
For additional information, see s117 policy and procedure.

35 Discharge against Medical Advice

There may be occasions when informal patients wish to discharge themselves against
medical advice.

Staff should make every effort to elicit the reason why the patient is wishing to leave the
hospital, or in the carer’s case for wishing to remove the patient from hospital. The
patient should be requested to speak with a doctor and nurse in charge or deputy
before they leave.
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If the patient refuses to speak to a doctor, the immediate risks must be assessed and
consideration given to the use of Section 5.4 or Section 5.2 of the MHA. Refer to the
relevant MHA policy for guidance.

Where the patient has an identified care coordinator in the community, they should be
contacted as soon as possible and informed of the developments.

The carers/family should be informed of the patient’s decision to leave hospital, with the
patient’s consent.
The patient should be requested to wait for their discharge medication. If they refuse
to wait, they should be advised to see their GP.

The patient should be asked to sign the Discharge from Inpatient Care Against Medical
Advice form (Appendix 5). An entry should be made in the patient’s clinical records
that the departure is against medical advice. If the patient declines to sign the form,
then the entry should reflect that.

36 Transport

Transport arrangements should be considered during the discharge planning process.

The Trust will only provide transport if there is a clinical need to do so.

The patient should be asked to make their own arrangements wherever possible. This
should be determined when discharge plans are first discussed with the patient.

37 Communication and Information Requirements

It is the responsibility of the key worker/primary nurse/named nurse to maintain effective

communication with the patient and their relative(s)/carer(s) and other relevant
professionals/agencies involved in their care in a timely manner.

The patient and/or their relative(s)/carer(s), with the patient’s consent,

• should be kept informed of the discharge date and any changes that occur
• will be given a copy of their care plan, and where appropriate safety plan (Safe
Plan) , and details of how to contact the service for support including emergency
contacts . In these circumstances the named nurse or another nurse nominated
by the person in charge of the ward should attempt to give the person a plan
based on the latest provisional discharge plan.
• will be provided with other relevant information as required, including information
about other agencies and sources of support in the community.

In the event of consent not being given, but where the carers involvement post
discharge is required/likely, staff need to ensure that enough information is provided
to enable the carers to carry out the support safely and effectively. Additional
guidance from senior staff should be obtained to assist with developing plans.

For discharges from under the MHA refer to the relevant MHA policy.

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The General Practitioner (GP) will be given a copy of the, Discharge Notification Form
and the Discharge Summary in accordance with the required timeframes. This must
include information about:

• mental health diagnoses, with ICD10 code

• physical health diagnoses/conditions
• medication (psychotropic and others)
• monitoring requirements of the above

Other professionals and agencies will be given relevant information on a need to know
basis, with the patient’s consent (refer to section 35.7), to ensure safety and continuity
of care.

The information provided on discharge must include, as a minimum:

• an up to date care plan, which includes crisis and contingency arrangements

• the most recent and up to date clinical risk assessment
• Mental Health Act (MHA) requirements, where applicable
• any infection and physical health conditions that needs to be managed
• any other relevant verbal or written information, including social, financial and
psychological factors affecting the patient’s ongoing care

38 Medication on Discharge

The Medicines Policy and RiO Standard Operating Procedure for Discharge must be
followed when prescribing and obtaining medication for discharge.

For physical health wards the medicines policy and agreed local medicines discharge
documentation must be followed and completed fully.

If possible, discharge medication should be obtained from pharmacy in advance of the

time of discharge to avoid unnecessary delays for the patient.

The nurse responsible for the discharge must check that the medication chart and the
Discharge Notification Form correspond to the dispensed medicines.

The nurse in charge must ensure the patient and/or their relative(s)/carer(s) understand
the medication regime and any possible side effects prior to handing discharge
medication to the service user.

Consideration about any risks on driving ability must be made and the necessary
action(s) taken. Refer to the Protocol for Driving and Psychiatric Disorders for further
guidance. https://www.gov.uk/guidance/psychiatric-disorders-assessing-fitness-to-drive

39 Infection Control Considerations

Prior to transferring, discharging or accepting patients into inpatient or residential areas,

the named nurse or nominated deputy must be mindful of issues relating to healthcare

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acquired infection (HCAI) and refer to the Infection Control Manual for guidance, where
required.

It is essential that this information is considered both when transferring a patient with a
known infection to other healthcare settings such as hospitals/wards,
nursing/residential homes and also when a patient is going back to their home and
receiving either district nursing input or other community support services to ensure that
appropriate precautions and care can be put in place. Further information and
guidance may be obtained from the Infection Prevention and Control (IPaC) Modern
Matron.

For patients with a MRSA (colonisation or infection) or any other active infection or
CDiff during their stay, follow the following procedures:

If the patient has diarrhoea and/or vomiting and is being discharged to another
institution, please inform that institution prior to transfer. Do not transfer until 48 hours
post symptoms without discussing with IPaC Modern Matron.
Complete an Infection Control Transfer Form

40 Follow Up Arrangements for patients on inpatient wards

All patients discharged from psychiatric inpatient care with ongoing mental health
issues, including those who have discharged themselves against medical advice, will
receive follow up from specialist mental health services.

Additionally, the Department of Health (DH) requires that all patients under adult mental
illness specialties on CPA discharged to their place of residence, care home, residential
accommodation, or to non psychiatric care must be followed up within 7 days of
discharge the timing of this dependant on the needs of the patient. All avenues need to
be exploited to ensure patients are followed up within 7 days of discharge. Where a
patient has been transferred to prison, contact should be made via the prison in-reach
team.3

Exemptions to this rule are set out below:

• Where legal precedence has forced the removal of a patient from the country.
• Patients transferred to NHS psychiatric inpatient ward
• CAMHS (child and adolescent mental health services) are not included
• readmitted within 7 days
• discharged to Drug and/or Alcohol Services/Community Drug Team
• discharged to Out of Area
• discharged having been admitted under the Ministry of Defence contract or as a
planned admission to a Detox bed
• transferred to other wards (patients transferred to NHS psychiatric inpatient
ward)
• admitted for whom it is deemed mental health services are inappropriate and are
referred back to their GP

Additional partial exemptions agreed by the Trust are:

3 This official definition and exceptions are taken from the Technical Guidance for the 2012/13
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 where patients are discharged to other hospitals (e.g. acute general hospitals), a
telephone discussion ‘by proxy’ with the clinical team caring for that patient will
count as a 7-day follow up to take account of the physical condition of the patient.
for patients discharged to prisons, a discussion with the relevant prison in-reach
team ‘by proxy’ will count as a 7-day follow up.

The 7 day period should be measured in days not hours and should start on the day
after the discharge. In all cases, follow up must take place within seven calendar days
of discharge, day one being the day after the date of discharge.

For services that are not covered by the Department of Health requirement above, such
as children and learning disability services, good practice would dictate a follow up
within 7 days of discharge.

The follow-up must be in person. Non face-to-face follow up can only be made on
agreement by the MDT based on clinical judgement, with a clear rationale documented
in the patient’s clinical records.
The arrangement for the follow up must be clearly documented in the discharge plan,
Discharge Notification Form and Discharge Summary.

The follow up must be recorded in the patient’s clinical records.

If the follow up does not take place, the reason must be recorded, including attempts
made to contact the patient.

Clinical judgement must be used to determine the number of the attempts made to
contact the patient, supported by an assessment of the risks involved. This must be
discussed with the MDT. Decisions made and actions subsequently taken must be
documented in the patient’s clinical records.

41 Suicide Prevention

The Trust has adopted a Zero Suicide strategy to help reduce the number of suicides of
service users. Central to this is good risk assessment and risk plan formulation.
Subject to information sharing consent this should routinely include involving carers,
friends and families in gathering information to help inform the assessment and plans.
Where the patient has been identified as a suicide risk prior to or during the period of
admission:
• the risk management plan including level of observation needs to take into
account the specific ward environment the patient is admitted to. The risk plan
should be reviewed on transfer to another ward as appropriate
• the discharge care plan should take into account the heightened risk of suicide in
the first three months after discharge and make specific reference to the first
week
• Follow up from a professional practitioner of the mental health service should be
made within 7 days, the timing of this dependant on patients need. Patients in
followed up by CRHT will normally be seen is 48 hours of discharge. This will be
recorded in the patient’s clinical records

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42 Carer Needs

This section is taken directly form the Trust’s Carers Policy. It is replicated here so that
there is consistency across relevant policies regarding the involvement of carers, and
so that staff can be clear about expectations and supported to work with what
sometimes can be, complex situations.

CPFT recognises the significant role often taken by carers in the care, treatment and
support of service users and should be proactive in developing constructive and
supportive relationships. Clarity and honesty about issues of information sharing
between staff, service users and carers are a vital part of developing such relationships.
The sharing of information with carers is crucial in order to provide the safest and best
clinical care possible to service users.

The issue of confidentiality should be discussed with the service user as early as
possible and discussion, and any agreements, should be recorded. Professionals
should explain to the service user the benefits of sharing appropriate information with
the carer.

The issue of confidentiality should also be raised as soon as possible with carers. It
should be explained that there is a limit to the information we can share with them if the
service user does not consent, or withdraws consent, and any current restrictions that
are relevant to them should be discussed. However, an assurance should also be given
that, in any case, staff will continue to support them as far as possible in their caring
role, to ensure that their needs are met.

In all cases staff should aim to reach a position where families can be fully involved in
the care and support of the cared for person to maximise the chances of a good
outcome for their family member. Once staff are able to involve families fully they
should make sure they do so.

Carers also should be able to expect that the information they provide will be held in
confidence by the professional care team if they request this..

Circumstances in which information should be disclosed when consent is given

It is imperative to remember that the prime use of patient information is for the delivery
of personal care and treatment.

• If a service user has consented to sharing of information with their family

and carers this information should be clearly recorded. If consent has been given

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 it is essential that this information is shared with family and carers and that this is
sharing is clearly recorded.

• Patients who have the capacity to consent but are unable to read, write or
require an interpreter, must receive appropriate support

Circumstances in which information must be disclosed without the consent

of the patient

There are some specific circumstances permitted by law where patients’ wishes in
relation to information being kept from their carer and relatives can and should be
overridden through clinical decision making: These are listed below.

• For the protection of the public or another individual such as a carer, service
user or staff member

• If a service user is considered to be at significant risk of suicide or serious

harm to themselves. Carers should be informed of this risk as soon as
possible and provided with appropriate support

• There may be a statutory duty to breach confidentiality where children at risk

are identified. Child protection (Children’s Act 1989)

• There is a specific duty to involve the nearest relative of patients who are
detained under the Mental Health Act (note: the term “nearest relative” has
a precise definition within the Mental Health Act). Mental health action
1983, section 11.

Wherever possible decisions about sharing information without consent should not
be made alone. Staff should consult their line manager or wider team treating the
patient and should follow trust policy in relation to the process of sharing
information without consent.

In the exceptional cases where clinical information is shared without the patient’s
consent, staff should if at all possible discuss beforehand with their line manager or
team. Where this is not possible – for example a mental health crisis where a
patient’s family are at risk from the patient – staff should inform their line manager
immediately afterwards.

For circumstances where there is no immediate clinical risk it is important to

discuss the appropriateness of breaching the service users confidentiality with your
line manager, team or Caldecott guardian if required.

Where issues arise that cannot be resolved or are complex the trust’s Caldecott
guardian is available to support staff. The Trusts’ Information governance manager
is there to provide guidance around ensuring that decisions are made within the
legal framework.

Where we do breach confidentiality a breaching confidentiality form should be

completed and submitted to the information governance team.
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 The organisation must be able to justify any exceptional decisions to pass on
information.
The reasoning for this must be documented within the notes, as well as signed and
dated.

Circumstances in which it must not be disclosed.

There may be times when in spite of continued efforts to encourage service users to
involve carers and relatives in their care consent to share information is still refused.
If there is no indication of the circumstances where it should be disclosed the service
users would be deemed to have a valid reason for refusing consent and their request
for confidentiality must be respect.

Where a patient has expressed a wish that information be withheld the

consequences of this must be explained to the service user and the patient's wishes
must be communicated to other staff who need to know. An example would be
where non- disclosure will affect the Trust’s ability to work with another agency such
as Adult Social Care.

Carer Engagement
Lack of consent from a service user must not preclude sensitive discussion and
appropriate and helpful sharing of general information. Every effort should be made
by staff to support carers in their caring role, and they should be supported and
encouraged to discuss and resolve any concerns or difficulties.

If the service user withholds consent, there should be discussion about whether this
applies to all information or specific details, and the outcomes of this discussion
recorded (For example, a service user may be willing to share information about
their care and treatment but reluctant to make carers aware of issues of sexuality
and relationships).

Where consent to share information is refused, the service user’s decision should be
shared sensitively with the Carer (alongside an offer to support them as far as
possible).

Refusal of consent should be reviewed regularly with the service user. They should
be made aware at the earliest opportunity that refusing consent will not mean staff
cannot provide support to the carer for their own needs. Staff should encourage the
use of advance decisions to confirm whether carers can be contacted in the event of
an admission or emergency.

The provision of general information about mental illness, emotional and practical
support for carers does not breach confidentiality. Neither does discussion about
matters that the carer is already aware of (for example, information discussed at a
meeting where the carer was present).

Receiving information from carers is not a breach of confidentiality. Carers will have
information about the service user and this information should be considered in the
forming of the care planning process.

It may well be helpful to support Carers to access information about a condition or

potential side effects of medication as long as this does not involve disclosure of
information
(such as a diagnosis) that the carer was not already aware of.

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 The provision of information about carer organisations and other sources of
support
(for example local groups) may be particularly helpful where staff are
precluded from sharing particular information.

Staff should encourage the use of advance decisions to confirm whether carers can be
contacted in the event of an admission or emergency.

Further information about Confidentiality Issues including useful case studies can be
found at: www.rcpsych.ac.uk/campaigns/partnersincare/carersandconfidentiality.aspx

Top Tips for Best Practice

• Aim for full involvement of the carer so that you can work together with them
• Ensure that confidentiality is clearly understood / agreed between all parties.
• When meeting a carer for an assessment, ensure that you have any appropriate
information leaflets. This will vary according to individual needs, and may need
to be focused to avoid an overload of information.
• Check that any referrals made have been picked up and action has been taken.
• Ensure that the Carer has a clear contact within the service in case the situation
needs to be reviewed.
• Ensure that the Carer is aware of support groups outside the statutory services.
• Ensure that health, cultural, religious and spiritual needs of the Carer have been
addressed.

43 Carers’ Assessment

The CPFT Carer Charter (2015) defines a carer as:

“Someone who is providing help and support, unpaid, to a family member,

friend or neighbour who would otherwise not be able to manage without this
support.”

In comparison the legal definition contained within the Care Act 2014 states:

“A carer is someone who helps another person, usually a relative or friend, in their day-
today life. This is not the same as someone who provides care professionally, or through a
voluntary organisation.”

In the context of CPFT, a carer is also:

Anyone who cares, unpaid, for a friend or family member who due to illness,
disability, a mental health problem or an addiction cannot cope without their
support.

Thus the legal definition of a carer is now very broad. The statutory role for inpatient
units is to identify carers and record this appropriately on the electronic patient record.

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Once identified, carers should be offered an assessment of their own needs. See the
Carers Policy for next steps.

The Care Act relates mostly to adult carers – people aged 18 and over who are caring
for another adult. However, regulations under the Act also sets out how assessments
of adults must be carried out to ensure the needs of the whole family are considered,
including the needs of young carers4.

If both the carer and the person they care for agree, a combined assessment of both
their needs can be undertaken. Consideration must be given to the capacity of the
patient and issues around confidentiality in regard to undertaking carers’ assessments.

Young carers (aged under 18) and adults who care for disabled children are assessed
and supported under The Children and Families Act. This gives young carers (and
parent carers) similar rights to assessment as other carers under the Care Act.

44 Mental Health Legislation and Legal Requirements

Refer to the relevant MHA policy and procedures, or to the Mental Health Legislation
Manager/Locality Mental Health Act Administrator for guidance on the following:

Scheme of Delegation under the MHA

Receipt and Scrutiny of Detention Papers Policy
Section 132/132a Reading of Rights Policy
Working with Independent Mental Health Advocates (IMHA) Policy
Section 26 The role of the Nearest Relative Policy
Section 5(2)/5(4) Doctor/Nurse Holding Powers
Section 58 Consent to Treatment Policy
Mental Health Act Hearings Policy
First Tier Mental Health Tribunal Hearings Policy
Detained patients in Acute Hospital Policy
Section 117 aftercare
Supervised Community Treatment (Section 17A-G)

Guardianship (Sections 7 and 37)

Mental Capacity Act Multi Agency Policy
Deprivation of Liberty Safeguards (DoLS) Policy and Procedures
Consent to examination and treatment policy

45 Delayed Transfers of Care (DTOC)

A delayed transfer of care (delayed discharge) occurs when a patient is ready to depart
from such care and is still occupying a bed. A patient is ready for discharge when:

A clinical decision has been made that patient is ready for discharge and

4 This includes assessing what an adult needs to enable them to fulfil their parental responsibilities
towards their children, or to ensure that young people do not undertake inappropriate caring
responsibilities.
Page 32 of 58
 A multi-disciplinary team decision has been made that patient is ready for discharge
and
The patient is safe to discharge.

The point at which all of the above criteria are met and there is thought to be social
carer requirements, the relevant team need to liaise with Social Care colleagues
following agreed processes. This also needs to be clearly recorded in the patient’s
records.

46 Monitoring Compliance

In addition to the responsibilities in relation to monitoring compliance with this policy set
out in Section 6 and 9, there are specific risk management standards that apply to
discharges which is outlines below.

Area to be monitored Arrangements for monitoring Frequency

Discharge requirements Discharge checklist – audit to be As agreed
for all patients determined on a risk based approach
Information to be given to Section - audit to be determined on a As agreed
the receiving healthcare risk based approach
professional Management and clinical supervision
Information to be given to Section - audit to be determined on a As agreed
the patient when they are risk based approach
discharged Management and clinical supervision
How a patient’s Section
medicines are managed Review of DNF by Pharmacy staff On-going
on discharge Audit to be determined on a risk As agreed
based approach

Out of hours discharge Section 32

process Audit to be determined on a risk As agreed
based approach

Compliance with specific standards around discharge is also monitored through clinical
audit using a risk-based approach as agreed in accordance with the Clinical and
Practice Audit Policy.

47 Links to Other Documents

In addition to the documents listed in Section 10, the following should also be referred
to for further guidance

Cambridgeshire and Peterborough Patient Discharge and Transfer protocol and

performance Monitoring

Information Sharing protocol to prevent Homelessness (multi-agency protocol for

patients discharged from Mulberry 1, 2 and 3)

48 References

Page 33 of 58
Care Quality Commission (2008), The Health and Social Care Act 2008 (Regulated
Activities 2009)
Department of Health (2011), Technical Guidance for the 2012/14 Operating
Framework
Preventing Suicide: A toolkit for mental health services (2009), NPSA
NHS England (Oct 2014), Specialised Mental Health Services Operating Manual
Protocol: Referral and access assessment procedures for children & young people into
inpatient services.
(http://nww.intranet.cpft.nhs.uk/Childrens/ChildrensBusinessUnit/Pages/howtogetabed.
aspx)

Page 34 of 58
49 Acknowledgements

A policy review group was established to support the effective review of this policy.
The author would like to acknowledge the contribution from key members of staff from
across the Trust’s services, as follows:

Neil Winstone, Associate Director of Performance & Service Delivery

Eddi Paul, Adult & Specialist Directorate Interim Head of Nursing
Joe Lynch, OPAC Directorate Head of Nursing (mental health)
Nicky Bidwell, OPAC Practice Development Lead
Orna Clark, Patient Information & MHA Legislation Manager
Rob Bode, Modern Matron – The Croft, The Darwin Centre and The Phoenix Centre.
Interim Service Manager for the Intensive Support Team.
Dr Julia Deakin, Consultant Psychiatrist and Trust Physical Health/mental health lead
Clare Mundell, Chief Pharmacist

Page 35 of 58
APPENDIX 1a

Mental Health Wards

ADMISSION CHECKLIST
For use in preparation for and during patient admission
Name of patient: Hospital Number:
Ward: Date of Admission:

Core tasks
Individual wards may add tasks or additional explanatory notes or guidance to this list.
Tick if Signature of
No. Action completed admitting
Or N/A Nurse
1 Complete Eliminating Mixed Sex Accommodation form (for AAU only)
Enter patient details on Bed Map/Board and on Named Nurse
2
List/Allocate Named Nurse.
3 Access patient’s historical notes/records.
4 Ensure bedroom is clean and ready.
5 Inform doctor of admission.
Contact care coordinator to ensure they are aware of admission and
6
request attendance at ward for review and discharge planning.
Ensure completed pre-admission paperwork is received, to include:
• up to date Core Assessment
• most recent and up to date risk assessment.
7 • up to date and current care plan
(Note: see s18.2 of Admission, Discharge & Transfer Policy for full
list of information/documentation)
Discuss discharge date with referring team.
On arrival,
• welcome patient and/or relatives, introduce self, show them to a
quiet room and offer a drink.
• give Welcome/Information Pack (patient & carers)
8 • Inform/confirm reason for admission
• outline plan of care, including discharge plan
• orientate to ward area, outline ward routine and other specific ward
policies and procedures
inform of Controlled Access procedures
Assess patient consent to admission care and treatment and record
outcome on the “Inpatient capacity to consent to admission care &
9 treatment” RiO form. (If the patient lacks capacity to consent to the
above, give consideration for the patient status under the appropriate
legal framework – i.e. DoLS, MHA, Court of Protection order)
Give the Consent to Share Information leaflet to the patient and
discuss with the patient their rights around sharing information.
10
Record outcome of discussion on RiO consent to share
information Form. Identify exceptions.
Inquire about arrangements for any domestic issues (e.g. pets, home
11
security, caring responsibilities)
• Identify carers
12
• Offer Carer’s Assessment, where applicable
Medications
• contact GP to request Medication Summary
• ask patient to hand in any medications and consent to use own
medicines
13 • In working hours – phone pharmacy to inform them of admission
(they will come to check and order any if required)
• Out of working ours – registered nurse can check patient’s own
medicines for re-use, and if not appropriate, can obtain stock via
out of hours procedure
Page 36 of 58
 Tick if Signature of
No. Action completed admitting
Or N/A Nurse
If required and only with patient’s consent, inform relatives of
14
admission and give information.
15 Complete other relevant consent forms and upload in RiO.
Screens & risk assessments: Complete and upload in RiO
• MRSA screening (if necessary)
• Falls screen / risk assessment
16 • VTE screen
• MUST
• People Handling Risk Assessment Form
• Keeping Children Safe Risk Assessment Form
Check/search belongings with patient/relatives.
• drugs or alcohol should be removed
• weapons/sharp objects should be handed to staff for safe-keeping.
17 • any electrical items need to be PAT tested.
• if patient has valuables, ascertain whether they wish these to be
taken home by relatives or handed over for safe keeping.
Log patient property handed over for safe keeping.
Have Disclaimers signed for:
18 • Non-prescription Drugs/alcohol
• Valuables
19 Give patient a bedroom key card/door fob
Enter patient details on
• fire safety board
20
• Bed state
• Task Board
If detained under the MHA:
• Receive section papers, check the forms by following the Nurse
Receipt and Scrutiny check list, complete H4A form and
scan/upload all detention papers onto RiO.
21
• Send original detention papers, AMHP’s SOC 323 form and signed
scrutiny list to the locality Mental Health Act Administrator.
• Read rights within 24 hour of admission. Upload successful rights
form onto RiO.
Undertake joint assessment interview with the doctor.
Complete/update jointly with admitting doctor:
• Core Assessment v2
• Risk Assessment (including driving risks)
22
• Identify any safeguarding issues/needs
Obtain/update all patient demographic details.
Agree the appropriate level of observation and communicate to
patient and all staff
Undertake Physical health examination
23 • Physical Health Check Part B completed
Note: Different versions for adults and CAMHS
For doctors: Complete
- See minimum documentation standards
• RiO Capacity assessment to consent to treatment for all inpatients.
• Medication Chart
24
• Physical Health Check Part A completed
• VTE assessment
FOR PHARMACISTS
• Medicines Reconciliation process and form
 Doctors and nurses
• Physical observations
24 • Summarise admission with appropriate entry in RiO patient’s
progress notes.
• Develop initial plan of care (48//72 hr care plan)

Page 38 of 58
APPENDIX 2

Minimum Standards for Admission Assessment Documentation

by Medical Staff

Background
These are the minimum standards of documentation for admission assessment carried
out by medical staff. Clinical records that document the assessment of service users
must comply with the Record Keeping standards set out in this policy

The CPA is the core assessment tool that will contain current and historic service user
information.

Interview
Standard: an interview/consultation must take place

Exception: A clearly recorded reason why this did not happen (e. g. service user
refused to talk, mute, violent) must be recorded. If this exception applies, the following
subsections of interview will also be excepted apart from the observable elements of
mental state examination. Service users who refuse interview may accept physical
examination and/or blood tests, so it must be recorded which elements of admission
have been omitted. Information previously obtained can be included provided it is
actually available (i.e “see notes – with location of relevant document” is ok if notes
available and have the information)

Demographic data
Name, age, ethnicity

Reason for admission/history of presenting complaint

Some description of events/symptoms leading to presentation

Past psychiatric history

Include information about previous admissions
Include information about previous psychiatric medications and treatment response
Reference to past problems or none

Past medical history/ medication: ***

Significant past illnesses or none
Current medication prescribed and taken
Any allergies/adverse reactions

Family and personal history ***

Report on family history of mental or physical illness
List of key family members. Include full names and dates of birth of any children in the
home
Some mention of developmental milestones
Reference to schooling and educational attainments
Employment and relationship history
List of substance use or “none” ***
Current circumstances
Employment or lack of it (or other activities)
Living alone/who with (or other support)
Financial situation (claiming benefits and which ones, debts, savings)

Forensic history/risks ***

Any criminal/delinquent behaviour, convictions
Risk of self-harm (may be in mental state examination), harm to others, self-Neglect
(include reference to past behaviours)

Mental state examination

Appearance & Behaviour: some description
Observed [these must be recorded even in service users who cannot be interviewed]
Speech: some description
Mood Subjective: some description
Mood Objective: Some description
Thought content/delusions: some description, must include suicidal thoughts or not
Perceptual abnormalities: some description
Cognitive: orientation in time and place

Capacity to consent to admission, care and treatment

Service user strengths, needs and expectations

Carer views and needs (include unpaid and informal carers)

Physical examination
Complete the Trust Physical Health Check form Part A

Investigations*
• FBC, U&E, LFT, HBA1c, CRP, TSH, CRP, non fasting lipid screen (consider
further tests such as Lithium, BFT, Urea, GGT, B12/Folate , CK, ESR, First
Presentation Psychosis and Clotting Screen as appropriate).

Summary
A statement including key demographics e.g. name, age, relationship, employment and
accommodation status. E.g. John Smith is a single 25 year old cleaner who lives with
his 13 year old son in rented accommodation.
Diagnosis (may be provisional or query) with supporting evidence
Risk assessment (may be above)
Statement of capacity/consent – if capacity/consent is lacking, what action is being
taken (e.g. Mental Health Act, Independent Mental Capacity Advocate)

Initial plan
Admit/not; if admitted, voluntary or not
Medication
Goal of admission – what is required for discharge to be acceptable?

* Exception is recorded refusal or other reason (e.g. risk of provoking violence)

**Exception is recorded lack of necessary equipment
*** May be split into more than one section/recorded under different headings

Page 40 of 58
Note about recording data in a Core Assessment
With the electronic records it becomes very helpful to be able to reuse information for
example in the Core Assessment and the Risk Assessment.

Your entries are much more helpful if you can use absolute time frames (e.g. “When he
was 20 years old” or “in 2012”) rather than relative ones (“last week” or Five years ago”)

It can be helpful to capture the patients own words, but with small additions you can
avoid confusing people later.

Bad: “He reports that he took an overdose five years ago”

Good: “He reports that he took an overdose five years ago (~2012)”
Good: “He reports that he took an overdose five years ago, when he was around 18
years old.”
Good: “Update 9 Sep 2017: Mr X reports that last week Y happened...”

Bad “He agreed to a home visit next Tuesday at 10am”

Good “He agreed to a home visit next Tuesday (30/1/2018) at 10am”

Dr David Dodwell (July 2005, reviewed Feb 2015, Dr Deakin reviewed 2018)

Page 41 of 58
 WARD ADMISSION CHECKLIST : DUTIES OF THE ADMITTING DOCTOR

This standard operating procedure is for the admitting ward or on call doctor working on the inpatient wards across
CPFT. Please note it runs in conjunction with the ward admission checklist which details the nursing roles and duties
for each admission. The following duties should be completed within 24 hours from the time the patient is admitted to
the ward, unless otherwise specified. The reason for any deviation from this should be documented in the progress
notes.

Page 42 of 58
APPENDIX 3

Mental Health Wards

DISCHARGE CHECKLIST
(For planned & unplanned discharges)
Name of patient: Hospital Number:

Ward: Date of Discharge:

Comments
Y/N Signature or
Date
No. Discharge Requirements or and further
Completed
N/A Designation actions
required
MDT review/pre-discharge meeting with
• Consultant Psychiatrist
1
• community Care Coordinator
• Carer/relative(s) with patient’s consent
For doctors: Complete Discharge
Notification Form. This must include:
• mental health ICD10 diagnosis
2 • any known physical health diagnosis/
conditions
• discharge medication
• monitoring requirements of the above
3 Review and update risk assessment
Risk to driving ability
• identify any risk(s) to driving ability
4 • inform patient and/or relative/carers of
any risk(s) from medication or diagnosis
• inform DVLA if required
Care planning
• Update care plan to reflect discharge
5 plans. Ensure any monitoring
requirements are explicitly stated.
• Complete contingency/crisis plan.
Identify and inform community Care
6
Coordinator/ CRHTT of discharge.
Follow up arrangements: Identify who will
follow up, where and when.
7 • mandatory 7-day follow up
• 48 hrs follow up for high risk/suicide
prevention (good practice)
Carers/relatives
• Carer/relatives informed of discharge
8 plans, with patient’s consent
• Carer care plan completed, where
applicable
Medication
• One copy of Discharge Notification form
printed and sent to Pharmacy with
9 patient’s medication
• TTO medication received on ward and
given to patient
• Medication leaflets given to patient/carer

Page 43 of 58
 Comments
Y/N Signature or
Date
No. Discharge Requirements or and further
Completed
N/A Designation actions
required
Other relevant information documents
completed:
• Observation charts
10 • Fire Safety Board
• Bed state
• All CPA paperwork
• Others, as required
• Mental Health Act 1983
• Discharge from Section paperwork
11 completed
• Section 117 paperwork completed (MH
Law Office notified)
Mental Capacity Act/DoLS assessments
12 for patient who lack capacity - actions
completed (MH Law Office notified)
Where applicable, inform other agencies
of discharge plan, with consent from
13
patient (E.g. police, social services,
voluntary agencies, MAPPA, etc.)
Social care
• Continuing Care Criteria met? Date
applied for____________________
14
• Benefits/Direct payments
• Caring arrangements
• financial and social care issues
Personal belongings and valuables
15
returned to patient
Where applicable, patients have their
16
walking aids to take home with them
Information given to patients
• Copy of care plan and crisis card
17
• Copy of Discharge Notification Form
• Sources of support in community
18 Room/door card/fob returned to ward
Final Discharge Notification Form printed
and
19
• faxed to GP and
• copy sent to Care Coordinator
Date discharge letter sent to GP (must be
20
within 7 days of discharge)
Last entry in notes including time of dis-
21
charge & who accompanied Service User
Discharge recorded in relevant electronic
22
patient record system (RiO)
Comments/Notes

Page 44 of 58
 APPENDIX 4

Mental Health Wards

DISCHARGE FROM INPATIENT CARE NOTIFICATION FORM

Client:

Date/time:

Assessment Referral:

Ward:

Ward Event Number:

Date of Birth: NHS / Hospital no.:

Date of Admission Date of Discharge:

MHA / MCA status on Admission: Inpatient Consultant:

S117 Aftercare Status: Care coordinator/key worker at time of

discharge:
Normal Place of Residence:

Discharge Address: If discharge address is the

same as normal place of residence (Tick box)

Discharge Address: if not the same as the normal place of residence

GP Details:

Name of Initial Community team Contact:

ICD10 Working Diagnosis:

ICD10 primary Diagnosis:

ICD10 Secondary Diagnosis:

Community Team (if applicable)

Medications at Discharge

Page 45 of 58
Allergies or Adverse Reactions

Discharge Medication
Medicine Amount
Time / Additional
Medicine Name Form Dose Route No. days Supplied
Day Instructions
(e.g. tabs) (Pharmacy)

Please include any changes during admission with reason why, and instructions for the GP

Medication Recommendation and Changes during Admission

I have considered the overdose risk when prescribing medications Yes No

Doctor’s signature: Doctor’s Designation:

Doctor’s Name: Date:

Pharmacist’s Name (Pharmacy Use Only):

Date:

Plan at Discharge
Please make sure that the patient plan at discharge includes follow up within 7 days, by GP, by
CPFT, Risk Management, Crisis Plan, Other Agencies, / services involvement and any additional
Information are provided below.

Day Follow up Required? (Yes, No, NA)

Is there a risk to the patient’s driving ability (Yes, No, NA)

If Yes, I confirm that I have advised the patient of the risk(s) of impaired driving ability
associated with their medication or diagnosis, and of their responsibility to inform DVLA
of this risk(s).

Doctor’s signature: Doctor’s Designation:

Doctor’s Name: Date:

Please print one copy and sign and send to pharmacy. When notified by pharmacy, please print
final version from RiO and give a copy to patient/carer and send a copy to the GP and care
coordinator.

Has the discharge plan been discussed with the patient? Yes No

Page 46 of 58
 APPENDIX 5

DISCHARGE FROM INPATIENT CARE AGAINST MEDICAL ADVICE

I…………………………………………………………..am discharging myself from

hospital in-patient care against medical advice. I have had an opportunity to see a
doctor to discuss my situation.

Signed……………………………………………………….. Date……………………..

Name in Capitals …………………………………………………………………..

Name of nurse in charge………………………………………………………….

Signature of nurse in charge……………………………………………….……..

IF THE PATIENT REFUSES TO SIGN

The patient…………………………………………………… has refused to sign

the Discharge from Inpatient Care Against Medical Advice Form.

Name of nurse in charge………………………………………………………….

Signature of nurse in charge……………………….. Date………………………

Witness Name………………………………………………………………………..

Signature of witness…………………………………. Date………………………

This form must be filed in the patient’s medical records

Page 47 of 58
Page 48 of 58
APPENDIX 6

OPAC – Physical Health Wards

ADMISSION CHECKLIST
For use in preparation for and during patient admission

Individual wards may add tasks as additional explanatory notes of guidance to this list.

Tick of Signature of
NO. Action completed admitting Nurse
or N/A
1 Enter patient details on white board

2 Access patient’s historical notes/ records.

3 Ensure bedroom is clean and ready.

4 Inform doctor of admission

5 Contact social services to ensure they are aware of admission

and request attendance at ward for review and discharge
planning
6 Ensure completed paperwork is received to include
• Up to date referral
• Northwick Park assessment
7 On arrival,
• Welcome patient and/or relatives, introduce self,
show them to their room and offer them a drink.
• Discuss reason for admission
• Give welcome/ information pack (patient and carers)
• Discuss plan of care, including discharge plan
• Seek and the patient (valid) consent to admission
care and treatment. If you are concern about the
patient capacity to consent, carry out a capacity
assessment and record it on the appropriate form.
• Orientate to ward area, outline ward routine and
specific ward policies and procedures
• Inform of Controlled Access Procedures
8 Give Consent to Share Information Leaflet to the patient and
discuss their rights around sharing information.
Record outcome of discussion in paper notes.
9 Inquire about arrangements for any domestic issues ( e.g.
pets, home security, caring responsibilities)

10 • Identify carers
• Offer Carers Assessment where applicable

Page 49 of 58
 Tick of Signature of
NO. Action completed admitting Nurse
or N/A
11 Medications
Nurse to complete first reconciliation
• Contact GP to request Medication Summary (if
applicable)
• Ask patient to hand in any medications and consent
to use own medicines
• Out of working hours – registered nurse can check
patient’s own medicines for re-use, and if not
appropriate, can obtain stock via out of hours
procedures.

12 If required and only with patient’s consent, inform relatives of

admission and give information.

13 Complete other relevant consent forms and upload in S1

14 Screens & Risk Assessments

MRSA Screen
Falls Screen
VTE Screen
MUST
Bedrail
Alcohol/ Smoking
SSKIN
Waterlow
People Handling risk assessment

15 Check/ search belongings with patient/relatives

(if appropriate)
• Any electrical items should be PAT tested
• If patient has valuables, ascertain whether they wish
these to be take home by a relative or handed over
for safe keeping
• Log patient property handed over for safe keeping
16 Have Disclaimers signed for:
• Non-prescription Drugs/alcohol
• valuables
17 Give patient a bedroom key card/door fob (if applicable)

18 Enter patient details on

• White board
• System one

19 For doctors: complete

• Medication chart
• Overview assessment.
• Complete VTE
• Review DNR status
20 Therapists and nurses :
Complete Observations
Develop initial plan of care

21 If the patient lacks capacity to consent to their admission care

and treatment and are under constant supervision and control
and are not free to leave the ward (Cheshire West supreme
court ruling “Acid Test”) consider applying the Deprivation of
Liberty Safeguards (DoLS)

Page 50 of 58
APPENDIX 7

OPAC Physical Health Wards

Discharge Checklist

For use in preparation for and during patient admission

Individual wards may add tasks as additional explanatory notes of guidance to this list.

Tick if Signature of admitting

NO. Action completed Nurse
or N/A
1 MDT review/ pre-discharge meeting with
• Consultant/ GP
• Social worker
• Carer/ relative (s) with patient consent
2 For doctors: Complete discharge summary
This must include
• Any known physical/ mental health
diagnosis/conditions
• Discharge medication
• Monitoring requirements of the above.
3 Risk to driving ability
• Identify any risk (s) to driving ability
• Inform patient and/or relative/carers of any
risk(s) from medication of diagnosis

4 Pressure areas checked on discharge and

documented

5 Care planning
• Update relevant care plan to reflect discharge
plans
• Update relevant care plans to reflect care
needs

6 Ensure section 5 on social services form is completed

if relevant.

7 Ensure ongoing referrals are completed.

8 Carers/relatives
• Carer/relatives informed of discharge plans,
with patient consent.
• Keys available
• Food available
9 Medication
• TTO medication received on ward and given to
patient
• Medication leaflets given to patient/carer
10 Mental Capacity Act/ DoLS assessments for patient
who lack capacity – actions completed
This would read better as:
If patient subject to MCA and DoLs update team re
patients discharge (Inform MH Law Office)

Page 51 of 58
 Tick if Signature of admitting
NO. Action completed Nurse
or N/A
11 Personal belongings and valuables returned to patient

12 Date discharge letter sent to GP (must be within 7

days of discharge)

13 Last entry made in notes inclusive of time of discharge

14 Discharge recorded in relevant electronic patient

record system (S1 or hand held document.)

15 If this patient is known to SALT- SALT advice on ward

sent home with patient

If known to SALT- inform SALT of discharge

Page 52 of 58
APPENDIX 8

Community midwife:
On-call midwife:
No baby movement?
Vaginal bleeding?
Care of the pregnant patient

On admission: On-call midwife!

☐ Ensure pregnancy is confirmed (midwife or blood test).
☐ Has patient felt baby move in last 24 hours? – If not call on call midwife.
☐ Ensure patient has a community midwifery team and referral to obstetric consultant
led care.
☐ Read electronic pregnancy notes and document particulars in care plan and notes.
☐ Record specific risks identified by community midwifery team in notes.
☐ Urinalysis; group bloods and regular admission bloods.
☐ Choose room carefully – consider dignity, close to nurses etc..
☐ Consider level of observations and document rationale; start MEOWS chart.
☐ Request previous pregnancy summaries from the obstetric service if applicable.
☐ Contact PMVA team to inform a physical intervention management plan and
document clearly.
☐ Record nature and dates of all upcoming appointments/investigations in notes and
ward diary.
At 27 weeks gestation:
☐ Devise a management plan (patient preferences, transport arrangements). Have an
emergency plan, and a plan if on leave (also inform community and on-call midwife
when patient is on leave).
At 30 weeks gestation:
Consider transfer to perinatal mother and baby unit. Referral is usually consultant to
consultant.
People to inform (ensure patient is aware of information sharing with these
professionals):
☐ Trust perinatal consultant
………………………………………………...................
☐ Community midwifery team/obstetric consultant
………………………………………………………………….
☐ Health visitor (from 20 weeks)
…………………………………………………………………..
☐ Mental health midwife at maternity hospital
……………………………………………………………………
☐ Named midwife for safeguarding
…………………………………………………………………….
☐ Trust perinatal nurse
………………………………………………………………….
☐ Social care and safeguarding team
…………………………………………………………………..
☐ Pharmacy (to inform prescribing)
…………………………………………………………………….
Once all professionals have been involved, consider inviting relevant parties to a care
planning meeting

Page 53 of 58
 ‘Think Family’ Keeping Children Safe Assessment Tool
a) Does the service user live in a household where there are children? Check Records
Yes No if no go to question b)

Please specify relationship :

Where there are children in the household please specify their age if known:
Name of Child Date of Birth Gender

b) Does the Service User have contact with children (not living in the same household) from
previous relationships?
Yes No if no go to question c)

If yes, please specify:

If no and there are children from a previous relationship, is it likely that the contact will be resumed;

c) Does the service user have significant contact with other children? For example, children within
extended family circumstances or children outside the family relationship?
Yes No

If yes please specify;

If no to all the above questions then no further action is needed with the form. Save copy in
patient notes

Family and Environmental Factors

Does the Service User experience any family and environmental difficulties that could impact on their
ability to care for children? Yes No

Please use this space to support your assessment outcome. Possible factors: Family Functioning,
Wider Family and Relationships, Housing, Employment, Income/Financial Difficulties, Social
Integration, Access to Community Resources

Page 54 of 58
Parenting Capacity

Consider the outcomes of the Adult Assessment. Can the Service User demonstrate their ability to care
for Children or do they require any additional support with parenting?

Yes No

Please use this space to support your assessment outcome. Indicators: Dependency of Child upon
Adult (consider age factors), Ability to provide Basic Care, Ensuring the Safety, Emotional Warmth,
Stimulation, Guidance and Boundaries and Stability

Child Developmental Needs

Does the information gathered so far suggest that there could be identified difficulties with the child’s
developmental needs? Yes
No

Please use this space to support your assessment outcome. Indicators: Potential Poor Health
Outcomes, Lack of Education, Emotional and Behavioural Development, Identity, Family and Social
Relationships, Social Presentation, Self Care Skills

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Domestic Abuse

Are there any factors of domestic abuse impacting on any known children? Yes No

Please use this space to support your assessment outcome. Document what you know.

Substance Misuse

Have any concerns been identified in relation to substance misuse? For example, drug and alcohol use
that may impact on daily functioning, offending behaviour, the care and wellbeing of children. Is the drug
use by the parent: Experimental? Recreational? Chaotic? Dependent?

Yes No

Please use this space to support your assessment outcome. Indicators: Impact on social,
physiological, psychological, and economical factors such as poor mental and physical health,
domestic abuse, criminal activity and associated peers

Mental Health, Delusional Ideations and Suicide Planning

Does the risk assessment profile indicate delusional beliefs involving children?

Yes No

Does the risk assessment profile (or any additional risk assessment tools used) indicate suicidal ideation
and or a suicide plan involving children?

Yes No

Are there any other mental health concerns which may impact on the service user’s ability to care for
children?

Yes No

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Please use this space to support your assessment outcome, taking into account what you know from
other risk assessments.

Current Risk/Need Status score =

Analysis =

Action =

The outcomes of the Keeping Children Safe Assessment will help you to summarise and inform your
decision as to whether additional support and services is required. It should also clearly explain the
identified risks. The recommendations and actions of the professional completing the Keeping Children
Safe Assessment Tool should be determined against the risk/need ratings below5. This will assist in
identifying the most appropriate referral pathway. In developing this guidance the following outcomes
have been determined to identify risks/need:

Current Risk/Need Status

0 = No Apparent Risk/need. No history or warning signs indicative of risk to children and no apparent
additional needs.

Outcome: No Further Action Required

1 = Low Apparent Risk/need. No current behaviour indicative of risk to children but person’s history
and/or warning signs indicate the possible presence of risk and additional needs for the children.
Necessary levels of screening/vigilance covered by standard current adult support/care plan and ongoing
review arrangements. Advice can be sought from the trust Safeguarding Children Team, and where
addition needs are apparent a referral may be appropriate.

5The numeric score is a simple indicator e.g. Zero (0) is a very low or nil concern, whereas a greater
number is an indication of a higher level of concern.

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Outcome: Support within Adult Services with relevant monitoring and identification of additional
needs with appropriate information sharing with consent and referral if required to Early Help
Assessment.

2 = Significant risk/needs. Person’s history and current presentation indicate the potential of risk to
children or the need for additional support and this is considered to be a significant issue. Additional
Support should be explored to minimise any risks.

Where Significant Risk/need a telephone conversation with Children’s Social Care should take place to
determine appropriate interventions and course of action to prevent risk escalating and meet additional
needs through team around the family. A copy of the Keeping Children Safe assessment Tool should be
shared.

Outcome: Advice should be sought from the Safeguarding Children Team or via Children’s Social
Care to determine appropriate course of action. Consider discussion with CPFT safeguarding
children team 01733 777961

3 = Serious Apparent Risk. Circumstances are such that potential risks to children are apparent and
referral to Children’s Social Care is required.

Where Serious Apparent Risk is determined an initial telephone consultation with Children’s Social
Care should take place and any referral documentation should be completed. The Keeping Children
Safe Assessment tool should be shared with the team and the appropriate course of action determined

Outcome: Contact Children’s Social Care and if appropriate support referral with the Keeping
Children Safe Assessment.

4 = Serious and imminent risk. The person’s history and presentation indicate high need for child
protection and the organisations child protection procedures should be implemented. This will result in a
referral to children’s social care – as a ‘child in need’ or ‘child protection’.

Where Serious Imminent Risk is determined. Immediate action required.

An initial telephone consultation with the Children’s Social Care should take place and any referral
documentation should be completed requiring services to follow their own child protection and child in
need procedures. The Keeping Children Safe Assessment tool should be shared with the team to
support referral and the appropriate course of action determined.

Outcome: Contact Referral and Assessment Team as high priority and support referral with this
Keeping Children Safe Assessment.

MAKING A REFERRAL
IF YOU THINK THAT A CHILD OR YOUNG PERSON IS AT IMMEDIATE RISK OF SERIOUS
HARM CALL THE POLICE (999) OR

CAMBRIDGESHIRE
Multi-Agency Safeguarding Hub
Professionals Number: 0345 045 1362 (Mon – Thurs) 8am – 5:30pm; (Friday) 8am – 4:30pm
Emergency Duty Team (Out of Hours) 01733 234724.
MASH.C&[email protected]

PETERBOROUGH
Telephone: 01733 864170 (Mon – Fri 9am to 5pm).
Emergency Duty Team (Out of Hours) 01733 234724.
[email protected]

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