The National Audit of Violence (2003 - 2005)

Final Report

The Audit Team The Royal College of Psychiatrists’ Research Unit 4th Floor, Standon House 21 Mansell Street London E1 8AA

CONTENTS Acknowledgements

4

Summary and key messages

5

Introduction

Background; participants

6

Methods

The audit standards The audit tools The audit programme The audit reports The audit data

7

Findings

Section 1: The ward/unit

10

• •

•

Environmental comfort Environmental safety Environmental privacy and security

Section 2: Communication systems and ward culture • • • • • • • •

•

Communication between staff Complaints Hand-over systems Staff mix Consensus on care Communication with management Communication with service users Employment status Access to information

Section 3: Staff training, supervision and supports • • • • •

•

•

•

24

Personal experiences of violence Witnessing violence ‘Triggers’ to violence Summoning help

Section 5: The way that violence is dealt with • • • • •

20

Induction training Training for trainers Types of training received Additional training requirements Supervision Support from staff/leadership

Section 4: Experiences of violent behaviour • • •

16

26

Between service users Towards service users from staff Towards staff from service users Use of medication/seclusion to control behaviour Response to alarm calls Reporting/recording incidents

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Final Report

Section 6: Respect, privacy and dignity • • •

•

30

Language Cultural needs Privacy when bathing Respect from staff/maintaining dignity

31

Section 7: Having things to do •

Therapies and activities during the day, evenings and weekends

Section 8: Being listened to and given adequate information • • •

•

32

Access to staff to talk Being ‘wound up’ Decisions re: care & support Information re: status on ward, medication/treatment, advocates, observation, ward management

Discussion

36

Next stages

38

Appendices

1. National guidance and initiatives relevant to safety in in-patient services 2. Contextual data by service type 3. Module 1 national and service type results 4. Environmental audit: overall national findings 5. Environmental audit: national findings by service type 6. Review of violent incidents 7. Good practice from participating wards/units

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39 41 45 59 60 61 65

Final Report

ACKNOWLEDGEMENTS The Audit Team would like to thank the following for helping to make the audit programme such a success. Firstly, the Healthcare Commission for funding the work and supporting us by attending both Introductory and Feedback Events. Special thanks to Rob Chaplin for helping revise the audit tools and helping out at events, and to Sarah King and Jon Hyslop for helping run the Introductory Events. Thanks also go to Alan Quirk for advising on the use of the N6 software and Ben Mango and colleagues from ‘Prospectus’ for setting up the databases that we used to manage the project data. Finally, we would like to name and thank all of the local project leads, without whom, the work would not have been completed: Barnet, Enfield & Haringey Mental Health Trust (Julie Meikle), Bedfordshire & Luton Community Trust (Maggie Nicholls), Bolton, Salford & Trafford NHS Trust (Gary McNamee), Bradford District Care Trust (Debbie Webster), Buckinghamshire Mental Health NHS Trust (Rita Ranmal/Jenny Davis/Jan Newell), Cardiff & Vale NHS Trust (Helen Bennett), Cheshire & Wirral Partnership Trust (Dr Patricia Mottram), Colchester PCT (Adam Stuart-Box), Conwy & Denbighshire NHS Trust (Stuart Mival), Community Integrated Care (Rob Harper), Cottage & Rural Enterprises Ltd (Mark Peel), Derbyshire Mental Health Services NHS Trust (Russell Mason), Devon Partnership NHS Trust (Barbara Lee), Doncaster & South Humber Healthcare NHS Trust (Kevin Bond), East Kent NHS & Social Care Partnership Trust (Lou Bean), 5 Boroughs Partnership (St Helens) NHS Trust (David Parry), 5 Boroughs Partnership NHS Trust (Gail Briers), 5 Boroughs Partnership NHS Trust (Sharon Eid), 5 Boroughs Partnership NHS Trust, (Julie Fay), 5 Boroughs Partnership NHS Trust, (Nick Pym), 5 Boroughs Partnership NHS Trust (Janice Sheath), Gwent Healthcare NHS Trust (Anne James), Hampshire Partnership NHS Trust (Audrey Hanna), Hertfordshire Partnership NHS Trust (Sally Pegrum), Hillingdon Hospital NHS Trust (Dr Haya Al-Mutairi), Hyndburn & Ribble Valley PCT (David McDonough), Isle of Wight Healthcare NHS Trust (Andrew Tate), Lancashire Care Trust (Karen Spencer), Lincolnshire Partnership NHS Trust (Anita Cassidy), Manchester Health & Social Care Trust (Janette Anderson), MCCH Society Ltd (Liz Lowe), Mersey Care NHS Trust (Nicola Beech), Newcastle, North Tyneside and Northumberland Mental Health NHS Trust (Robin Green), Norfolk Mental Health Care NHS Trust (Angie Carty), North Cumbria Mental Health & Learning Disability NHS Trust (Jonathan Comber), North Essex Mental Health Partnership NHS Trust, (Chris Reneham), North Staffordshire Combined Healthcare NHS Trust (Karina Johnson), North West Surrey Mental Health Partnership NHS Trust (Sue Brace), Norwich Primary Care Trust (Edward Johnson), Nottinghamshire Healthcare NHS Trust (Mark Smith), Oxfordshire Mental Healthcare NHS Trust (Jan Newell/Jenny Davis), Oxleas NHS Trust (Shaun Gravestock), Pembrokeshire & Derwen LD NHS Trust (Melanie Handly), Pembrokeshire & Derwen Mental Health NHS Trust (Dylan Williams), Sandwell Mental Health Learning Disability NHS & Social CareTrust (Ken Bascombe), Sandwell Mental Health Mental Health NHS & Social Care Trust (Richard Rhodes), Solihull PCT (Sarah Stonehouse), South Essex Partnership Trust (Daphne McCambridge), South Of Tyne and Wearside Mental Health NHS Trust (David Pratt), South West London & St George's NHS Trust, (Liz Collins), South West Yorkshire NHS Trust (Karen Holland), Suffolk Partnership Trust, (Janet Roper), Swansea NHS Trust (Mandy Rayani), Swindon PCT (Graham Walker), Surrey Hampshire Borders NHS Trust (Mark Trickey), Tees & North East Yorkshire NHS Trust (Phillip Brown), West Sussex Health & Social Care NHS Trust (Liz Fair), West Kent NHS & Social Care Trust (Dr Claude Pendaries).

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Final Report

SUMMARY AND KEY MESSAGES Between December 2003 and March 2005, 265 mental health and learning disability wards/units took part in a national audit programme that supported them to gather systematic data about the ways in which they maximised safety and minimised risk in relation to the prevention and management of violence. The audit focused on individual wards/units and data were gathered from the whole constituency – staff of all types, service users, and visitors. Information collected included more than 6500 anonymised questionnaire returns, which contained over 20,000 lines of comments. Both the factors that cause violence, and potential solutions, are highly individualised. There is no ‘magic bullet’. The audit has offered participating units an insight into particular factors that are either increasing the likelihood that violence will happen, or mean that it will not be managed effectively if it does. Commonly, factors included one or more of the following: • Unsafe environments: the design of many of our wards/units fails to meet many basic safety standards. It is vital that systems ensure staff and service users are fully involved in the design process for every new mental health or learning disability residential unit. Great efforts should be made to upgrade and improve existing wards in ways that optimise safety. • Inadequate staffing: nationally, many services are operating with vacancy factors. This was commonly linked to the on-going drain of experienced staff into higher paid, and often more highly-regarded, community posts. Many in-patient services are being left reliant upon inexperienced leaders. Additionally, many services are experiencing problems recruiting staff and are overly-reliant upon bank and agency staff. Under either or both of these circumstances, it can be hard to build a coherent team than can work proactively to prevent and manage violence. It is vital that the status of in-patient nursing is raised to at least that of community nursing. • Client mix and over-crowding: many acute mental health services are ‘fire fighting’ as they struggle to work with an increasingly unwell population, some of whom will have a dual diagnosis. For many, faced with high bed occupancy figures and inadequate staffing, the delivery of a therapeutic service can become impossible. There are great inequities in staffing levels and skills mix across the country. Action is required for both commissioners and managers to address this. • Substance misuse was identified as the most common trigger for violence. The quantitative data revealed that problems associated with the use of alcohol and illegal drugs were more common in mental health services – particularly Acute, PICU and Forensic services (alcohol was rated as especially problematic in Acute services). More must be done to support staff teams to address the problems caused by the use of alcohol and illegal drugs in in-patient services.

• High levels of boredom: many wards/units are unable to offer service users a structured and therapeutic

system of care. This is linked to low staffing levels and high volumes of paperwork. As well as the obvious link between ‘boredom’ and ‘violence’, this is seen to have an impact on recovery rates for service users, and on job satisfaction for staff. Ways have to be found of supporting staff to spend more time in face-to-face contact with service users – doing the job that they were trained to do.

• Staff training in the prevention and management of violence: significant numbers of staff reported

dissatisfaction with the timing, content, or quality of the training they received. Additionally, and perhaps more concerning, many felt unable to apply the training in real life situations. Training must be tailored to individual needs and more emphasis placed on the prevention rather than the management of incidents. The audit findings indicate, however, that training will only be effective if the other issues described above are also addressed.

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Final Report

INTRODUCTION BACKGROUND Concern about the prevention of violence in health and social care settings, and the adequacy of staff training in its containment and management is not new, and reflects wider concerns about violent crime in society in general. This has been acknowledged at a national level by the Department of Health with the introduction of ‘Zero Tolerance’ and targets for the reduction of violence against health and social care staff, and by an ever-growing number of national bodies, groups, guidance and initiatives that target this area. • The National Service Framework for Mental Health (1999). • National Institute for Mental Health in England (NIMHE): ‘Policy Implementation Guide on Adult Acute Inpatient Care Provision’ (2002). • Mainstreaming Gender and Women’s Mental Health Implementation Guidance (2003). • Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health In-Patient Settings (2004). • The Sainsbury Centre for Mental Health: ‘Breaking the Circles of Fear’ and the National Visit 2 (SCMH 2000, 2002). • The Independent Inquiry into the Death of David Bennett (2004). • The Clinical Practice Guidelines for ‘The Short-Term Management of Disturbed (Violent) Behaviour in Inpatient Settings and Emergency Departments’ (2005). • The ‘Management of Violence’ and ‘Use of Restraint’ Cross-Government Groups. • The NIMHE and National Patient Safety Agency ‘Management of Violence & Aggression’ Project. • The NIMHE Benchmarking Exercise. • The Counter Fraud and Security Management Service. • The C128 Study. • The National Confidential Inquiry into Suicide & Homicide by People with Mental Illness.

(Please refer to Appendix 1 for more detailed information) The Royal College of Psychiatrists’ Research Unit has developed an approach to auditing violence in mental health and learning disability services that has proven popular and feasible with services. In 2003, the Healthcare Commission funded a new phase of data collection.

PARTICIPANTS A mixture of mental health (MH) and learning disability (LD) wards and units took part in the programme. Mental Health: ward/unit ‘type’ Acute (MH) PICU (MH) Forensic (MH) Long stay (MH) Elderly (MH) TOTAL

No. of units

Learning Disability: ward/unit ‘type’ Small Group Home (LD) Challenging behaviour (LD) Long stay (LD) Short stay (LD) TOTAL

120 25 25 14 19 203

No. of units 10 21 18 13 62

Definition of terms

Each ward/unit was categorized into one of 9 service ‘types’. This was done to help them to benchmark themselves against other similar services. The categories can be described as follows: • • •

Acute: any mental health acute in-patient service. PICU: any psychiatric intensive care unit for people with a primary diagnosis of mental heath problems. Forensic: any forensic service for people with a primary diagnosis of mental health problems.

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• • • • • •

Long stay: any long-stay in-patient mental health service not covered by the above e.g. continuing care, rehabilitation wards/units. Elderly: any mental health service specifically for the care for older people (generally over 65 years). Small group home (LD): any small, usually community or non-hospital-based, residential service for people with a primary diagnosis of learning disability. Challenging behaviour: any unit providing support for people with learning disability whose primary problems were associated with challenging behaviour. Long Stay (LD): any hospital-based unit providing long-term residential services for people with learning disability e.g. continuing care wards/units. Short Stay (LD): any hospital-based service for people with learning disability providing short-term residential services e.g. assessment unit wards/units.

METHODS The audit standards • • •

In 1998, the College Research Unit published a guideline on ‘The Management of Imminent Violence’ 1. The Unit has already used standards from the Guideline as the basis for national audit programmes – two in residential services for people with mental health problems, and one in learning disability services. The standards for the audit were revised in close consultation with the Guideline Development Group for the recently published NICE Guideline ‘The short-term management of disturbed (violent) behaviour in in-patient psychiatric settings and emergency departments’ 2.

The audit tools A range of approaches were used to gather feedback from all groups of people who are likely to be affected by violence or the threat of violence, either through residing in, working in, or spending significant amounts of time in wards and units. These approaches gathered different types of information: feedback about people’s experiences of the ways that safety is maximised, and risk minimised; feedback from staff teams about their experiences of managing actual incidents. The ‘unit of analysis’ throughout the programme was the individual ward or unit. • Contextual data: a proforma was used to gather systematic information about the participating wards/units to support bench-marking and networking. • Module 1: an anonymised questionnaire survey for staff, service users3 and visitors to the wards/units. The questionnaires examined the supports that each group received to maximise safety, and minimise risk that a violent incident would occur. Each questionnaire contained a mixture of closed ‘yes/no’ questions, and free text boxes for comments. Local project teams were guided to aim for a response rate of at least 50% from staff, and 20 questionnaire returns from service users.4 • Module 2: an environmental audit where staff and non-staff teams rated the environment against a set of evidence-based standards and agreed ideas for improvement. • Module 3: a series of violent incident reviews, where staff groups worked through a ‘good practice’ framework and agreed an action plan for improving the management of incidents.

The audit programme Once trusts and organisations signed up to the audit programme, they were sent a ‘Project Management Pack’ which detailed the main elements and materials for the programme, including guidance on how to set 1

Wing, J.K., Marriott, S., Palmer, C. and Thomas, V. (1998) The Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services. Occasional Paper OP41. London: The Royal College of Psychiatrists.

2

Ref www.nice.nhs.uk

3

Additional data collection methods, tools and guidance were developed for services where the questionnaire format was unsuitable i.e. interview schedule, discussion group format, framework for observation. 4

If the service was very small and or had a long-length of stay, individual advice was given about adjusting this target. The Healthcare Commission National Audit of Violence 2003-5 Final Report 7

up the project locally. As part of this, they were encouraged to establish a local project team who would oversee the programme of work. It was advised that this team had strong leadership and direct links to its trust board, or equivalent, to ensure that the process of and outcomes from the audit would be supported. The programme began with a series of regional events where these local teams were brought together to learn about the programme and begin planning how they would manage and support it in their own organisations. Contextual data were gathered at the beginning of the programme, collated according to service ‘type’, and circulated to participants to support them to identify possible benchmarking partners. The collection of Module 1 and 3 data ran alongside each other from spring 2004, while a longer run-in time was allowed for Module 2 which took place in early autumn 2004.

The audit reports Reports were sent out at the end of each phase of data collection: • Contextual data: trusts were sent a breakdown of the contextual data for each of their service types, and a copy of the national summary tables (Appendix 2). • Module 1: participants were sent a report based on their local data and a copy of the overall national findings (Appendix 3). Additionally, copies of the results broken down according to service ‘type’ were available on request. • Module 2: each trust/organisation was sent a table detailing their compliance with each standard by each participating unit. In addition, they received a copy of the overall national findings (Appendix 4). Participants also received an analysis of the overall qualitative data, detailing the types of problems people were experiencing, relative to each standard, ideas for improvement, and ‘good practice. Reports of the national quantitative data, broken down according to service ‘type’, were available on request (Appendix 5). • Module 3: the background information about each incident i.e. gender, age, ethnicity of service user, what forms of violence were involved e.g. pushing, hitting - was collated and presented according to service ‘type’ (Appendix 6). Participants also received an analysis of the overall qualitative data, detailing the various interventions that had been identified to address short-falls in practice.

The audit data Module 1 The questionnaire survey generated a massive response. The national report was based upon 6330 questionnaires. The data presented in this report includes an additional 339 returns received after the deadline.

Nursing Clinical 5 NonClinical 6 Service users Visitors Total

5

ACUTE

PICU

FORENSIC

CONT CARE

ELD MH

CB LD

SHORT STAY LD 140 11 9

LONG STAY LD 145 15 13

TOTAL

223 18 11

SM GP HOME LD 86 0 2

1573 361 259

233 18 17

257 55 24

228 29 20

185 40 36

1079

81

109

117

57

58

16

15

28

1560

675 3947

55 404

48 493

90 484

62 380

82 392

16 120

47 222

26 227

1101 6669

3070 547 391

The term ‘Clinical’ refers to any non-nursing member of the multi-disciplinary team.

The term ‘Non-clinical’ refers to any other staff member whose role is neither nursing nor clinical, but whose job brings them into regular contact with the ward/unit. The Healthcare Commission National Audit of Violence 2003-5 Final Report 6

8

In addition to the quantitative data, the comments from the questionnaires generated over 20,000 lines of qualitative data. This data was analysed using N6 software.

Module 2 The local and national results were sent out in January 2005 based upon data received from 187 wards/units. The results presented in this report are based on 194 returns, as tabled below: Acute Rehabilitation/Continuing Care PICU

95 13 12

Forensic Elderly MH Challenging behaviour

19 11 18

Long Stay LD Small Group Home Short Stay LD

11 7 8

Module 3 The local and national results were sent out in February 2005, based upon data received from 119 individual wards/units, as detailed below. Acute Rehabilitation/Continuing Care PICU

47 5 8

Forensic Elderly MH Challenging behaviour

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17 4 15

Long Stay LD Small Group Home Short Stay LD

7 6 10

Final Report

FINDINGS PRESENTATION OF FINDINGS • The table at the beginning of each section relates to the Module 1 national survey data. Each number indicates the percentage of the total number of respondents from each respondent group i.e. nursing staff, service users - who answered ‘yes’, ‘no’, or who failed to answer. • The text beneath each table offers a summary description of the overall trends across the different respondent groups, and between the different service ‘types’ i.e. Acute, Small Group Home (LD). Please note: caution should be exercised in weighting the responses from smaller service type and/or respondent groups (please refer to the table on page 8 for further details). Particular trends that have emerged from the data will be raised in the Discussion section. • Where appropriate, anonymised quotes from the Module 1 have been used to illustrate the themes that came out of the qualitative data. • Additional data has been drawn from the Module 2 Environmental Audit. • As part of events to mark the end of the data collection phase, participants were invited to make ‘good practice’ presentations. Brief descriptions of these have been woven through the findings and are included at Appendix 7. Contact details have been included with the permission of the named individuals.

SECTION 1: THE WARD/UNIT 1.

Environmental comfort

1.1

Is there enough space on this ward/unit? Nursing staff Clinical Non-Clinical Service users Visitors

Yes 50 39 54 68 68

No 48 58 37 30 29

Other 2 3 9 2 3

Over half of Acute nursing staff (n=1573) felt that the space in their ward/unit was inadequate, a worse rating than in all other areas, with the exception of Elderly MH services where almost two-thirds (n=185) expressed dissatisfaction. Across most service user respondent groups, the availability of space was rated by about one-quarter to one-third of people as being problematic, with the exceptions of users of PICU and Long Stay services where greater problems were described (40% and 54% dissatisfaction, respectively). In the Environmental Audit, teams were asked to rate whether the ward/unit met the following standard:

There is a perception of space and overcrowding is avoided. The national compliance rate of 65% was higher than indicated by the responses from the staff questionnaires, and more in accordance with service users and visitors. Although staff were more likely than service users to report dissatisfaction with the adequacy of space, the qualitative data suggested that dissatisfaction was linked to very different problems: for staff, the absence of space was generally linked to overcrowding and poor access to specific areas e.g. interview or activity areas; for service users, concerns were often associated with lack of privacy.

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1.2

Is it usually quiet during the day/during the night? Yes Nursing staff Clinical Non-Clinical Service users Visitors

Day 27 48 48 60 67

No Night 60 37 24 72 -

Day 64 45 40 35 26

Other Night 26 11 9 22 -

Day 9 7 12 5 7

Night 14 52 67 6 -

Levels of satisfaction with daytime noise were consistently low across nursing staff in MH services (ranging from 24% [Acute] to 37% [Forensic]), with Elderly MH services as outliers with only 16% agreeing that it was quiet during the day and 78% disagreeing. Nursing staff in LD services reported very similar levels of satisfaction (26% [Short Stay] to 36% [Challenging Behaviour]). A different picture, however, emerged from service users who in MH services, reported satisfaction levels of one-half to two-thirds for daytime noise levels, compared with about one-third of users of Short Stay and Long Stay LD services. The other members of the clinical team reported satisfaction levels of around 50% in most service types with the interesting exceptions of Short Stay and Long Stay LD services, where their high levels of satisfaction were in direct contrast to the reported experiences of service users. When asked about noise levels during the night, the picture from nursing staff was markedly different with most reporting relatively high levels of satisfaction (61% [PICU] to 78% [Long Stay LD]); Acute and Elderly MH services were the outliers with satisfaction levels of only 56% and 37%, respectively. For service users, night-time satisfaction levels were consistently high at around 75%, with the exception of Long Stay LD who rated their satisfaction at only 36%. The Environmental Audit asked local teams to rate themselves against the following standard:

Noise levels are adjusted to meet the needs of the people living/residing here. Nationally, 71% of wards/units met this standard, which is higher than most questionnaire respondent groups and most similar to the national visitor rate of 67%. Linked to this, teams were also asked to look at compliance with the standard:

There are adequate quiet spaces for patients and staff. Nationally, only 46% of wards/units felt that they met this standard. The discrepancy between compliance rates with these two environmental standards is interesting and perhaps reflects the tension between ‘accepted’ levels of noise, versus ‘desirable’ levels of quiet.

1.3

Does the temperature usually feel comfortable? Nursing staff Clinical Non-Clinical Service users Visitors

Yes 46 62 53 64 70

No 52 36 42 33 27

Other 2 2 5 4 3

When nursing staff were asked about their satisfaction with the temperature of the ward/unit, the biggest problems were experienced in three MH service types: Acute (41%), PICU (36%) and Elderly (35%). For service users, satisfaction levels were relatively high, ranging from 58% (PICU), to 85% (Long Stay LD). Interestingly, non-clinical staff were generally more likely to report dissatisfaction with temperature than their clinical colleagues, perhaps linked to the amount of time being spent in the ward/unit. In the Environmental Audit, teams were asked to rate whether the ward/unit met the following standard:

Ambient temperatures and ventilation area adequately controlled. Nationally, this standard was met by only 39% of wards/unit – even lower than the national nursing compliance rate (46%).

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Large numbers of staff and service users chose to comment on their experiences of the temperature and ventilation in their ward/unit. The most frequent theme was ‘lack of control’, as the following quotes illustrate:

“30°c last summer at night! Noisy water/air coolers that cost a fortune to hire in, do little except make you hot and damp, and disturb the psychotic patients especially.” (staff member from an acute ward/unit) “Heating often broke and not properly regulated.” (service user from an acute ward/unit) “Temperature is either too hot or too cold, never a happy medium” (staff member from an elderly ward/unit)

1.4

Other aspects of environmental comfort

The Environmental Audit looked at a number of other factors that contribute to the creation of a pleasant and comfortable environment. National compliance with these basic standards was often disappointingly low. All areas look clean. All areas look friendly. All areas smell clean. There is natural daylight. There is natural fresh air. The day rooms are open at night for people who cannot sleep. Non-smoking areas are provided and are adequately separated.

2.

Environmental safety

2.1

Is the alarm system on this ward/unit satisfactory? Nursing staff Clinical Non-Clinical

Yes 61 66 68

No 35 18 16

MET 71% 58% 68% 68% 48% 92% 70%

NOT 29% 42% 32% 32% 52% 8% 26%

N/A 0 0 0 0 0 1% 5%

Other 4 16 16

Satisfaction with the ward/unit alarm systems ranged across both LD and MH services, from a low of 44% (Elderly MH) to 83% (Forensic). Equally important, however, were the high levels of dissatisfaction recorded in Acute, PICU and Elderly MH services (41%, 42% and 53%, respectively). Amongst other members of the staff team – clinical and non-clinical – satisfaction levels were fairly consistent and generally more favourable than their nursing colleagues – perhaps indicative of the relative significance each group attaches to having effective alarm systems. Where staff commented on the problems they experienced, these were often associated with systems that did not work effectively, could not be heard, or systems that did not meet the needs of the staff on the ward/unit.

“The alarm system is unreliable and unsafe. There are incidents of it not working and as a result staff have been injured.” (staff member from an acute ward/unit) The Environmental Audit asked teams to consider whether the ward/unit met this standard:

Existing alarm systems are appropriate to the needs of the ward/unit. The standard was met by 62% of wards/units, a finding that was very much in line with the staff questionnaire responses.

2.2

Other aspects of environmental safety

Again, the Environmental Audit looked at additional safety-related standards and again, compliance rates were low: The Healthcare Commission National Audit of Violence 2003-5 12

Final Report

Sight-lines are unimpeded. All exits and entrances are within sight of staff. Doors are easily accessible and can facilitate prompt exit. Inside and outside activity areas are safe. A quiet, low stimulus area is provided. A safe time-out room or 'Extra Care Area' (in addition to the seclusion room) is provided. The selection of moveable objects takes into account of the needs of the individuals living there. The ward size and design is appropriate to the patient population.

MET 34% 44% 73% 77% 59% 32% 84% 48%

NOT 59% 49% 26% 22% 39% 53% 12% 48%

N/A 7% 7% 1% 1% 2% 15% 4% 4%

Good Practice Mersey Care NHS Trust

Contact: [email protected]

•

Audit team allowed protected learning time to support implementation of audit findings; massive improvements to physical environment: early indications of positive impact on staff morale and retention.

Newcastle, North Tyneside & Northumberland NHS Trust (PICU ward) Contact: [email protected]

•

High levels of compliance with environmental standards

Nottinghamshire Healthcare NHS Trust (LD Challenging Behaviour) Contact: [email protected]

•

In spite of having a poor physical environment, staff are able to offer high standards of care and therapeutic input; dignity and respect; staff training in the prevention and management of violence; access to therapies and activities; service users feeling they can talk to staff; service users feeling they are involved in decisions about their care

Oxfordshire Mental Healthcare NHS Trust Contact: [email protected]

•

£30K grant from Kings Fund ‘Enhancing The Healing Environment’ (www.kingsfund.org.uk) matched by £90k from trust Consultation exercise to agree how best to spend the money.

South of Tyne and Wearside Mental Health NHS Trust (PICU) Contact: [email protected]

•

•

Single sex living rooms; seclusion and time out room; adequate quiet areas; activity area; personal alarms for all staff; mandatory C&R training for all staff; stable staff team; good knowledge of service users due to extended length of stay; use of The Sainsbury Centre model of risk assessment; fortnightly group supervision; routine review of violent incidents; routine debriefing following violent incidents, including service user; therapy co-ordinator. Considering creating a prayer/reflection area; piloting use of advance directives.

3.

Environmental privacy and security

3.1

Do you ever have to share space with other members of the opposite sex when you don’t want to? Service users

Yes 23

No 71

Other 6

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Final Report

Service users were asked about whether they ever had to share parts of the ward/unit that were designated for use by their sex only. Across all services types, response levels were encouragingly low, ranging from 0% in Small Group Home LD, to 35% in PICUs. Where problems did exist, some service users took the opportunity to describe their experiences and concerns.

“Separate smoking rooms for men and women would be nice. I feel uncomfortable with some of the men in here.” (Acute ward/unit) “As a female on mixed wards there is always the real danger of other mentally ill people coming into your bedroom at any time of the day.” (PICU)

3.2

Are there enough places where you can spend time in private, for example, with family, friends, or members of staff? Service users

Yes 61

No 34

Other 5

Service users were asked about whether they had access to space where they could spend time in private – for example – to read or spend time with family. In LD services, experiences were generally positive, with only 6% (Small Group Home) to 29% (Long Stay) reporting problems. In MH services, however, dissatisfaction levels were markedly higher, ranging from 26% (Continuing Care) to 47% (PICUs). Again, many service users chose to describe their experiences.

“I hate having nowhere private to sit with visitors or talk on the ‘phone because I feel really uncomfortable when people are listening (regardless of what we're talking about).” (acute ward/unit) “(I am) tired of not having any space - feels demoralising.” (PICU) As part of the Environmental Audit, teams were asked to consider whether the following standard was met:

Adequate private spaces are provided for interactions. National compliance with the standard was 53%, somewhat lower than the national response from service users (61%). This part of the audit also explored other ways in which the environment of the ward/unit did or did not support privacy and dignity for service users. The Environmental Audit asked additional questions that related to specific ‘types’ of private spaces. As can be seen from the tables below, national levels of compliance varied tremendously. MET 62% 32% 37% 95% 34%

Provision is made for children visiting the ward/ unit. There are separate areas for patients with police escorts. There is access to external space that includes a covered area. Sleeping and day areas are separate. Toilet & bathing facilities are clearly labelled.

3.3

NOT 32% 41% 60% 5% 60%

N/A 6% 27% 3% 0 6%

Do you have somewhere secure to store your belongings, for example money, jewellery? Can you get to your belongings whenever you want? Yes Service users

Storage 76

No Access 77

Storage 21

Other Access 18

Storage 4

Access 5

When asked about whether they had somewhere safe to store their personal belongings, the majority of service users felt that this was not a problem. The biggest difficulties seemed to occur in Acute, Forensic and Elderly MH services, where almost one-quarter of people reported that they did not. When asked about ease of access to their personal belongings, the biggest reported problems came from PICUs (29%), Long Stay LD (25%) and Forensic services (24%). The types of problems people described:

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“According to the nurses you are supposed to get a key to your door but in practise this does not happen. Also I had items taken from me.” “I am unaware of any place to store valuables so I keep all my things on me at all times.” The Environmental Audit addressed this issue with the following standard:

Personal effects area safe and accessible. Nationally, 70% of wards/units felt that they met this standard, a similar finding to the national service user response.

3.4

Is there ever trouble on this ward/unit because of people getting drunk/taking illegal drugs? Yes Nursing staff Clinical Non-Clinical Service users Visitors

Alcohol 45 44 30 21 23

No Drugs 53 53 32 24 25

Alcohol 53 44 49 74 65

Other Drugs 45 34 41 69 61

Alcohol 2 12 21 5 12

Drugs 3 13 27 7 14

Alcohol

In general, nursing staff in LD services were unlikely to report that alcohol caused trouble on the ward/unit (1% [Short and Long Stay LD] to10% [Challenging Behaviour and Small Group Home]). The picture from MH nursing staff was more varied, ranging between 3% (Elderly), to 74% (Acute) believing that alcohol did cause problems. The perception of service users was substantially different from that of their nursing staff: while users of LD services were even more unlikely than LD staff to express concerns (0% in both Small Group Homes and Short Stay services, to 9% in Challenging Behaviour services), users of MH services were still consistently less likely than staff in their services to express concerns (7% in Elderly to 26% in Acute services).

Illegal drugs

In LD services, the vast majority of nursing staff agreed that this was not a problem (ranging from 94% [Small Group Home and Long Stay] to 97% [Challenging Behaviour]). This was not the case in most MH services: most extremely, in Acute services and PICUs, 81% and 70%, respectively, of nursing staff agreed that illegal drugs did cause problems. Again, the opinion of services users in LD services was generally in accordance with that of the staff, and in MH services, far smaller proportions of service users expressed concerns about problems caused by illegal drugs compared to nursing staff (7% in Elderly rising to 29% in Acute services). Interestingly, other members of the clinical team from Acute services were far more likely than any other service type to rate alcohol as problematic (61%), though on the subject of the use of illegal drugs, this respondent group also reported problems in PICUs. The negative impact of alcohol and illegal drugs was raised by over one-third of visitors to Acute services.

Substance misuse

The discrepancies between nursing staff and service users can, it would seem, be explained by the qualitative data. Many nursing staff opted to comment on the impact of alcohol and drugs on the safety of the ward. Indeed, the theme of ‘substance misuse’ was the most commonly cited trigger for violence (see section 4). The following quotes illustrate the kinds of problems nurses were experiencing:

“Quite often staff feel very unsafe due to patients going out and returning very drunk or high on drugs. On occasions when there have been no male staff on duty, female staff have been intimidated or threatened by male patients being very out of control.” (staff member from an acute ward/unit) “There is a culture of using drugs and alcohol among the young men. It is almost accepted by staff and little is or can be done to stop it. There is even dealing witnessed on the ward or in the grounds of the hospital.” (staff member from an acute ward/unit) The Healthcare Commission National Audit of Violence 2003-5 15

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Some service users also spoke of their concerns:

“There are too many people taking drugs and alcohol and it should be that those responsible should be segregated from patients that do not take or misuse substances.” (acute ward/unit) “Staff allow people to come back drunk.” (acute ward/unit) The overall picture, however, is that for service users, substance misuse in an annoyance that can impact on the safety of the ward/unit, but that it is ‘separate’ from them. For nursing staff, however, an explicit link is commonly made between substance misuse and violence. The fact that many staff appear unable to manage this threat is often described in terms of feelings of frustration and powerlessness.

Good Practice: South Essex Partnership NHS Trust (Forensic ward)

Contact: [email protected] •

Overall approach is to acknowledge, educate and minimise the impact of substance misuse.

•

Various measures: personal searches; CCTV; police liaison; random search dogs (wards manager decides when needed based on local intelligence; links with substance misuse services (1 WTE substance misuse nurse); links in to MDT meetings; problems of substance misuse are acknowledged and dealt with through health education and health promotion work with service users and staff; breath and urine testing; patient contracts (withdrawal of leave); ‘no alcohol’ policy.

Devon Partnership NHS Trust (Acute service) Contact: [email protected]

•

Mental health awareness attachments with police and shift swaps; local protocols e.g. dealing with service users who are AWOL; if illegal drugs are found in possession, police will caution; if ‘intent to supply’, police will prosecute; good liaison function: on site presence perceived to reduce violence.

Doncaster & South Humber NHS Trust Contact: [email protected] •

Rolling programme with good investment in environment.

SECTION 2: COMMUNICATION SYSTEMS AND WARD CULTURE 1.1

Do you have sufficient opportunities to raise and discuss issues with colleagues on the ward/unit? Nursing staff Clinical Non-Clinical

Yes 77 84 69

No 21 14 2

Other 2 2 10

Across most services types, nursing staff agreed they had adequate opportunities to talk with colleagues (75% [Acute] to 85% [Forensic and Small Group Homes]). Exceptions were Elderly MH services (69%) and Long Stay LD services (61%). Highest levels of dissatisfaction amongst other members of the clinical team were expressed by Short Stay LD services (18%). Amongst non-clinical staff, PICUs stood out as having lowest levels of satisfaction and highest levels of dissatisfaction. Where problems did exist, these were often linked to staff shortages, the ward being busy, and consequent limits on opportunities to meet as a team.

“Continued staff shortages have meant that regular staff/ward meetings are difficult to arrange.” (staff member from an acute ward/unit)

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1.2

Are your complaints taken seriously? Nursing staff Clinical Non-Clinical Service users Visitors

Yes 67 74 62 64 79

No 26 12 19 22 8

Other 7 14 18 14 14

The extent to which nursing staff agreed that their complaints were taken seriously varied relatively little between service types (59% [Elderly MH services] to 74% [Forensic]). Levels of satisfaction were consistently higher amongst other members of the clinical team (70% [Acute] to 93% [Continuing Care]). Interestingly, the spread of responses were very similar between staff and service users (46% [Long Stay LD] to 81% [Small Group Home LD]). For visitors, satisfaction levels were consistently and impressively high (69% [Forensic] to 89% [Elderly MH]).

1.3

Are the hand-over systems on this ward/unit effective? Nursing staff Clinical Non-Clinical

Yes 82 58 39

No 15 18 10

Other 3 23 51

Expressed satisfaction with handovers amongst nursing staff was generally high (77% [Continuing Care] to 86% [PICUs, Challenging Behaviour and Small Group Home services]). The notable exception was Elderly MH services, where only 69% of nursing staff expressed satisfaction and 25% said they were dissatisfied. Satisfaction levels amongst other members of the clinical staff were consistently lower than their nursing colleagues, ranging from 45% (Short Stay LD) to 83% (PICU).

Good Practice Barnet, Enfield and Haringey NHS Trust •

Trying to increase time by 30 minutes to 1 hour; named nurse hands over.

Nottinghamshire Healthcare NHS Trust: Trent Ward (Acute ward) Contact: [email protected] •

Good handover systems; staff spend lots of time with service users; staff feel listened to so they are more willing to listen to service users.

West Kent NHS & Social Care NHS Trust (LD assessment and treatment unit) Contact: [email protected] •

1.4

Using a structured system, designed by unit staff; takes 30 minutes.

Are the numbers, skills, experience, and qualifications of the staff on this ward/unit appropriate to the resident population? Are the gender and ethnic mix of the staff on this ward/unit appropriate to the resident population? Yes Nursing staff Clinical Non-Clinical

No

Other

Skills/experience

Gender/ethnicity

Skills/ experience

Gender/ethnicity

Skills/experience

Gender/ethnicity

56 45 49

71 71 58

40 41 20

25 18 14

3 14 31

4 11 28

When asked whether the numbers, skills and experience, and qualifications of the staff was appropriate for the resident population, the rate of positive responses from nursing staff in LD services was significantly higher than in MH services (63% - 70% in LD, compared with 52% - 65% in MH). Interestingly other clinical colleagues were consistently less likely to agree (38% [Elderly MH and Continuing Care] to 62% [Forensic]). In their comments, many staff referred to problems associated with high turnover, reliance on bank and The Healthcare Commission National Audit of Violence 2003-5 17

Final Report

agency staff, and newly qualified staff being left to run wards/units, as the following quotes illustrate.

“…insufficient numbers of experienced senior staff to act as 'role' models for new members of the team, insufficient trained staff and constant changes within a short time of staff becoming trained.” (staff member from an acute ward/unit) “The full time staff, when working with agency staff, feel vulnerable and incomplete. The staffing levels never appear to be right when agency staff and trained staff are mixed.” (staff member from a forensic ward/unit) In relation to the suitability of the ethnic and gender mix of staff, responses varied more across service types, from 63% in Small Group Homes LD, to 81% in Continuing Care MH and Long Stay LD. Many staff complained about low numbers of male staff: “Male and female ratios not balanced, often not enough men to make unit feel safe.” (staff member from an

acute ward/unit)

1.5

Is there multi-disciplinary consensus on the clinical care of service users? Nursing staff Clinical Non-Clinical

Yes 75 79 46

No 15 12 5

Other 10 9 49

When asked whether they agreed that there was multi-disciplinary consensus on care, levels of satisfaction amongst nursing staff were generally high, ranging from 68% in PICUs, to 90% in Small Group Homes LD. Concordance levels with other members of the clinical team were generally high, with the exceptions of PICUs - where only 47% of the clinical team agreed, compared with 68% of the nursing team. In some services, concerns were expressed by nursing staff that they were not being treated as ‘equal’ members of the team.

“Nursing staff and SHO/RMO often come into direct conflict or disagreement over management of potentially violent individuals which leads to nursing staff feeling undervalued, vulnerable, unsafe and that their professional input is not valid.” (staff member from an acute ward/unit) “Service appears to be predominantly RMO led, sometimes feels only lip service paid to nursing assessments.” (staff member from a challenging behaviour ward/unit)

Good Practice Barnet, Enfield and Haringey NHS Trust •

1.6

Nurses work alongside SHO’s and consultants; CPA is started on admission.

Communication between staff and management

Although staff were not asked specifically about their experiences of support from their management, many chose to comment on the subject. A range of common and concerning themes were expressed, as the following quotes illustrate.

Being listened to “Complaints taken seriously by direct management but seem to be disregarded by top management”. Decision-making “ …overall decisions regarding management of patients/risk situations made at higher management level by person who has not been on the ward and experienced situation first hand.” Expectations “My senior clinical manager told me 'if you want safe, go and work in Safeways’.” “Attitude from management feels like violence is part of the role of the nurse.”

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Final Report

1.7

Do you think that service users feel comfortable talking to staff? Nursing staff Clinical Non-Clinical

Yes 86 82 70

No 8 7 6

Other 6 11 23

The large majority of nursing staff agreed that service users felt comfortable talking to staff (84% [PICU] to 93% [Long Stay LD]). In MH services, other members of the clinical team and non-clinical staff were often less likely to agree that this was the case.

1.8

Would you describe your employment status here as ‘stable’? Nursing staff Clinical Non-Clinical

Yes 81 84 84

No 14 10 8

Other 5 6 8

While the majority of nursing staff described their employment status as ‘stable’ (71% [Short Stay LD] to 91% [Forensic]), it is perhaps of more interest that in five of the nine service areas, over 15% of nursing staff did not agree with the statement.

1.9

Do you have access to a copy of the organisation’s policies on physical interventions? Nursing staff Clinical Non-Clinical

Yes 88 75 52

No 7 15 28

Other 5 10 20

When asked about whether they had access to local policies on physical interventions, most nursing staff said that they did (80% [Elderly MH] to 98% [Challenging Behaviour]). Across all service types, other members of the clinical team were less likely than their nursing colleagues to agree that they had access to the policies (64% Short Stay LD to 89% Long Stay LD). Amongst non-clinical staff, access was consistently lower still – ranging between 46% (Long Stay LD) and 81% (Challenging Behaviour).

Good Practice Doncaster & South Humber NHS Trust Contact: [email protected] •

Robust culture; effective complaints system; organisational commitment to continuing professional development; stable workforce; strong leadership; feedback encouraged.

•

Lots of movement locally between neighbouring services; work with universities to recruit; unqualified posts converted into admin posts to reduce burden of paperwork.

Norwich Primary Care Trust (Medium Secure LD unit) Contact: [email protected]

•

Weekly multi-disciplinary ward rounds where information is fed into daily 1 hour handovers; monthly staff meetings; rotational rota; clinical supervision; monthly service user reviews (clientcentred risk management plans).

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Final Report

SECTION 3: STAFF TRAINING, SUPERVISION AND SUPPORTS 1.1

Did you receive any training in relation to the prevention or management of violence before you began working on this ward/unit? Nursing staff Clinical Non-Clinical

Yes 59 54 22

No 39 43 71

Other 2 3 7

When asked whether they had received training in relation to the prevention and management of violence before they began working on the ward/unit, the response from nursing staff varied across service types, with a range of 34% (Elderly MH) to 72% (Forensic and Long Stay LD) agreeing that they had received induction training. Worryingly, in Elderly MH and Acute services, 63% and 42% (respectively), said they had not. For other members of the clinical team, the numbers receiving induction training were generally lower than for nursing staff, with the exceptions of Elderly MH and Challenging Behaviour services, where they were more likely than their nursing colleagues to have received induction training. The picture for nonclinical staff was very concerning: in MH services, numbers receiving training before being asked to work on the wards/units ranged between only 17% (Elderly services) and 29% (PICUs and Forensic services). In LD services, this was somewhat improved, ranging between 15% (Long Stay) and 55% (Challenging Behaviour).

1.2

Have you received any training in how to train others in relation to the prevention or management of violence? Nursing staff Clinical Non-Clinical

Yes 10 7 3

No 79 83 76

Other 11 10 21

Not surprisingly, the numbers of people who had received the more intensive training in how to train others in the relation to the prevention and management of violence were low, ranging between 8% (Elderly MH and Short Stay LD) and 14% (Small Group Home LD).

1.3

In the past five years, have you received any training that is directly related to the prevention or management of violence? Nursing staff

Clinical

Non-Clinical

Had it? Adequate prevention Adequate management? Had it? Adequate prevention Adequate management? Had it? Adequate prevention Adequate management?

Yes 86 75 74 72 63 47 37 29 20

No 10 19 20 25 27 41 52 41 48

Other 4 6 6 3 10 12 11 29 32

All staff were asked whether they had, in the past five years, had any training that directly related to the prevention and management of violence. For nurses, the response was generally good, with between 79% (Short Stay LD) and 91% (PICUs and Challenging Behaviour services) agreeing that they had. However, the figures in Elderly MH services were concerning, with only 67% of nursing staff saying they had received training and 26% saying that they had not. When asked about whether they felt the training had been adequate to enable them to either prevent an incident from occurring, or manage it effectively if it did occur, the responses showed a similar pattern: satisfaction levels ranged between 71% (Continuing Care and Short Stay LD) to 87% (Forensic and Small Group Home LD) in relation to the prevention of violence, and 64% - 87% (Short Stay LD and Small Group Home LD, respectively) for the management of actual incidents. Nursing staff from Elderly MH services were again the outliers, rating their satisfaction with training at only 50% (prevention) and 43% (management). The Healthcare Commission National Audit of Violence 2003-5 20

Final Report

In relation to overall training, national figures clearly indicate that within a five year period, by far the majority of nursing and clinical staff receive some sort of training in the prevention and management of violence. However, concerns are evident for many about the timing of this training, and for around one-fifth of nursing staff about the effectiveness of the training. Reference to the qualitative data provides some insight as to the problems and the consequences.

“I have been involved in numerous violent incidents and restraints. I have requested training and they have refused it on the grounds of cost. I feel that staff are under a great deal of pressure and are not adequately trained.” (staff member from an acute ward/unit) “Lack of staff training in managing violence leaves staff unaware of what to do.” “Staff are extremely supportive, however, there are often not enough MVA trained people on shift to cover potential incidents.”

1.4

Training received

All staff were invited to indicate what training they had received in relation to the prevention and management of violence. The table below shows the top five training types received across each staff group type. Nursing Control & restraint Breakaway techniques Resuscitation MVA De-escalation

1 2 3 4 5

1.5

(n=1513) 690 478 278 252 129

Clinical Breakaway techniques Resuscitation Control & restraint MVA Risk assessment

(n=349) 176 68 52 28 19

Non-Clinical Breakaway techniques MVA Control & restraint Resuscitation De-escalation

(n=245) 62 16 9 7 4

Additional training needs

All staff were invited to indicate what training they would like in relation to the prevention and management of violence. The table below shows the top five training requested across each staff group type. 1 2 3 4 5

Nursing Control & restraint De-escalation MVA Updates/refreshers Breakaway techniques

1513 152 132 82 77 74

Clinical Breakaway techniques Control & restraint De-escalation Any/all Updates/refreshers

349 44 39 27 14 17

Non-Clinical Breakaway techniques Control & restraint De-escalation MVA Any/all

245 17 10 7 5 4

Good Practice Bradford District Care Trust

Contact: [email protected]

•

2-week programme for all staff runs twice a month; includes theoretical and legal issues relating to PMVA and breakaway training; all staff expected to attend course prior to commencing work; those who require additional training are booked in at recruitment and mentored until training is received; worked successfully with local university to ensure student nurses receive accredited PMVA training.

Lincolnshire Partnership NHS Trust Contact: [email protected]

•

14 in-house trainers; 5 days training within 1 month of starting; use actual incidents to focus content; separate course for non-clinical staff; annual updates unless requested more frequently.

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Norfolk Mental Healthcare NHS Trust •

Board backing for training for all staff; collaboration with UEA, funded by trust; inked to management and clinical governance via risk information systems (trend analysis); pool of permanent training staff plus rotational trainers; trainers act as advisors in ward; 3-day course for less-able staff.

Norwich Primary Care Trust (Medium Secure LD unit) Contact: [email protected]

•

All staff PMVA trained; super-numary until trained; trainers do shifts on ward and advise staff.

Pembrokeshire and Derwen NHS Trust (LD) Contact: [email protected]

•

High levels of exposure to violence, yet excellent scores in relation to training; 5 day induction; emphasis on de-escalation; physical intervention techniques are tailored to the needs of individual service users; training is standardised across social services and Mencap services.

Cardiff and Vale NHS Trust (Acute wards)

Contact: [email protected]

•

Introduced 4-day REACT training (focuses on prevention and de-escalation); staff teams trained together; clear policies; strong communication systems; use of rapid response team.

Nottinghamshire Healthcare NHS Trust (Acute ward) Contact: [email protected]

•

1.6

New training emphasis on prevention and diffusion (Studio 3); initial resistance from some staff, however, incidence of violence has decreased since using this new training.

Do you currently receive supervision? Nursing staff Clinical Non-Clinical

Yes 56 69 29

No 34 24 54

Other 9 7 17

All staff were asked whether they currently received supervision: amongst nursing staff, the bulk of responses ranged from around one-half to three-quarters agreeing that they did. Once again, Elderly MH services stood out with just over one-third saying that they did receive supervision, and 51% that they did not.

Good Practice Barnet, Enfield and Haringey NHS Trust •

1.7

Fortnightly supervision; includes physical interventions; linked to all violent incidents; by same discipline colleague; choice of supervisor; 8 hours protected time per year.

How would you rate your satisfaction with the frequency and quality of supervision that you get? Nursing staff Clinical Non-Clinical

Frequency Quality Frequency Quality Frequency Quality

> Satisfied 47 52 62 63 27 27

The Healthcare Commission National Audit of Violence 2003-5 22

< Satisfied 13 8 7 6 6 6

Other 40 40 31 31 67 67

Final Report

When asked about their satisfaction with both the frequency and quality of supervision, levels of satisfaction amongst nurses were generally high: in relation to frequency, the percentage of the total respondent group that reported they were at least satisfied ranged from between 46% (Acute, PICU and Short Stay LD) and 71% (Small Group Home LD) – with Elderly services standing out with a low satisfaction level of only 28%. On the subject of the quality of supervision, figures were similar, ranging from 48% to 71% (Long Stay LD and Small Group Home LD, respectively). Again, Elderly MH services stood out with a reported satisfaction level of only 31%. With the notable exception of Challenging Behaviour services, clinical staff were consistently more likely to report satisfaction with both the frequency and quality of supervision than their nursing colleagues. The overall impression from comments received was that supervision was generally accessible and well-received, as the following quotes illustrate:

“Supervision set as monthly, but available at request, as I need it, if more regularly required.” “Excellent supervision, all of the team are very helpful in teaching new skills and passing on their knowledge.” There were, however, exceptions where staff complained that supervision was either absent or inconsistent, often due to staff shortages:

“Due to lack of qualified staff, there is not enough time for supervision sessions.”

1.8

In relation to the management of violence, how would you rate your satisfaction with the supports that you get from other staff on this ward/unit? How would you rate your satisfaction with the quality of leadership on this ward/unit? Nursing staff Clinical Non-Clinical

Team Leadership Team Leadership Team Leadership

> Satisfied 86 77 85 76 76 71

< Satisfied 10 17 7 14 7 11

Other 4 6 9 9 17 18

When asked to rate their level of satisfaction with the supports they received from colleagues, nursing staff were generally positive, ranging from between 83% (Short Stay LD) and 99% (Challenging Behaviour LD) with the exception of Elderly MH where only 71% said that they were satisfied and 21% less than satisfied. Amongst clinical staff, a variable picture emerged, with some reporting higher levels of satisfaction than their nursing colleagues, whilst others – notably PICUs and Short Stay LD – rated lower. The qualitative data revealed a strong sense of ‘team’, perhaps borne out of working together in difficult circumstances, as these quotes show:

“The moment any staff anxiety or doubt about a situation is felt, support from fellow staff is sought (advice/help/reassurance).” (acute ward/unit) “We are extremely supportive of each other and all committed to the safety of patients and staff. We discuss better ways of dealing with situations.” (elderly MH ward/unit) However, some staff described situations where the team was unable to provide adequate supports, often attributed to the skills and experience of the team:

“I rely on my staff team. I can work with any varying type of challenging behaviour, but if the staff team is not there and challenging behaviour occurs this is where the team folds.” (long stay LD ward/unit) “I feel unsafe dependant on who I am working with. Most bank staff are unaware of issues in mental health therefore it is often left to you as possibly the only regular staff to try and keep things safe. Continuity of care is so important at night if possible.” (acute ward/unit) “The term "staff" in these questions is a major problem. Staff with relevant experience and training in dealing with violence create safer working conditions. Inexperienced staff with no training can be a liability and leave others at increased risk.” (PICU) When asked about quality of leadership, the response from nursing staff was generally less favourable, with levels of satisfaction ranging from 66% (Elderly MH services) to 83% (Small Group Home LD). The The Healthcare Commission National Audit of Violence 2003-5 23

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qualitative data revealed a number of different problems: unfilled management posts; unsupportive leaders; poor leadership, sometimes linked to inexperienced senior staff but most commonly, to unit leaders being too busy, as the following quote illustrates:

“They seem too busy - too overworked to discuss clinical matters or service development.” (acute ward/unit)

Good Practice Nottinghamshire Healthcare NHS Trust (Acute ward) Contact: [email protected]

•

Strong ethos of mutual support.

SECTION 4: EXPERIENCES OF VIOLENT BEHAVIOUR 1.1

During the time you have been on this ward/unit, have you personally been attacked, threatened, or made to feel unsafe? During the time you have been on this ward/unit, have you witnessed anyone else being attacked, threatened, or made to feel unsafe? Nursing staff Clinical Non-Clinical Service users Visitors

Experienced Witnessed Experienced Witnessed Experienced Witnessed Experienced Witnessed Experienced Witnessed

Yes 78 89 41 62 32 57 36 47 18 33

No 20 8 56 35 62 39 60 49 81 65

Other 3 3 3 3 6 4 4 4 1 2

Staff were asked whether they had experienced or witnessed violence whilst working on the ward/unit. Amongst nursing staff, levels that had experienced violence were consistently high, ranging from 73% (Forensic), to as high as 86% (Short Stay LD). For other members of the clinical team, the range of experience was markedly lower (27% [Long Stay LD] to 44% [Challenging Behaviour services]). The experiences of non-clinical staff were generally better, with the notable exceptions of PICUs, Small Group Homes and Long Stay LD, where levels rose close to half. Amongst service users, a considerable range of experience was evident, from 18% in Elderly MH services, to 64% in Long Stay LD services saying they had. Not surprisingly, but with the exception of Elderly MH services, service users were more likely than visitors to report that they had experienced violence. Some typical descriptions of people’s experiences:

From staff “On many occasions myself and peers have been subjected to threatening abusive assaults. On occasions harassment and actual physical assault.” (staff member from an acute ward/unit) “I personally have been physically attacked on the ward more than once and threatened with physical violence more times than I remember. You begin to accept this as part of the job.” (staff member from an acute ward/unit) “ … many verbal threats seem to be regularly disregarded despite its effect on the victim” (staff member from a forensic ward/unit) From service users “Staff are threatened often and receive a lot of abuse. Staff should be made safer.” (service user from an acute ward/unit) “Whilst I have been here on this ward I have been attacked and it was such a horrible thing to happen and I felt so unsafe.” (service user from an acute ward/unit) “Threats, intimidation and mind games are common, usually between or by the same small group of people.” (service user from an acute ward/unit) The Healthcare Commission National Audit of Violence 2003-5 24

Final Report

When asked about whether they had witnessed violence, rather than being directly involved, not surprisingly all figures were higher, peaking at 95% for nursing staff in Long Stay LD services, 72% for clinical staff in PICUs, 82% for non-clinical staff in PICUs, 68% for service users in Long Stay LD and 40% for visitors in PICUs.

1.2

Can you think of anything that ‘triggers’ violent behaviour on the ward/unit?

Service users and visitors were asked to describe anything that they felt ‘triggered’ violent incidents on their ward/unit. Responses were widely varied, with the top five most commonly cited as follows: 1. 2.

Substance misuse Staff

3.

Space and overcrowding Medication and treatment Frustration

4. 5.

Including: the use of alcohol, illegal drugs, and withdrawal from these substances Including: problems associated with staffing levels, skills, experience; staff attitudes e.g. being patronising, overly custodial; interactions with service users; nature or absence of interventions. Associated with: bed numbers; ward/unit layout; proximity of other people; lack of privacy. Including: side effects; compliance; changes to regimen. Including: external i.e. lack of activities, noise levels; internal i.e. independent of the ward/unit itself, such as frustration about being away from family and friends, lack of visitors.

Other relatively common themes were as follows: • Smoking: lack of cigarettes, overcrowded smoking areas, annoyance at others smoking behaviour. • Excessive noise: both ‘expected noise’, such as radios, people shouting, and ‘unexpected noise’, such as squeaking doors, door bells ringing, other service users being allowed to make noise late at night. • Intimidation by other service users. • Theft of personal belongings. • Temperature.

1.3

Has anyone given you advice on what to do if you see or hear about a violent incident, for example, how to summon help? Would you like to be given advice on what to do? Service users Visitors

Given Wanted Given Wanted

Yes 36 57 40 47

No 57 29 57 18

Other 7 14 3 35

In recognition that they were being asked to spend time in places where there was a threat of violence, service users and visitors were asked whether they had been given advice on what to do if violence did occur. Nationally, only 36% of service users and 40% of visitors said that this had happened. When asked whether they would have liked advice, 57% of service users and 47% of visitors said that they would. Particular problems for service users were evident in Acute and Short Stay LD services.

Good Practice Conwy & Denbighshire NHS Trust (Acute ward) Visitors feeling safe • Welcoming reception area, staffed 8.30am – 8pm; given advice upon arrival; offered alarms and explained how to use them and what assistance to expect if they are used; visible notices in English and Welsh; good safety culture - Use of Wales ‘Passport Scheme’ re: training criteria; flexibility to release staff for training.

The Healthcare Commission National Audit of Violence 2003-5 25

Final Report

SECTION 5: THE WAY THAT VIOLENCE IS DEALT WITH 1.1

Do you think that staff deal well with threatening and violent behaviour between service users? Do you think that staff deal well with threatening and violent behaviour towards service users from staff? Do you think that staff deal well with threatening and violent behaviour towards staff from service users? Nursing staff

Clinical

Non-Clinical

Service users

Visitors

Between service users Towards service users Towards staff Between service users Towards service users Towards staff Between service users Towards service users Towards staff Between service users Towards service users Towards staff Between service users Towards service users Towards staff

Yes 90 66 83 85 58 81 82 65 78 75 63 72 76 60 70

No 6 7 10 4 7 6 4 4 4 12 15 12 4 5 5

Other 4 27 7 11 35 13 14 31 18 13 22 16 20 35 25

All respondent groups were asked to rate how well they felt that violence was being managed on their ward/unit.

Violence between service users

Responses from members of the nursing team were consistently high, with agreement ranging from between 84% (Elderly MH) and 95% (Forensic). Feedback from other members of the clinical team were similar, with a range of 72% (PICUs) to 100% (Challenging Behaviour LD and Long Stay LD), and the non-clinical team (66% [Elderly MH] to 100% [PICUs, Small Group Home LD and Long Stay LD]). Amongst service users, opinion was more varied, ranging from 46% (Long Stay LD) to 93% (Short Stay LD).

Violence by staff towards service users 7

The way respondents answered this question was ambiguous. Many commented that the answer ’yes’ implied that staff were acting in a threatening or violent way towards service users. For this reason, a large proportion chose to leave the answer blank. Perhaps the most reliable indicator therefore was the percentage of respondents who answered ‘no’, thus indicating that this type of violence was not being managed effectively: for nursing staff, this figure was consistently low, ranging from between 3% and 27%; amongst other members of the clinical team, figures ranged between 0% and 19%; for non-clinical staff, between 0% and 46%; for service users, between 5% and 27%, and; for visitors, between 0% and 15%. These findings should, however, be interpreted with caution. Despite giving all respondents the opportunity to add anonymous comments, very few service users described actual incidents that had occurred. Indeed, many were keen to stress that this type of behaviour did not occur, as the following quote reveals:

“I have never observed staff being threatening or violent towards service users.” Additionally, many staff took the opportunity to virulently oppose the suggestion that violence towards service users by staff was tolerated:

“If a member of staff was threatening/violent towards staff or patients I have confidence they would not be working on the ward any longer.” (acute ward/unit)

Whilst many services actively objected to the inclusion of this question, service users insisted that the opportunity be given to expose any behaviour of this type that might be occurring. The Healthcare Commission National Audit of Violence 2003-5 Final Report 7

26

“Any threatening and violent behaviour by any nursing staff would be dealt with immediately, including said staff removed immediately, however I personally have never met a threatening member of staff.” (PICU ward/unit) Violence towards staff by service users

Members of the nursing team consistently rated this highly, with between 76% (Elderly MH services) and 88% (PICUs and Challenging Behaviour LD) answering ‘yes’. Other members of the clinical team gave a similar range of responses, from 72% (PICUs) to 100% (Long Stay LD), and non-clinical staff from 67% (Forensic) to 100% (PICUs, Small Group Home LD and Short Stay LD). Service users were less satisfied with the management of violence towards staff, with levels ranging between 43% (Long Stay LD) and 88% (Challenging Behaviour LD). Examination of the qualitative data indicates that amongst staff, many feel that their colleagues are doing all that they can to protect each other.

“I feel staff here are far more skilled nowadays when dealing with violent incidents/or appear to calm the situation down very quickly and effectively with good teamwork/communication skills.” (staff member from an acute ward/unit) Where opinions differ, this is often linked to staffing issues, such as low staffing levels, inexperienced/ untrained staff. As illustrated by the following quotes:

“Due to occasional faulty alarm system and shortage of staff the support you get from other staff during a 'violent incident' is not always satisfactory and the situation is normally dangerous for both staff & patients.” (staff member from an acute ward/unit) “It must be highlighted that the usage of agency staff on secure units dealing with mentally unfit people is, in my opinion, inappropriate. They have not had any training such as C&R and when it is needed these people are at a loss.” (staff member from a forensic ward/unit) “Although the skills, experience and qualifications are appropriate, numbers are lacking. In some cases when panic alarms have been activated there has been no-one to answer them.” (staff member from a long stay LD ward/unit)

1.2

Do you think that staff threaten to use medication or ‘seclusion’ to control service users’ behaviour? Nursing staff Clinical Non-Clinical Service users Visitors

Yes 30 24 31 48 30

No 61 56 34 36 43

Other 9 20 35 16 27

All respondent groups were asked whether they felt that the threat of medication or seclusion was used to control behaviour. A relatively high percentage from all groups agreed that it was. Amongst nursing staff, between 23% (Challenging Behaviour LD) and 35% (PICUs) agreed that it was. Responses from other members of the clinical team ranged more widely, between 11% (Challenging Behaviour LD) and 45% (Continuing Care MH). With the exception of Elderly MH services, service users were consistently far more likely than nursing staff to agree that this happened. Once again, it is the qualitative data that lends some insight to the problems experienced. Many staff explained that medication and seclusion are used only as part of a treatment plan:

“I think 'threaten' is a contentious/provocative use of language - patients are informed of the choices available in the management of their behaviour.” (acute ward/unit) “Patients are never threatened, they are encouraged to take oral medication; team approved methods or intramuscular medication are used as a last resort; seclusion has not been used for 2 years.” (PICU ward/unit) Of those staff that did agree that this was a problem, some described how they felt there was often no alternative. The Healthcare Commission National Audit of Violence 2003-5 27

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“Medication is often the only option felt to be available. There is a desperate lack of experienced staff on the ward. The staffing levels are not adequate to deal with aggression that we face.” (staff member, acute ward/unit)

1.3

Is the way that staff respond to alarm calls agreed and applied consistently? Nursing staff Clinical Non-Clinical Visitors

Yes 75 73 72 57

No 16 6 5 7

Other 9 21 22 36

Nationally, around three-quarters of all staff respondent groups felt that the response to alarm calls was agreed and applied consistently. Where this was not the case, some respondents commented on their experiences, citing poor alarm systems, low staffing, and poor co-ordination of response as factors.

“The alarm system goes off and no-one knows exact location of problem.” (acute ward/unit) “Attack alarm activated. Four alarms pulled not one worked. Therefore long delay in anyone responding to the attack.” (acute ward/unit) “Staffing can sometimes hinder response to alarm calls.” (long stay ward/unit) “On a few occasions there has been a substantial delay from the neighbouring unit (upstairs) and on one occasion at least, no response at all.” (PICU)

1.4

Are all incidents of threatening behaviour or violence reported and recorded? Nursing staff Clinical Non-Clinical

Yes 71 53 59

No 22 16 9

Other 7 31 32

Nurses were more likely than other members of staff to state that all violent incidents were reported. Consistently lower compliance rates were, however, evident across three service types - Acute, Elderly MH and Short Stay LD. Two broad reasons were given as to why under-reporting was happening: acceptance that violence is seen as ‘part of the job’; volume of incidents and consequent paperwork.

“Violent incidents are reported however certain degree of complacency surrounding threatening behaviour has been accepted as 'part of the job'”. (staff member from an acute ward/unit) “If all incidents were to be recorded staff would again have patients contact time reduced due to increase paperwork.” (acute ward/unit)

Good Practice Buckinghamshire Mental Health NHS Trust (PICU) Contact: [email protected]

•

Staff are motivated in terms of safety; advocate works with staff team; post-incident debriefing; ‘body map’ used post incident to record which staff did what; individual performance is fed back through team meetings; if staff cannot carry out C&R effectively after being trained, they are sent back for more training; if unable to learn, they will be moved from the ward/unit.

Mersey Care NHS Trust

Contact: [email protected]

•

Reviews of violent incidents now carried out routinely using Module 3 audit tool.

Tees & North East Yorkshire NHS Trust (Forensic services) Contact: [email protected]

•

Well-established security culture; good balance between therapy and security: low boredom (choice of therapies on and off the ward; training induction for all new staff; support for staff

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(buddy system); mentor package; good supervision; do not use bank or agency staff (use over-time); good policies and procedures. Devon Partnership NHS Trust (Forensic services) Contact: [email protected]

•

Risk assessment system: Generic Integrated Risk Assessment For Forensic Environments (GIRAFFE: www.GiraffeOnline.co.uk).

•

Initial risk profile created; collates incidents; can produce graphs showing frequency of different types of incident.

Sandwell Mental Health NHS & Social Care Trust (LD and Adult services) Contact: [email protected] •

Philosophical approach (based on NICE guidelines); Attitudinal: core values of dignity and respect are interwoven; Organisational: safety is the lever behind policy and practice; Situational: reasons/stresses towards violence are addressed; Environmental: making sure it’s safe.

South West London & St George’s NHS Trust (LD service) Contact: [email protected]

•

De-briefing is structured; GRAPHITE software used to analyse incidents and risk behaviour; 22 month programme to collect systematic data which was used in a number of ways - to develop personal management plans for service users; to identify high risk situations/times; to highlight linkages between internal and external factors.

Newcastle, North Tyneside & Northumberland NHS Trust (Acute Ward) Contact: [email protected]

•

Routine review of violent incidents; team liked having a structured framework; encouraged teams to think proactively; helped identify cultural differences in relation to managing violent incidents which have fed into training needs.

Forensic Unit • • •

Violence is dealt with well due to good recruitment and retention; focus on staff nurses; attract students; good links with university; use of job fairs; carrot - will be moving to a new build in the near future. Additional associated factors include good training and supervision with quality and frequency; strong leadership; 50:50 qualified to unqualified staff; bank staff are offered training in the prevention and management of violence (though not paid for their time). Service users reported they felt treated with respect.

Nottinghamshire Healthcare NHS Trust (High Secure LD treatment ward) Contact: [email protected]

• •

Reduction in incidence of violence; reduction in use of seclusion; ward is free from alcohol and illegal drugs Associated with all nursing staff inducted in the management of violence before beginning work on the ward (clinicians get training soon after); strong ward team (good communication); strong team support; mutual respect between team members; advocate on ward; good supports for user involvement: ward representative elected by service users; regular, minuted community meetings; person-centred planning.

Acute ward •

De-briefing after most incidents; established policy (10/15 years old); all staff (qualified and unqualified).

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SECTION 6: RESPECT, PRIVACY AND DIGNITY 1.1

Are staff on the ward/unit able to speak your language?

Service users

Yes 90

No 8

Other 2

With a national compliance rate of 90%, the biggest problems were encountered in PICUs and Continuing Care services. Where problems did occur, these were generally associated with languages not being spoken or staff not understanding service users’ accents.

Good Practice Mersey Care NHS Trust

Contact: [email protected] • Use of ‘Language Line’ with service users whose first language is not English; available in 52

languages; www.languageline.co.uk.

1.2

Are your particular cultural needs respected on the ward/unit e.g. religious festivals, diet?

Service users

Yes 78

No 12

Other 10

In general, around three-quarters of service users reported that their cultural needs were being met. However, this figure was exceeded in both Elderly MH (91%) and Short Stay LD services (86%). Where problems were evident, these were often associated with not being supported to meet their religious or dietary needs.

1.3

Do you have privacy when using the toilet, washing and bathing/showering?

Service users

Yes 87

No 10

Other 3

With a national compliance rate of 87%, the area of concern of particular concern was Challenging Behaviour services, where 19% of services users disagreed that this standard was being met. Examples of the types of problems people experienced included.

“When dressing and undressing/washing…only woman should use the door viewer. Men should not look in woman’s rooms including the male staff.” (service user from an acute ward/unit) “Staff enter bathroom unannounced.” (service user from an acute ward/unit) “I feel there should be separate shower areas and toilet areas for male and female.” (service user from an acute ward/unit) In the Environmental Audit, local teams were asked to consider whether the ward/unit met this standard:

Privacy in toilets and bathrooms is ensured. Nationally, 82% agreed that it was – a similar compliance rate to the individual questionnaires.

1.4

Do you think staff treat you with respect? Have you felt able to maintain your dignity during your stay? Yes

Service users

Respect 80

No Dignity 76

Respect 14

Other Dignity 18

Respect 6

Dignity 6

Nationally, four-fifths of services agreed that they were treated with respect. Where this was not the case, a variety of factors were cited.

“I feel that when a patient is having a one to one with a member of staff that an allocated counselling room is available as it's very disruptive when different members of staff walk in and out. And when the staff are The Healthcare Commission National Audit of Violence 2003-5 30

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having handovers they expect not to be disturbed. Double standards? It seems like, and lack of respect for the patient.” “Some staff treat me with respect. They rule, we don't. Staff are in charge, we are not equal.”

Good Practice Doncaster & South Humber NHS Trust (Acute services) Contact: [email protected]

•

Adequate space; active user and carer involvement at all levels, including staff MOV training; access to staff (ward closed for 4 hours per day); use of language: strong, senior lead for staff to use respectful language.

MCCH Society Ltd (Small Group Home LD services) Contact: [email protected]

•

Staff induction in the organisations philosophy - embedded in culture and enacted through example; NVQ unit on the subject; person-centred planning used; user involvement community groups.

West Kent NHS and Social Care Trust (PFI Forensic Unit) Contact: [email protected]

•

Safety of possessions; culture respected; privacy; provision of information about the unit; management of violence; high compliance with environmental standards

•

Associated with: Single floor purpose-built unit; high staffing levels; budget for additional therapies; twelve week post-discharge outreach service

SECTION 7: HAVING THINGS TO DO 1.1

Are you satisfied with the choice of therapies and activities that are available to you during the day/during the evening/at weekends?

Service users

Day 59

Yes Even 45

Weekend 39

Day 35

No Even 48

Weekend 52

Day 5

Other Even 7

Weekend 9

Service users were asked about their satisfaction with activities during the day, evenings and at weekends. With a national compliance level of less than 60% for daytime activities, dropping to 45% during the evenings and to less than 40% at weekends, problems were apparent. The services reporting highest levels of dissatisfaction were PICU and Long Stay LD. The Environmental Audit asked local teams to rate whether the ward/unit complied with the following standard:

There are activity areas inside and outside. Although the national compliance with this standard was 79%, the qualitative data revealed that the presence of a specified area does not always equate with activities taking place. Large numbers of service users commented on their experiences.

“There are too few sessions available Mon-Fri, sometimes cancelled with no notice and then no information as to the situation.” “I get bored stiff. Only option seems to be TV or sleep.” “Evenings and weekends stretch out before you, with no organised activities on offer and effectively a weekend lasts from Friday lunch to Mon 2.30pm because there's no OT.” “There is nothing to do here at all, except watch TV. The art room has lots of paint but no paintbrushes. I find boredom gives me far too much time to think which doesn’t help the depression.” The Healthcare Commission National Audit of Violence 2003-5 31

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Many people suggested activities, ranging from aromatherapy and hairdressers, to exercise and bingo. The overall message seemed to be that services need to try to respond to the individual activity needs of their service users.

Good Practice Community Integrated Care

Contact: [email protected]

•

Person-centred philosophy of care nurtures the individual; generous monies and resources available via S117 aftercare and mobility component of DLA; staffing levels and skills mix appropriate to the needs of the service users; easy access to community resources.

Doncaster & South Humber NHS Trust Contact: [email protected]

•

Out-of-hours activity sessional workers: some evidence of decrease in staff sickness, boredom levels and incidence of violence.

5 Boroughs Partnership NHS Trust (Acute services) •

Developed and implemented strategy to improve patient experience comprising of multiprofessional and multi-agency advisory group; two new activity staff members; visits from mobile library • Early stages of a sports initiative subject to the release of further funding; hope to receive sessional input for weekends and evenings in the hospital gym. Newcastle, North Tyneside & Northumberland NHS Trust (Acute Ward) Contact: [email protected]

•

Have a ‘gym buddy’ scheme, where volunteers accompany service users to a local gym.

Mersey Care NHS Trust

Contact: [email protected]

•

Staff members seconded to OT Department; nursing staff given protected time and space to carry out activities with service users.

Suffolk Mental Health Partnership NHS Trust (Acute ward) Contact: [email protected]

• • • •

Pre audit: low morale; high turnover. Refocusing project: focuses on what CAN be done. Reduced perceived triggers for violence; identified 24 ‘quick wins’. Outcomes: reduction in incidence of violence; reduction in absconding. Examples of initiatives: activities now available until 8pm.

SECTION 8: BEING LISTENED TO AND GIVEN ADEQUATE INFORMATION 1.1

Are you able to speak to staff when you need to, for example, if you are concerned or upset?

Service users Visitors

Yes 80 90

No 15 6

Other 5 4

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A relatively high 80% of service users reported that they were able to speak to staff when they needed to.

“The staff are brilliant when you have a problem with anything and they help you to sort it out.” “Staff have made it clear that I can approach them at any time.” Where problems were experienced, these were often associated with staff being ‘too busy’.

“Staff are often very busy, it is sometimes difficult to talk when required, staff have never deliberately refused to talk.” “Sometimes lack of staff can cause problems, not enough attention for patients who are in need of advice, or an ear to listen to their problems.” The impact can be significant, as one service user describes:

“I'd really like the staff to approach me and ask me how I'm feeling when I'm upset/down because that's when I really need to talk but I'm not able to tell them…at home at least you're on your own so it is okay but to be surrounded by people who should be helping you but actually ignore you is far worse than being alone.”

Good Practice Oxfordshire Mental Healthcare NHS Trust Contact: [email protected] •

Small nursing office: engagement, rather than paperwork; have moved away from an ‘observation’ model; have introduced ‘protected therapeutic time’: 1 hour per day when visitors and calls are not allowed. Very well received.

•

OASIS Project starts April: qualified staff have been increasing their skills base e.g. CBT, care planning; unqualified staff will deal with paperwork associated with running the ward, leaving qualified staff to spend time with service users.

1.2

Do staff ever ‘wind you up’?

Service users

Yes

35

No 59

Other 6

Visitors

12

73

15

Nationally, 35% of service users reported that they had felt ‘wound up’ by staff. At the outliers were Small Group Homes, where only 6% felt this was a problem, and Forensic services where 46% did. These were the types of situations people described:

“Staff wind me up by shouting at me and others instead of walking up to them and talking properly (we're not dogs!).” “Staff are very rarely violent towards service users. They instead use the power that they have to deliberately wind up or antagonise a patient.” “They wind me up sometimes when they don't do their jobs the way they should and perhaps reading or watching TV when they could be doing something more to help the patients out.”

1.3

Are you satisfied with your involvement in decisions about your care and support?

Service users

Yes 65

No 29

Other 6

Almost 30% of service users were not satisfied with their level of involvement in decisions about their care and support. In PICUs, this figure rose to an alarming 41%. Many service users chose to comment on this subject, some citing examples of good practice around information leaflets, notice-boards, and staff being receptive to questions. This was not, however, the case for everyone. The Healthcare Commission National Audit of Violence 2003-5 33

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Accessibility: “You have to be forceful and most aren't. They suffer. If you ask you get … information is not volunteered and is often misunderstood.” Control: “Often you find yourself 'second guessing' what the care plan is - the reasons why some things are being done. Often feel as though you do not have much choice i.e. you are officially informal but if you want to leave you will be sectioned. This is often very intimidating and leaves you confused as to what you rights are/where you stand.” Timing: “When you come in you’re told a lot of things but how do they expect you to hear if you are ill.”

1.4

Have you been given enough information about why you are on this ward/unit?

Service users

Yes 67

No 26

Other 7

A similar response was given to a question about the provision of information about why they were on the ward/unit, with around two-thirds expressing satisfaction. A plea from a service user:

“I would like if someone sat with me and explained why I had to be looked after on this ward.”

1.5

Have you been given enough information about the medication and treatments that you are being given?

Service users

Yes 62

No 31

Other 7

Levels of satisfaction relating to information about medication and treatments were lower, particularly in PICUs and Long Stay LD services. While many explained that they had been given adequate written and verbal information, this was not everyone’s experience, as one service user explained:

“Regardless of how a patient may be anticipated to react from finding out, a patient should always have the right to know about the medication that said patient is being compelled to take ESPECIALLY if that medication is being administered forcefully and if the patient doesn't need to take it, being non-sectioned.”

Good Practice Norfolk Mental Healthcare NHS Trust •

1.6

Pharmacists have produced a handbook of ‘questions and answers’ relating to medication; medication education sessions are held weekly.

Have you been given enough information about how to get advice or help from someone who does not work here, for example, an advocate?

Service users

Yes 59

No 33

Other 8

Figures relating to the provision of information about advocacy services were even lower, particularly in Elderly MH and Long Stay LD services, though few service users chose to comment on the subject.

1.7

Have you been given enough information about how closely you are observed or watched by the nursing staff?

Service users

Yes 54

No 38

Other 8

In relation to the information about observation, national satisfaction dropped to just over half, though again, few service users commented on the subject.

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1.8 Have you been given enough information about how the ward/unit is run? Service users

Yes 68

No 25

Other 7

Levels of satisfaction with the provision of information about how the ward/unit was run were consistently higher, with the exception of Long Stay LD services, though again, the issue about the timing of the delivery of information was raised.

Good Practice Bedfordshire & Luton Community Trust (Acute service) Contact: [email protected] •

Organisation of ward rounds: focus groups held in 2000 to identify standards for ward rounds; checklist devised for pre-ward round; subsequent audit demonstrated effectiveness of improvements.

5 Boroughs Partnership NHS Trust (Specialist MH) •

• •

Service user involvement in decisions; information regarding admission, medication/treatments, how to get help, ward routine. Associated with retention of core staff team; clear roles/responsibilities; information booklets; service user meetings including routine for the day; community meetings resolve problems. Further developments to include independent advocacy; service user/carer involvement in acute care forums; care pathways for service users and carers; implementation of protected therapeutic time.

Solihull PCT (LD Small group homes) •

Good results associated with person-centred planning; Use of ‘Me and My life’ books; DVD recently produced based on ‘Valuing People’ (government white paper): looks at effective ways to provide service users with choices, rights, inclusion and independence.

Oxleas NHS Trust (Learning Disability)

Contact: [email protected]

•

Have developed and are piloting a format to assess service users’ capacity to give consent; increased user involvement in both proactive and reactive care; more training needed.

Suffolk Mental Health Partnership NHS Trust (Acute ward) Contact: [email protected] •

Examples of initiatives: concept of ‘purposeful admission’; focused work with service users; maximum length of stay is 14 days; admission is based upon a planned programme of therapy; comprehensive pre-admission information, plus ward resource pack.

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DISCUSSION The Guideline which underpins the audit programme reflects the depth and complexity of the subject area. The programme has engaged 265 mental health and learning disability units in a protracted process of auditing themselves against standards drawn from the guideline. From the findings, it is clear that there is widespread variation in both the frequency and severity of violent incidents – both between and across different service types. It is also clear that the combination of factors that increase the risk of violence, and/or decrease the likelihood that an incident will be managed effectively, are highly individualised. There is no ‘magic bullet’. However, through their participation, units have gathered broad-based insight into their own areas for improvement.

Variation between services of different type A number of trends were apparent within services of the same type. • Good practice in learning disability services With the exception of Long Stay services, learning disability services consistently produced higher than national compliance levels for most standards in the Module 1 survey component of the programme. Particular areas of excellence related to the following: space; temperature; privacy in general and in singlesex areas in particular; safe storage of and access to possessions, and; multi-disciplinary consensus on care. It is likely that much of this success can be linked to the small and more homely nature of many of the wards/units. • Concerns relating to elderly mental health services Although the data indicated that the incidence of violence was as somewhat higher than the national average, compliance ratings were markedly lower in relation to many standards, including the following: temperature; alarm systems; communication with colleagues; support from colleagues in relation to managing violent incidents; handovers; all training relating to the prevention and management of violence; supervision; leadership; satisfaction with the management of all violent incidents; reporting of violent incidents. These concerns relate largely to staffing issues – painting a picture of a particularly unsupported and vulnerable group of people. The extent of deviation from the national figures suggests considerable work is needed to enhance safety in this speciality. • Concerns relating to PICU services In PICUs, a different but equally concerning profile of findings were apparent. Low levels of compliance with standards were apparent in the following areas: temperature; privacy in general and in single-sex areas in particular; multi-disciplinary consensus on care; the provision of activities; service user involvement in decision-making about their care and about their medication.

Key messages A number of themes were apparent across the dataset and in discussions with local teams at workshops. • Unsafe environments: the design of many of our wards/units fails to meet many basic safety standards. It is vital that systems ensure staff and service users are fully involved in the design process for every new mental health or learning disability residential unit. Great efforts should be made to upgrade and improve existing wards in ways that optimise safety. • Inadequate staffing: nationally, many services are operating with vacancy factors. This was commonly linked to the on-going drain of experienced staff into higher paid, and often more highly-regarded, community posts. Many in-patient services are being left reliant upon inexperienced leaders. Additionally, many services are experiencing problems recruiting staff and are overly reliant upon bank and agency staff. Under either or both of these circumstances, it can be hard to build a coherent team than can work proactively to prevent and manage violence. It is vital that the status of in-patient nursing is raised to at least that of community nursing.

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• Client mix and over-crowding: many acute mental health services are ‘fire fighting’ as they struggle to work with an increasingly unwell population, some of whom will have a dual diagnosis. For many, faced with high bed occupancy figures and inadequate staffing, the delivery of a therapeutic service can become impossible. National inequities in staffing levels and skills mix and stark and sizeable. Action is required from both commissioners and managers to address this. • Substance misuse was identified as the most common trigger for violence. The data revealed that problems associated with the use of alcohol and illegal drugs were more common in mental health services – particularly Acute, PICU and Forensic services (alcohol was rated as especially problematic in Acute services). More must be done to support staff teams to address the problems caused by the use of alcohol and illegal drugs in in-patient services. • Staff training in the prevention and management of violence: significant numbers of staff reported dissatisfaction with the timing, content, or quality of the training they received. Additionally, and perhaps more concerning, many felt unable to apply the training in real life situations. Training must be tailored to individual needs and that more emphasis placed on the prevention rather than the management of incidents. However, the audit findings indicate that training will only be effective if the other issues described above are also addressed. • High levels of boredom: many wards/units are unable to offer service users a structured and therapeutic system of care. This is linked to low staffing levels and high volume of paperwork. As well as the obvious link between ‘boredom’ and ‘violence’, this is seen to have an impact on recovery rates for service users, and on job satisfaction for staff. Ways have to be found of supporting staff to spend more time in face-toface contact with service users – doing the job that they were trained to do.

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NEXT STAGES The audit gave services an evidence-based framework for highlighting particular areas for improvement. The challenge now lies with participants to take forward service improvements based upon the findings from their local data.

Feedback Events A series of 10 regionally-based events were held where local teams came together to do the following: • • • •

hear about the national findings; share ‘good practice’; network with other participants; action plan.

From these events, it is apparent that progress to date is highly varied. Some local project teams have struggled to embed the audit within their local governance structures. For them, the challenge lies to either take forward what improvements they can – at the ward/unit level, or retrospectively lobby for senior level support. Many other project teams have enjoyed the active support of their trust board or equivalent. Amongst this group, some were able to describe significant improvements already. As part of these events, participants were invited to make ‘good practice’ presentations: brief descriptions of these have been woven through the findings and are included at Appendix 7.

Implementation Events The Royal College of Psychiatrists’ Research Unit will be running a series of events to support local teams to implement service improvements. These will include topic-based workshops where participants can hear presentations from local and national experts in the subject areas.

Additional uses of the audit data The timing of the audit coincided with an unprecedented level of national interest in the subject of the prevention and management of violence. To date, the Audit Team and the findings from the audit have contributed directly to the following pieces of work and events. • The Mental Health Policy Implementation Guide (NIMHE). • The National Survey of Psychiatric Inpatient Wards in England (The Sainsbury Centre for Mental Health, in association with NIMHE). • The London Development Centre’s Acute Care Collaborative. • The Counter Fraud and Security Management Service’s various initiatives to tackle violence against staff. • The NPSA’s ‘Safer Wards’ initiative. • The Cross Government Expert Group on the management of violence and aggression in mental health settings. • The accreditation and regulation of physical intervention trainers and programmes of education and training Cross Government Sub Group. • The NICE Guideline: The short term management of disturbed (violent) behaviour in inpatient psychiatric settings and emergency departments. • The NIMHE national conference on the prevention and management of aggression and violence in mental health services.

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APPENDIX 1 National Guidance and initiatives relevant to safety in in-patient services • The Clinical Practice Guidelines for the Short-Term Management of Disturbed (Violent) Behaviour in Adult Psychiatric In-patient Settings and Emergency Departments (2005) • The National Service Framework for Mental Health (1999): standards 4 and 5 refer to the fact that service users, especially women and people with a history of abuse, do not feel safe in hospital. The safety of staff is also mentioned, in association with high bed occupancy, the high proportion of patients detained under the Mental Health Act and the growing problem of substance misuse. • The NIMHE Policy Implementation Guide on Adult Acute In-patient Care Provision (2002): highlights the problems with current in-patient services. It calls for improvements in the physical environment and, in particular, the creation of ‘risk averse environments’ through regular audit and detailed risk assessments. • Mainstreaming Gender and Women’s Mental Health Implementation Guidance (2003): recommends the ‘implementation of trust-wide policies and procedures to address patient safety, privacy and dignity in relation to both the physical layout and day-to-day management’. It also recommends the provision of training for staff, and single-sex accommodation (both night and day), in order to ensure that women service users on mixed-sex wards are protected from intimidation, coercion, violence and abuse. • Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health In-Patient Settings (2004): was developed as part of the NPSA/NIMHE joint funded project on the management of violence and aggression. This guidance contains positive practice standards that cover all aspects of training, education, policies and procedures, highlighting issues particular to vulnerable groups. These are intended to help mental health services to review policies and procedures relating to the safe and therapeutic management of aggression and violence. There is an emphasis on the development of training, particularly on the importance of qualified trainers and of appropriate and up-to-date training. • The Sainsbury Centre's Breaking the Circles of Fear and the National Visit 2 (2000; 2002): point to problems of racial harassment of black and minority ethnic groups by other patients or staff, and the concern regarding the lack of current policies on this problem. • The Independent Inquiry into the Death of David Bennett (2004): highlights several issues in the treatment of people from black and minority ethnic groups, and the management of violent incidents in psychiatric settings. The Inquiry asserted that there was institutional racism within the NHS and recommended training for all staff in cultural awareness and sensitivity. The recommendations also covered training and practice in the use of control and restraint techniques, the treatment of people with schizophrenia, and the rights of service users. • The Management of Violence of Violence and use of Restraint Cross-Government Group: the group has over 50 representatives from various branches of the DH, Home Office, police and prison services, mental health and learning disability services – all with a common interest in matters relating to the prevention and management of violence. The group which meets quarterly with the primary purpose of information exchange. • NIMHE and National Patient Safety Agency ‘Management of Violence & Aggression’ Project: two halftime project managers have been appointed jointly by NIMHE and NPSA to help co-ordinate the various initiatives on behalf of the Cross-Government Group.

The Healthcare Commission National Audit of Violence 2003-5 39

Final Report

• The NIMHE Benchmarking Exercise: was conducted by The Sainsbury Centre and is a detailed survey of the acute wards in England. Much of the data collected related to the prevention and management of violence. • The Counter Fraud and Security Management Service: is leading a number of national initiatives aimed at improving NHS staff safety in the workplace. • The "C128" Study: funded by NHS Service Delivery and Organisation (SDO) Programme, this City University study is working with 128 acute psychiatric wards to examine practice and outcomes of observation and self-harm, in relation to staffing levels and organisation, and other conflict and containment measures. • The National Confidential Inquiry into Suicide & Homicide by People with Mental Illness: was established at The University of Manchester in 1996. Its main aims are to: collect detailed clinical information about people who die by suicide of commit homicide and who have been in contact with mental health services; make recommendations about clinical practice and policy that will reduce the risk of suicide and homicide by people under mental health care.

The Healthcare Commission National Audit of Violence 2003-5 40

Final Report

Total number of female beds

mean range

Total number of beds

Number mean range

Age range for admissions

14+ 14-64 16-17 16+ 16-30 16-64 16-65 16-70 17-64 18+ 18-64 18-65 19+ 28-64 65+

Numbers of staff hrs used during previous wk

Qualified agency

Number mean range

Unqualified agency

Number mean range

Qualified bank

Number mean range

Unqualified bank

Number mean range

*(In each case ‘Number’ = the number of responses to the particular question)

10 3 0-6 4 2 0-4 11 4 3-8 1 10 1 17 0-17 2 30 0-50 2 72 0-77.5 9 57 0-141

13 8 0-24 6 ? 0-5 18 8.7 1-24 7 10 1 4 67 0-125 7 67 0-144 6 39 0-44.5 14 74 0-190

16 6 0-25 9 5 0-17 21 8 1-42 7 14 6 37 0-125 8 85 0-146 4 39 0-97.5 12 58 0-135

6 5 0-8 5 3 0-4 12 9 4-20 2 1 5 4 2 51 0-54 4 239 0-404.5 9 36 0-71 11 77 0-208

REHAB/CC MH (n = 15)

12 9 0-21 4 7 0-12 16 14 8-21 5 11 2 60 0-90 5 115.6 0-173 4 125 0-33 6 101.3 0-259

SHORT STAY LD (n = 12)

10 7.5 4-23 7 3.8 1-8 19 9.2 4-23 4 1 2 11 1 7 26.2 0-65 9 94.4 0-193.4 11 60.1 0-150 14 111.7 0-238

SMALL GROUP HOME (n = 11)

11 10 0-16 11 11 0-15 15 22 11-36 4 11 2 50 0-70 7 41 0-97 6 49 0-111 13 111 0-273

LONG STAY LD (n = 21)

range Number

79 11.5 0-25 75 10.2 0-25 112 20.4 4-54 2 11 1 2 4 1 2 1 11 74 1 1 1 18 54.3 0-190.5 44 79.2 0-500 56 64 0-249 87 86 0-363

CHALL BEHAV (n = 18)

mean

FORENSIC (n = 16)

Number*

PICU (n = 19)

Total number of male beds

ELDRLY MH (n = 15)

SUMMARY DATA

ACUTE (n = 112)

APPENDIX 2: Contextual Data summarised by service type

10 10 4-25 8 7.8 0-17 15 17.6 6-42 1 4 9 1 1 11.75 0-11.75 3 92.25 0-146 6 64 0-140 8 95.2 0-239

Number 0 1-29 30-40 40+

Number of staff left to community posts in past year

Number mean range

Staff trained in critical incident debriefing

Number Yes No

Do you have policy/ procedures relating to the following?

Post emergency debriefing

Number Yes No Don’t know

Searches of users

Number Yes No Don’t know

Children visiting wards

Number Yes No Don’t know

Observing high risk users

Number Yes No Don’t know

Managing violent incidents

Number Yes No Don’t know

2 1.5 0-3 1 3 0-3 16 2 5 9 12 2.0 0-6 16 6 10 16 6 10 16 16 16 16 16 16 16 16 -

4 2.5 0-3 3 3 0-4 0 2 3.5 0-5 11 7 4 11 4 6 1 11 6 5 11 6 5 11 11 11 11 -

42

REHAB/ CC MH (n = 15)

Hours of A&C support per week

7 3.3 0-6 7 4 0-8 18 7 7 3 1 14 1.9 0-5 19 4 14 19 4 14 19 18 1 19 19 19 19 19 18 1

SHORT STAY LD (n = 12)

mean range

5 2 0-3 5 2 0-3 15 8 5 2 6 1.5 0-3 15 2 13 15 4 7 4 15 11 4 15 10 5 15 13 1 1 15 12 1 2

LONG STAY LD (n = 21)

Number

41 3 0-8 29 2.5 0-8 110 16 40 46 8 79 2.5 0-9 106 32 74 109 73 19 17 110 103 6 1 112 106 5 1 112 108 3 112 107 4 1

CHALL BEHAV (n = 18)

range

In past 6 months

SMALL GROUP HOME (n = 11)

mean

F’RENSIC( (n = 16)

Number

PICU (n = 19)

In past 3 months

ELDRLY MH (n = 15)

Advertised posts unfilled

ACUTE (n = 112)

SUMMARY DATA

9 2 0-6 6 3 0-7 18 10 8 4 2 0-3 18 7 11 18 10 4 4 18 14 2 2 18 12 5 1 18 16 1 1 18 18 -

6 1.3 0-2 8 2.1 0-7 21 13 6 1 1 7 1.3 0-3 21 6 15 21 12 8 1 21 8 12 1 21 8 11 2 21 15 5 1 21 20 1

2 6.5 0-7 4 4.5 0-7 12 9 2 1 5 2.4 0-6 12 2 10 12 8 3 1 12 7 4 1 12 7 4 1 12 11 1 12 12 -

0 2.3 0-4 5 4.2 0-8 15 5 7 3 7 1.8 0-3 15 4 11 14 9 2 3 14 9 3 2 14 9 3 2 15 14 1 14 12 2

No Don’t know

Using/recording of restraints

Number Yes No Don’t know

Using/recording of seclusion

Number Yes No Don’t know N/A

Locking the ward

Number Yes No N/A Don’t know

Do you consider the unit to be safe?

Number Yes No Both N/A

Amount reported in last year

Violent incidents

Number

Suicide

Number

Deliberate self harm

Number

Absconding

Number

Range Range Range

Range

Homicide

Number Range

LONG STAY LD (n = 21)

16 6 7 3 16 16 16 15 1 19

18 7 8 3 19 18 1 19 13 4 2 16

11 9 2 11 11 11 2 9 11

18 4 12 2 18 18 18 13 3 2 18

21 5 15 1 21 20 1 21 9 12 21

11 8 3 11 10 1 11 5 5 1 12

14 5 7 2 14 12 1 1 14 6 6 1 1 15

85 24 2 110 95 15 94 0-200 24 0-5 91 0-180

10 3 2 15 13 2 14 0->1000 0 0 6 0-8

18 1 18 18 16 2-115 4 0-10 15 0-100 (ALL)

13 1 2 16 16 15 0-319 1 1 10 0-104

6 5 11 10 1 9 0-238 0 0 8 0-350

13 3 2 18 15 2 1 17 0-347 0 0 7 0-37

14 7 21 16 4 1 19 0-220 0 0 14 0-400+

9 2 1 12 8 2 1 1 6 0-114 0 0 7 0-11

8 7 14 11 3 12 0-63 1 1 8 0-55

91 0-78

10 0-6

10 0-8

5 0-2

3 0-30

8 0-3

2 0-2

6 0-13

112 1 incdnt

0 0

15 0-42 (ALL) 0 0

1 attmpt 1 attmpt

0 0

0 0

0 0

1 1

0 0

43

REHAB/CC MH (n = 15)

15 11 4 15 5 7 3 15 12 2 1 15

SHORT STAY LD (n = 12)

107 32 54 21 108 93 11 4 107 82 14 2 9 111

CHALL BEHAV (n = 18)

SMALL GROUP HOME (n = 11)

Yes

FORENSIC (n = 16)

Number

PICU (n = 19)

Safety of women

ELDRLY MH (n = 15)

Do you have policy/ procedures relating to the following?

ACUTE (n = 112)

SUMMARY DATA

How often does ‘specialing’ or high intensity observation occur?

REHAB/CC MH (n = 15)

SHORT STAY LD (n = 12)

LONG STAY LD (n = 21)

CHALLENGING BEHAVIOUR (n = 18)

19

16

11

18

21

12

15

6 51 237 15 3 112 41 70 1 112 69 43 112 24 37 20 24 4 4 104 31 73 -

2 9 3 1 15 3 12 15 4 11 14 1 13 15 5 9 1

1 9 5 4 19 9 10 -

2 2 7 4 1 16 10 6 16 13 1 1 16 2 7 2 4 1 16 2 10 2 2

3

4 4 7 2 1 18 3 15 18 5 13 16 1 1 14 18 16 2 -

4 5 5 3 4 21 4 16 1 21 2 19 19 2 17 21 18 2 1

2 1 33 4 1 12 3 9 12 2 10 12 2 9 1 12 1 7 3 1

1 2 5 5 2 15 3 11 1 15 7 8 13 5 7 1 14 3 11 -

Freq

Number Yes No N/A Number Yes No N/A Number Always Freq Occas Rarely Never N/A Perm

Do staff have access to advance directives drawn up by service users?

SMALL GROUP HOME (n = 11)

15

Never

How often have service users been placed in a PICU over the past year?

FORENSIC (n = 16)

112

Always Occas

Do you have access to a PICU/intensive care area?

PICU (n = 19)

Number

Rarely

Do you use seclusion?

ELDRLY MH (n = 15)

ACUTE (n = 112)

SUMMARY DATA

Number Yes No N/A Don’t know

N/A -

N/A

18 8 7 1 2

44

2 3 3 11 11 11 6 5 10 1 9 11 11 -

APPENDIX 3: MODULE 1 NATIONAL RESULTS SECTION 1: THE WARD/UNIT 1.

Environmental comfort

1.1

Is there enough space on this ward/unit?

NATIONAL Nursing staff Clinical Non-Clinical Service users Visitors

Yes 50 39 54 68 68

No 48 58 37 30 29

ACUTE

Nursing staff Clinical staff Non-Clinical Service users Visitors

1.2

Y 44 37 47 67 61

N 54 59 43 31 35

Other 2 3 9 2 3

PICU

Y 62 33 73 57 80

2 4 10 2 4

N 36 67 12 40 16

FORENSIC

2 0 12 3 4

Y 63 51 75 69 75

N 36 47 21 29 23

C CARE

Y 58 41 65 68 86

1 2 4 2 2

N 40 55 35 22 12

ELD MH

Y 34 43 66 75 79

2 4 0 9 2

N 63 58 23 23 21

CB LD

3 0 11 2 0

Y 60 39 64 79 73

N 39 61 36 16 24

SM GP HOME LD

1 0 0 5 3

Y 66

N 38

1

50 100 69

50 0 31

0 0 0

SHORT STAY LD

Y 72 55 67 71 89

N 25 45 33 29 5

3 0 0 0 6

LONG STAY LD

Y 43 33 70 43 65

N 56 60 15 54 27

1 7 15 4 8

Is it usually quiet during the day/night? Yes

NATIONAL

No

Day 27 48 48 60 67

Nursing staff Clinical Non-Clinical Service users Visitors

Night 60 37 24 72 -

ACUTE

Y Nursing staff

NIGHT

Clinical staff

NIGHT

NonClinical

NIGHT

Service users

NIGHT

Visitors

DAY

DAY DAY DAY DAY

24 56 44 37 43 25 61 71 66

Day 64 45 40 35 26

PICU

N 66 29 49 12 43 10 35 23 28

10 15 7 51 14 65 4 6 6

Y 26 61 50 39 47 47 53 80 65

N 64 28 50 0 47 6 43 14 24

FORENSIC

10 11 0 61 6 47 4 6 1

Y 37 72 67 44 75 17 65 72 73

N 57 18 27 5 21 0 34 23 23

Other Night 26 11 9 22 -

Day 9 7 12 5 7

C CARE

6 10 6 51 4 83 1 5 4

Y 29 69 55 31 60 25 58 75 58

N 66 21 39 0 35 10 35 18 35

Night 14 52 67 6 -

ELD MH

5 10 7 69 5 65 7 7 7

Y 16 37 43 23 66 9 67 73 71

45

N 78 43 53 20 29 6 26 21 23

CB LD

6 20 5 58 6 86 7 5 6

Y 36 75 56 44 64 45 55 74 56

N 58 19 44 17 36 0 40 17 27

SM GP HOME LD

6 6 0 39 0 55 5 9 17

Y 34 71

N 59 17

7 12

0 0 88 75 94

100 0 6 19 6

0 100 6 6 0

SHORT STAY LD

Y 26 64 64 18 22 22 36 71 68

N 63 24 36 0 56 22 64 21 15

11 12 0 82 22 56 0 7 17

LONG STAY LD

Y 31 78 67 60 38 15 36 36 88

N 59 15 20 0 31 8 50 21 0

10 7 13 40 31 77 14 43 12

1.3

Does the temperature usually feel comfortable?

NATIONAL Nursing staff Clinical Non-Clinical Service users Visitors

Yes 46 62 53 64 70

No 52 36 42 33 27

ACUTE

Nursing staff Clinical staff Non-Clinical Service users Visitors

2.

Y 41 57 50 63 67

N 57 41 43 33 31

Other 2 2 5 4 3

PICU

2 2 7 4 3

Y 36 72 47 53 58

N 63 28 47 43 38

FORENSIC

Y 51 71 54 59 60

2 0 6 4 4

N 47 25 46 41 40

C CARE

Y 58 83 50 61 61

2 4 0 0 0

N 39 17 50 33 33

ELD MH

3 0 0 6 6

Y 35 73 63 82 82

3 4 10

Y 44 53 63

CB LD

N 63 25 31 18 15

2 3 6 0 3

Y 60 50 64 76 76

4 33 20

Y 76 67 91

N 38 44 36 19 18

2 6 0 5 6

SM GP HOME LD

SHORT STAY LD

Y 74

N 22

3

50 69 81

50 25 19

0 6 0

Y 57 82 67 79 83

N 37 18 22 21 11

6 0 11 0 6

LONG STAY LD

Y 52 100 67 64 85

N 46 0 27 29 12

2 0 6 7 3

Environmental safety

Is the alarm system on this ward/unit satisfactory? NATIONAL Nursing staff Clinical Non-Clinical

Yes 61 66 68

No 35 18 16

ACUTE

Nursing staff Clinical Non-Clinical

Y 55 66 64

N 41 20 19

Other 4 16 16

PICU

4 14 17

Y 55 50 53

N 42 28 29

FORENSIC

3 22 18

Y 83 80 92

N 16 7 0

C CARE

Y 68 72 85

1 13 8

N 29 24 5

ELD MH

N 53 15 17

CB LD

N 21 6 0

3 27 9

SM GP HOME LD

SHORT STAY LD

Y 60

N 23

16

50

0

50

Y 71 55 67

3.

Environmental privacy and security

3.1

Do you ever have to share space with other members of the opposite sex when you don’t want to? Yes 23

Service users

No 71

ACUTE

Service users

Y 24

N 71

5

N 59

7 27 33

LONG STAY LD

Y 76 73 92

N 23 7 8

1 20 0

Other 6

PICU

Y 35

N 22 18 0

FORENSIC

6

Y 12

N 85

C CARE

3

Y 22

N 72

ELD MH

6

Y 27

46

N 74

CB LD

4

Y 19

N 65

SM GP HOME LD

5

Y 0

N 88

12

SHORT STAY LD

Y 7

N 64

29

LONG STAY LD

Y 14

N 61

25

3.2

Are there enough places where you can spend time in private, for example, with family, friends, or members of staff? Yes 61

Service users

No 34

ACUTE

Service users

3.3

Y 58

Other 5

PICU

N 37

5

Y 48

FORENSIC

N 47

Y 65

5

N 32

C CARE

Y 74

3

ELD MH

N 26

Y 64

0

CB LD

N 32

Y 88

4

N 7

5

SM GP HOME LD

SHORT STAY LD

LONG STAY LD

Y 94

Y 79

Y 39

N 6

0

N 21

0

N 29

32

Do you have somewhere secure to store your belongings. For example, money, jewellery? Can you get to your belongings whenever you want? Yes Service users

Service users

STORAGE ACCESS

3.4

No

Storage 76

Other

Access 77

Storage 21

Access 18

Storage 4

ACUTE

PICU

FORENSIC

C CARE

Y 74 77

N 22 18

Y 80 70

4 5

N 14 29

Y 75 75

6 1

N 24 24

1 1

Y 75 81

N 17 15

Access 5 ELD MH

Y 73 80

8 4

N 23 14

CB LD

4 5

Y 86 84

N 10 11

SM GP HOME LD

4 3

Y 100 81

N 0 19

SHORT STAY LD

0 0

Y 86 86

N 7 7

LONG STAY LD

7 7

Y 82 68

N 7 25

11 7

Is there ever trouble on this ward/unit because of people getting drunk/taking illegal drugs?

NATIONAL

Yes

No

Alcohol 45 44 30 21 23

Nursing staff Clinical Non-Clinical Service users Visitors

Drugs 53 53 32 24 25

ACUTE

Nursing staff

ALCOHOL

Clinical

ALCOHOL

NonClinical

ALCOHOL

Service users

ALCOHOL

Visitors

ALCOHOL

DRUGS DRUGS DRUGS DRUGS DRUGS

Y 74 81 61 70 42 44 26 29 35 36

N 23 15 24 14 33 25 69 65 53 50

PICU

3 4 15 16 25 31 5 6 12 14

Y 36 70 39 67 18 35 11 21 11 24

Other

Alcohol 53 44 49 74 65 N 61 27 44 17 59 41 79 70 76 62

Drugs 45 34 41 69 61

FORENSIC

3 3 17 17 24 24 10 9 13 14

Y 18 44 9 27 0 8 10 25 4 4

N 81 55 84 58 79 63 86 72 79 81

1 1 7 15 21 29 4 3 17 15

Alcohol 2 12 21 5 12

C CARE

Y 27 21 21 17 20 15 18 16 7 10

N 70 75 76 79 70 65 75 78 80 77

Drugs 3 13 27 7 14

ELD MH

3 4 3 4 10 20 7 6 13 13

47

Y 3 1 0 0 0 0 7 7 3 2

N 96 98 98 98 83 83 93 89 94 89

CB LD

1 1 2 2 17 17 0 4 3 9

Y 10 2 0 0 0 0 9 6 2 5

N 90 97 99 99 91 91 86 84 85 80

0 1 1 1 9 9 5 10 13 15

SM GP HOME LD

SHORT STAY LD

Y 10 3

N 88 94

1 3

0 0 6 0 0 0

100 100 94 94 100 100

0 0 0 6 0 0

Y 1 2 0 18 0 0 0 7 2 4

N 98 96 82 64 100 100 100 93 7 85

1 2 18 18 0 0 0 0 11 11

LONG STAY LD

Y 1 5 7 13 8 8 4 4 0 0

N 98 94 93 87 85 85 79 79 81 81

1 1 0 0 7 7 18 18 19 19

SECTION 2: COMMUNICATION SYSTEMS AND WARD CULTURE 1.1

Do you have sufficient opportunities to raise and discuss issues with colleagues on the ward/unit?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 77 84 69

No 21 14 2

ACUTE

Nursing staff Clinical Non-Clinical

1.2

Y 75 83 66

N 23 15 22

PICU

2 3 12

Y 81 89 53

N 17 11 35

FORENSIC

Y 85 85 81

2 0 12

N 15 15 25

C CARE

Y 83 93 75

0 0 4

N 15 7 20

ELD MH

Y 69 90 77

2 0 5

N 30 10 11

CB LD

1 0 12

Y 80 89 82

N 19 11 18

1 0 0

SM GP HOME LD

SHORT STAY LD

Y 85

N 12

3

100

0

0

Y 81 73 89

N 18 18 11

1 9 0

LONG STAY LD

Y 68 87 92

N 32 13 0

0 0 8

Are your complaints taken seriously?

NATIONAL Nursing staff Clinical Non-Clinical Service users Visitors

Yes 67 74 62 64 79

No 26 12 19 22 8

ACUTE

Nursing staff Clinical Non-Clinical Service users Visitors

1.3

Other 2 2 10

Y 65 70 60 63 78

N 27 16 20 23 9

Other 7 14 18 14 14

PICU

8 14 20 12 13

Y 64 83 59 57 76

N 31 0 29 23 13

FORENSIC

5 17 12 20 11

Y 74 78 58 64 69

N 19 9 17 24 8

C CARE

7 12 25 10 23

Y 71 93 90 70 86

N 21 7 0 19 3

ELD MH

8 0 10 11 11

Y 59 83 66 75 89

N 35 8 17 7 3

CB LD

5 10 17 18 8

Y 72 78 82 67 74

6 25 57

Y 86 56 55

N 23 6 18 16 9

5 18 0 17 17

SM GP HOME LD

SHORT STAY LD

Y 73

N 19

8

100 81 88

0 13 12

0 6 0

Y 71 82 56 71 79

N 24 9 44 29 4

4 9 0 0 17

LONG STAY LD

Y 70 80 62 46 85

N 26 0 8 21 0

4 20 30 32 15

Are the hand-over systems on this ward/unit effective?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 82 58 39

No 15 18 10

ACUTE

Nursing staff Clinical Non-Clinical

Y 82 57 37

N 14 20 10

Other 3 23 51

PICU

4 23 53

Y 86 83 41

N 11 6 18

FORENSIC

3 11 41

Y 84 60 33

N 16 22 8

C CARE

0 18 58

Y 77 62 60

N 9 3 10

ELD MH

4 35 30

Y 69 60 43

48

N 25 15 0

CB LD

N 12 11 9

2 33 36

SM GP HOME LD

SHORT STAY LD

Y 86

N 13

1

50

0

50

Y 80 45 11

N 17 18 11

3 36 78

LONG STAY LD

Y 84 53 46

N 14 13 8

2 14 46

1.4

Are the numbers, skills, experience, and qualifications of the staff on this ward/unit appropriate to the resident population? Are the gender and ethnic mix of the staff on this ward/unit appropriate to the resident population?

NATIONAL

Yes

No Gender/ Ethnicity

Skills/ experience

Gender/ Ethnicity

Skills/ experience

Gender/ Ethnicity

56 45 49

71 71 58

40 41 20

25 18 14

3 14 31

4 11 28

FORENSIC

C CARE

ELD MH

Nursing staff Clinical Non-Clinical

ACUTE

Nursing

SKILLS/EXPER GENDER/ETHN

Clinical

SKILLS/EXPER GENDER/ETHN

Non-Clinical

SKILLS/EXPER GENDER/ETHN

1.5

Y 52 65 44 68 47 57

N 44 29 44 21 23 16

PICU

Y 55 70 39 56 47 41

4 4 12 11 30 28

N 42 29 44 22 29 29

Y 60 72 62 65 50 46

3 1 17 22 24 29

N 37 23 25 19 13 13

3 5 13 16 37 31

Y 65 81 38 83 55 65

N 33 17 31 7 10 0

2 2 31 10 35 35

Y 54 74 38 83 46 66

N 45 20 48 10 20 6

CB LD

1 6 15 8 34 29

Y 59 80 39 72 73 73

N 36 17 44 22 0 18

SM GP HOME LD

5 3 17 6 27 9

Y 70 63

N 28 33

2 5

50 50

0 0

50 50

SHORT STAY LD

Y 64 84 55 91 56 67

N 32 13 18 0 11 11

4 3 27 9 33 22

LONG STAY LD

Y 63 81 60 93 69 85

N 35 17 33 0 0 0

Is there multi-disciplinary consensus on the clinical care of service users?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 75 79 46

No 15 12 5

ACUTE

Nursing staff Clinical Non-Clinical

1.7

Other

Skills/ experience

Y 71 79 43

N 19 12 5

Other 10 9 49

PICU

Y 68 47 59

10 9 52

N 24 24 18

FORENSIC

Y 86 87 42

8 29 24

N 9 9 4

5 4 54

C CARE

Y 80 90 55

N 9 10 0

ELD MH

11 0 45

Y 71 80 43

N 16 5 3

CB LD

12 15 54

Y 81 72 73

N 11 22 18

9 6 9

SM GP HOME LD

SHORT STAY LD

Y 90

N 0

10

0

0

100

Y 84 82 22

N 5 9 22

11 9 56

LONG STAY LD

Y 83 93 69

N 10 7 0

7 0 31

Do you think that service users feel comfortable talking to staff?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 86 82 70

No 8 7 6

ACUTE

Nursing staff Clinical Non-Clinical

Y

N

85 81 67

9 8 8

Other 6 11 23

PICU

5 11 25

Y

N

84 72 88

12 6 6

FORENSIC

4 22 6

Y

N

89 76 63

5 13 8

6 11 29

C CARE

Y

N

86 83 80

7 10 0

ELD MH

7 7 20

Y

N

89 90 77

5 0 0

49

CB LD

5 10 23

Y

N

87 70 91

4 8 0

9 22 9

SM GP HOME LD

SHORT STAY LD

LONG STAY LD

Y

N

Y

N

Y

N

88

6

6

50

0

50

85 100 78

7 0 0

93 80 69

3 7 0

6 0 22

3 13 31

1 2 7 7 31 15

1.8

Would you describe your employment status here as ‘stable’?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 81 84 84

No 14 10 8

ACUTE

Other Clinical staff Non-Clinical

1.9

Y 82 83 81

N 13 12 9

Other 5 6 8

PICU

5 5 10

Y 79 78 88

N 15 11 6

FORENSIC

6 11 6

Y 91 85 83

N 7 11 4

C CARE

Y 79 93 95

2 4 13

ELD MH

N 17 4 5

4 3 0

Y 81 85 86

CB LD

N 14 5 9

5 10 6

Y 83 94 100

SM GP HOME LD

N 13 0 0

4 6 0

Y 79

N 19

2

100

0

0

SHORT STAY LD

Y 71 73 100

N 21 0 0

8 27 0

LONG STAY LD

Y 76 87 100

N 24 13 0

0 0 0

Do you have access to a copy of the organisation’s policies on physical interventions?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 88 75 52

No 7 15 28

ACUTE

Nursing staff Clinical Non-Clinical

Y 86 72 48

N 8 17 31

Other 5 10 20

PICU

6 11 21

Y 90 78 47

N 8 17 18

FORENSIC

2 6 35

Y 90 89 67

N 5 5 17

5 4 16

C CARE

Y 91 79 65

N 4 10 15

ELD MH

5 11 20

Y 80 70 57

N 16 18 26

CB LD

4 12 17

Y 98 89 81

N 1 0 18

1 11 0

SM GP HOME LD

SHORT STAY LD

Y 87

N 9

4

50

50

0

Y 92 64 44

N 5 18 44

3 18 11

LONG STAY LD

Y 89 87 46

N 7 13 31

4 0 23

SECTION 3: STAFF TRAINING, SUPERVISION AND SUPPORTS 1.1

Did you receive any training in relation to the prevention and management of violence before you began working on this ward/unit?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 59 54 22

No 39 43 71

ACUTE

Nursing staff Clinical Non-Clinical

1.2

Y 56 51 20

N 42 46 73

Other 2 3 7

PICU

2 3 7

Y 67 61 29

N 31 39 71

FORENSIC

2 0 0

Y 72 67 29

N 27 33 63

C CARE

1 0 8

Y 63 62 25

N 35 33 75

ELD MH

2 5 0

Y 34 53 17

N 63 40 74

CB LD

3 7 9

Y 65 72 55

N 34 28 36

1 0 9

SM GP HOME LD

SHORT STAY LD

Y 69

N 28

3

50

50

0

Y 56 27 22

N 38 64 56

6 9 22

Have you received any training in how to train others in relation to the prevention or management of violence?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 10 7 3

No 79 83 76

Other 11 10 21

50

LONG STAY LD

Y 72 67 15

N 28 33 70

0 0 15

ACUTE

Y 9 7 3

Nursing staff Clinical staff Non-Clinical

1.3

N 80 83 78

PICU

11 10 19

Y 13 0 6

FORENSIC

N 79 89 53

8 11 41

Y 11 7 4

C CARE

8 5 25

Y 10 10 0

N 82 83 75

ELD MH

Y 8 3 3

8 7 25

N 82 87 80

CB LD

10 10 17

Y 9 6 9

N 76 83 64

15 11 27

SM GP HOME LD

SHORT STAY LD

Y 14

N 73

13

0

50

50

Y 8 9 0

N 69 73 67

23 18 33

LONG STAY LD

Y 13 20 0

N 79 80 92

8 0 8

In the past five years, have you received any training that is directly related to the prevention or management of violence?

NATIONAL Nursing staff

Yes 86 75 74 72 63 47 37 29 20

Had it? Adequate prevention Adequate management? Had it? Adequate prevention Adequate management? Had it? Adequate prevention Adequate management?

Clinical

Non-Clinical

ACUTE

Nursing staff

Y 87 74 74 69 60 44 36 25 19

Had it? Adeq prevention? Adeq management?

Clinical

Had it? Adeq prevention? Adeq management?

NonClinical

Had it? Adeq prevention? Adeq management?

1.6

N 81 88 71

N 10 20 20 27 31 44 54 47 52

PICU

Y 91 80 80 72 56 39 59 53 29

3 6 6 3 9 12 10 28 29

N 7 18 17 28 28 39 24 29 47

No 10 19 20 25 27 41 52 41 48

Other 4 6 6 3 10 12 11 29 32

FORENSIC

C CARE

Y 91 87 84 84 76 60 42 38 13

2 2 3 0 17 22 18 18 24

N 5 10 11 16 20 31 46 25 38

Y 85 71 67 83 76 52 40 45 25

4 3 4 0 4 9 12 37 49

N 13 23 25 17 14 34 55 25 40

ELD MH

2 6 8 0 10 14 5 30 35

Y 67 50 43 80 68 48 20 20 6

N 26 38 44 18 13 35 60 37 53

CB LD

7 12 13 3 20 18 20 43 41

Y 91 83 84 67 67 61 64 64 45

N 5 13 15 28 17 33 27 18 27

SM GP HOME LD

4 4 1 5 16 6 9 18 28

Y 90 87 87

N 5 9 10

5 3 3

50 0 0

0 50 0

50 50 100

SHORT STAY LD

Y 79 71 64 64 55 45 33 33 11

N 17 20 24 36 36 36 56 44 56

4 9 12 0 9 18 11 22 33

LONG STAY LD

Y 88 79 80 80 67 67 46 38 46

N 8 16 14 20 27 33 56 31 15

Do you currently receive supervision?

NATIONAL Nursing staff Clinical Non-Clinical

Yes 56 69 29

No 34 24 54

ACUTE

Nursing staff Clinical staff Non-Clinical staff

Y 55 68 28

N 36 25 55

Other 9 7 17

PICU

9 7 17

Y 55 50 35

N 39 33 47

FORENSIC

6 17 18

Y 60 73 29

N 32 25 54

8 2 17

C CARE

Y 58 69 35

N 30 10 65

ELD MH

12 21 0

Y 36 63 34

51

N 51 28 43

CB LD

13 10 23

Y 74 67 27

N 26 33 64

SM GP HOME LD

0 0 9

Y 72

N 14

14

50

50

0

SHORT STAY LD

Y 58 100 37

N 31 0 44

11 0 22

LONG STAY LD

Y 54 73 310

N 38 13 46

8 14 23

4 5 6 0 6 0 0 31 38

1.7

How would you rate your satisfaction with the frequency and quality of supervision that you get?

NATIONAL Nursing staff

> Satisfied 47 52 62 63 27 27

Frequency Quality Frequency Quality Frequency Quality

Clinical Non-Clinical

ACUTE

Nursing staff Clinical

>sat