Policy Framework for the Facilitation of Managing Violence in GP Surgeries
NHS North of Tyne
Primary Care Organisations in Northumberland, Tyne and Wear in collaboration with Northumbria Police
2 Document Control
Owner NHS North of Tyne Version 2.0 Approval Body Issue Date August 2010 Review Frequency Next Review Date Northumberland Tyne & Wear SHA Tackling Violence Author Working Group on behalf of Primary Care Organisations in Northumberland Tyne and Wear
Revision History
Date of this revision: August2010
Date of Next revision:
Revision Version Summary of Changes Changes Date Section 03.08.2010 1.0 PCO Framework for Managing Violence in GP Practices 03.08.2010 2.0 NHS NoT General updates to names of organisations including provision of the Violent Patient Scheme by a service provider
Distribution
This document has been distributed to:
Name Title Organisation Date of Issue Version
Warning! References to Primary Care Trust, PCOs, FHSA and other NHS Organisations are subject to change as the current organisational process is concluded
3 Policy framework for the facilitation of
managing violence in GP surgeries
1 INTRODUCTION 4
2 RESPONSIBILITIES 5
3 TRAINING 6
4 PROTOCOL FOR HANDLING INCIDENTS. 7
5 PCO/FHSA PROCEDURE FOR REMOVAL, RE-ALLOCATION AND MARKING RECORDS OF VIOLENT PATIENTS 11
6 SECURE PREMISES 14
7 VIOLENT PATIENTS WORKING ARRANGEMENTS 15
8 TEMPLATES 17
APPENDIX 1. DEVELOPING A PRACTICE STRATEGY 24
APPENDIX 2. RISK ASSESSMENT GUIDANCE 26
APPENDIX 3. EXPECTED RESPONSES32
APPENDIX 4. WHAT HAPPENS AFTER A CASE IS REPORTED TO THE POLICE 35
APPENDIX 5. TREATMENT OF PATIENTS 39
APPENDIX 6. CCTV CODE OF CONDUCT IN RELATION TO DATA PROTECTION ACT 1998………………………………………… 42
APPENDIX 7. POSTER EXPECTED STANDARDS OF BEHAVIOUR 48
APPENDIX 8. TRAINING STRATEGY 49
4 1 Introduction
The information included in this policy is intended to support the protocol between Northumbria Police and Northumberland, Tyne and Wear Strategic Health Authority and Primary Care Organisations.
The documents outline arrangements that GP surgeries can undertake to prevent violence taking place, and where violence does take place, to minimise harm to the victims and take action to prevent repetition in future.
Northumberland, Tyne and Wear Strategic Health Authority and Primary Care Organisations are signed up to the NHS Zero Tolerance Zone campaign.
The NHS Zero Tolerance Zone campaign has two principal aims:
to communicate to the public that violence against staff working in the NHS is unacceptable and the Government (and the NHS) is determined to stamp it out; and to communicate to all staff that violence and intimidation is unacceptable will not be tolerated and is being actively tackled.
The definition of work related violence:
“ Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health.”
While a threatening act or an assault is relatively easy to define, abuse may b more difficult. Based on the expected standards of behaviour in the NHS Zero Tolerance Campaign the following actions should be considered to be abusive when directed toward practice staff, other patients or members of the public and would fall within the definition of a violent incident:
Abusive language e.g. swearing or offensive remarks Racist or sexist remarks Offensive sexual gestures or behaviour Malicious allegations relating to members of staff, patients or visitors Excessive noise e.g. loud or intrusive conversation or shouting Threats or threatening behaviour Abusing alcohol or drugs in practice premises, (However, all medically identified substance misuse problems will be treated appropriately) Drug dealing Theft from other patients, staff or theft of equipment Vandalism to the building, furniture or equipment
5 2 Responsibilities
2.1 GP and other employers’ responsibilities
It is the responsibility of all employers to assess the health and safety risks to their staff that arise from the activities they are involved in. Employers must take all practicable steps to remove, reduce and control the risks to their staff and others who might be affected (e.g. other patients). A legal duty of care is placed on them to do so. Breach of this duty of care may place employers at risk of subsequent litigation. Violence is accepted as a health and safety risk.
Guidance on developing a practice strategy to reduce the risk of violent incidents is provided in Appendix 1
There is no single solution to preventing violence, but there should be, as a minimum, a full assessment of the risks. Risk assessment should be comprehensive and carried out by the appropriately trained staff. Guidance on performing risk assessments is included in Appendix 2.
2.2 Practice managers responsibilities
Managers have a key role to play in tackling violence in the NHS. Appendices 1 and 2 identify some of the things that can be done to reduce the risk of violence and aggression against staff and explain how to deal effectively with violent incidents when they occurEstablishing procedures for dealing with violent situations will help members of the practice gain the confidence to handle such incidents.
2.3 Employee responsibilities
Staff working in the NHS should report all violent or abusive incidents to their managers and, where appropriate, incidents should be reported to the police. Above all, staff should not feel that they have to cope alone with violence, that it is part of the job, or that they do not have the support of their employer or local Primary Care Organisation.
6 3 Training
Staff safety must be the paramount concern. They should not be knowingly put in situations that make them feel unsafe. However, if they are, they need to know how to deal with them.
Appropriate staff training is therefore crucial. Managers should assess the risks to staff and analyse their training needs. In doing so it will be possible to gauge the sort of training they require according to their roles and ensure that this is appropriate to the degree of risk an individual employee faces.
Support staff should not be overlooked in this process, including caretakers and cleaners.
3.1 Context and content of training The theory behind violence at work is to understand:
why it occurs and how any individual could be a potential aggressor given a certain set of circumstances. how staff actions may contribute to or exacerbate a violent situation. Provide the ability to recognise a potential violent incident in the making and to take appropriate actions to counter this. Diffusion or de-escalation training is the most suitable approach for equipping staff to deal with the frustration and aggression of patients, family, friends and bystanders.
A risk assessment (see Appendix 1) will identify whether other types of training, including training in physical techniques, are appropriate. Ideally, managers should receive the same training as their staff to ensure continuity.
3.2 Training provision
Primary Care Organisations will support employers in the implementation of this policy by providing appropriate training on all aspects of violence in GP Surgeries. This will be undertaken as part of their overall Training Strategies. See Appendix 8 for guidance on training approaches and appropriate training.
7 4 Protocol for handling incidents
The protocol does not seek to outline every option/avenue that staff at GP surgeries could be faced with; it merely seeks to highlight the considerations available. In particular, in respect of risk assessments and action plans, each situation will need to be addressed according to the circumstances; the considerations listed merely being a starting point.
4.1 Standards of behaviour The following are examples of behaviour that are not acceptable:
Physical assault, attempted physical assault or threat of physical assault Abusive language e.g. swearing or offensive remarks Racist or sexist remarks Offensive sexual gestures or behaviour Malicious allegations relating to members of staff, patients or visitors Excessive noise e.g. loud or intrusive conversation or shouting Threats or threatening behaviour Abusing alcohol or drugs in practice premises (However, all medically identified substances misuse problems will be treated appropriately) Drug dealing Theft from other patients, staff or theft of equipment Vandalism to the building, furniture or equipment
A poster format of these standards is included as Appendix 7
4.2 Classification of unacceptable behaviour
Level 1 General nuisance: Excessive noise e.g. loud or intrusive conversation or shouting, offensive gestures or behaviour (sexual or otherwise).
Verbal Abuse: Swearing or other offensive remarks e.g. racist or sexist remarks or malicious allegations in relation to members of staff, patients or visitors. Level 2 Criminal Damage/Vandalism: Deliberate damage or vandalism to the building, furniture or equipment.
Theft: Theft from other patients, staff or theft of equipment.
Other inappropriate behaviour: e.g. Abusing alcohol or drugs in practice premises, drug dealing. Level 3 Threatening Behaviour Level 4 Violent Behaviour Level 5 Physical assault or attempted physical assault Level 6 Dealing with patients referred to the scheme
8 4.3 Recommended actions
First Incident Subsequent Incidents Level 1/2 Verbal Warning from Agree actions between the practice manager or GP GP and PCO
Report to police if Consider removal from appropriate practice list
Record incident Consider adding violent marker to patient record Consider written warning to patient
Conduct risk assessment and implement recommendations Level 3/4/5 Contact Police
Record incident using the relevant incident form
Conduct risk assessment and implement recommendations
Agree actions between the GP and PCO
Add violent marker to patient record
Consider removal from practice list
4.3.1 Verbal Warning
GP or other senior member of practice staff will explain to the patient that his/ her behaviour is unacceptable and explain the expected standards that should be observed in future. It should be made clear that the patient may be removed from the list if there are further instances of unacceptable behaviour.
4.3.2 Report to police
If an immediate threat of violence is present, call the police using the 999 emergency call system. The Police will make every effort to respond within the agreed Northumbria Police targets. If the immediate threat is passed, call the local police station to report the incident. Obtain a crime/incident reference number from the Police. If the immediate threat has passed call the police using the non-emergency contact number.
9 4.3.3 Record incident
When considering how to counteract violence it is helpful to know the extent of the problem. It is important that the number and nature of incidents of violent or threatening behaviour in general practice are highlighted. To this end a report from should be completed for each incident of violence or abuse that happens in a practice (see section 8.2)
4.3.4 Written warning
Continued behaviour, outside the expected standards, should result in a written warning detailing the conditions for future treatment (see template letter, section 8.1)
4.3.5 Risk assessment
Prevention of violence at work must start with a full assessment of the risks. Risk assessment should be conducted prior to or following an incident to determine appropriate countermeasures to reduce the risk of incident occurring/re-occurrence. Guidance on risk assessments can be found in Appendix 2.
4.3.6 Agree action plan with PCO
Where a patient has demonstrated behaviour likely to be a risk to staff a referral should be made to the Violent Patient Scheme Provider, Primary Care North East based at Scotswood GP practice (PCNE). PCNE will review the referral and feedback to the practice with two working days and an action plan will be agreed.
Where there is clear evidence the patient has transgressed acceptable behaviour standards, a warning may be displayed on the patients file and communicated to other relevant professionals, specifying the risk posed by the patient. This information should be shared with community (nursing, mental health, social services etc) colleagues likely to come into contact with the individual. The patient should be notified in writing and a copy of this letter placed on the patients record.
Where the patient is being removed, the practice will notify the NEFHSA using the Removal of Patient form (see section 8.5) and the appropriate removal notices and patient record markers established. If it is felt that the patients behaviour is such that it could be managed by another practice, the NEFHSA will send the patient a list of practices where they can
10 re-register.
If this is not a suitable course of action, the patients will be dealt with via the Violent Patient Scheme and allocated accordingly to the PCNE service. PCNE will notify system partners of the acceptance of the patient onto the VPS.
11 Review/Removal of potentially violent warning
If no further incidents occur, the potentially violent classification will be reviewed in 12 months. Where the warning is retained, even though no incidents have occurred, reasons must be justified and a written copy kept with the patient medical record.
Where the warning marker is to be removed, the decision will be communicated in writing to the patient by North East Family Health Services Agency. A copy of the letter must be kept with the patient medical record. All warning markers, on both manual and electronic records must be removed.
4.3.7 System Care Pathway
Care Pathway.docx
12 5. PCO/FHSA procedure for removal, re-allocation and marking records of violent patients
5.1 Role of the practice
The practice will be responsible for identifying the problem, carrying out a risk assessment and issuing the patient with an initial warning letter about their behaviour. If the problem persists or a Level 3, 4 and 5 incident occurs, the practice should in the first instance discuss the issue with the service provider.
5.2 Role of the PCO
PCNE will discuss the problem with the practice and, together, decisions will be made about future provision of General Medical Services to the patient and whether their records should be marked to indicate that they are a violent patient. PCNE, when notified, will conduct an assessment of patients moving into the region who are on a Violent Patient Scheme in another PCO area. They will also liaise with representatives from MAPPA / MARAC regarding assessment of individuals subject to the MAPPA process.
5.3 Role of the FHSA
On being informed by the PCO, the FHSA Registration Manager will write to the patient informing them why they are being removed from the practice they are currently registered with and giving details of the practice they are being allocated to. The letter will also inform the patient about their records being marked and their rights in this situation. The FHSA will also arrange for the patient’s records to be fast-tracked to the new practice on the same working day.
5.4 Procedure
Practice identifies problem
Practice carries out risk assessment
Practice issues patient with warning letter if appropriate
13 Outcomes:
Situation resolved No further action Repeated levels 1 or 2 incidents Practice contacts Nominated Lead at PCO to discuss appropriate action. Escalation to Level 3, 4 or 5 incident “Out of the blue” level 3, 4 or 5 incident
NB: Protocol with Northumbria Police should be followed with regard to involvement of Criminal Justice System
5.4.1 Where a patient is removed but not assigned to the Violent Patient Scheme
If the situation cannot be allowed to continue and the patient must be removed from the practice, discussions will focus on the following possible outcomes:
If it is felt that the patient’s behaviour is such that it could be managed by another practice, the NEFHSA will provide details of alternative practices to the patient.
If it is felt that the patients behaviour is such that it could be managed by another practice but it is inappropriate fo the patient to select their own practice, the FHSA will work with the PSCA Commissioning lead to assign the patient to another practice.
Violent Patient Register Decision to be made whether patient’s records to be marked to indicate risk of violence. If a Level 3, 4 or 5 incident has taken place, this should be automatic.
5.4.2 Action by the FHSA
Following notice from the practice and PCNE the Registration Manager at the NEFHSA will ensure the registration system is properly updated.
Allocation to another practice or the Violent Patient Scheme.
Marking patient’s record to indicate risk of violence where appropriate.
Letter to the patient on behalf of PCNE, by registered post, indicating: - the action that has been taken; - how the patient can contact their new GP practice or the VPS.
14 Details will also be provided of the date for review by the Service Provider of the violent warning marker and the patient’s right of appeal.
NEFHSA Registration Manager arranges for the patient’s records to be transferred to the new practice or PCNE within 1 working day.
5.4.3 Further Action by the PCO
PCNE will agree directly with the removing practice acceptance of tients deemed suitable for the scheme.
PCNE will, within their own procedures, inform other relevant agencies and personnel of the violent warning marker, e.g. community staff, social services, A&E and out-of-hours provider(s).
Where the service provider of VPS believes the patient is not suitable for the scheme they should advise the practice to contact the FHSA to request a seven day removal.
Where the NEFHSA believe it is necessary to callocate a patient subject to seven day removal, rather than allowing them choice of practice, they should work with the PCSA Commissioner to idebtify a practice and ensure both former and new practice are aware of the change in responsibilities.
5.4.4 Appeals Process
PCNE will ensure that any appeal by the patient against the violent warning marker is handled according to locally agreed procedures.
The FHSA Registration Manager will remind PCNE when the date for review of the violent warning marker is imminent. PCNE will then take the matter to the appropriate review committee.
PCNE will carry out its own review of the patient’s progress with the new service.
15 6. Premises
PCNE will ensure arrangements have been made for patients identified as being suitable for the Violent Patient Scheme to be registered with or treated at an appropriate location by staff who have had additional training in managing potentially violent patients.
16 7. Violent Patients working arrangements
It is not possible to predict with certainty the likelihood that any individual may commit a violent act in the future. However, an assessment of risk based on a number of factors shown to contribute to the potential for future violence, should be undertaken.
7.1 Determining whether a patient is suitable for Violent Patient Directed Enhanced Service
The General Medical Services (Choice of Practitioner) Regulations entail that any patient that is removed with immediate effect for violence forfeits their right to receive primary care at the place of their choice. It is not only patients removed with immediate effect who may be admitted to the violent patient scheme. There may also be patients, who have not been removed with immediate effect, but because of serial acts of lower level violence may be deemed suitable for the scheme following removal from the practice list.
7.2 Determining whether a patient should remain under the Violent Patient Scheme or return to mainstream General Practice
PCNE convene a meeting every quarter with a panel comprising of:
Representatives from the Violent Patient Service Providers PCO Commissioning Lead Deputy Medical Director LMC representative
This panel will review the behaviour of the patient over the period they have been under the care of the Service and make a decision as to whether the patient should remain on the scheme or be returned to mainstream general practice.
The minimum time a patient is kept on the Scheme is 12 months. Time will be longer when there has been actual violence or repeated difficult behaviour involving the patient and NHS staff.
The length of time will be extended if the Provider Service reports ongoing difficulties in dealing with the patient.
In cases where the patient never presents to the service provider the usual minimum time in this case will be 3 years. However this will be longer in cases of actual violence against NHS staff anf may be indefinite until the patient has been assessed in the Scheme and considered appropriate for routine primary care.
17 VIOLENT PATIENT SCHEME
Index to Documentation
Reference Description Action VPS L1 Warning letter to Patient GP warns patient that their behaviour is not acceptable VPS F1 Incident Report Form GP to complete report form for incidents of violence or abuse VPS F2 Risk Assessment Form GP to complete risk assessment form VPS L2 Letter to Patient GP advises patient that they are now identified as a violent patient VPS L3 Removal of patient from GP form to have patient practice list removed from list 7 day and immediate removal Appendix 1 Developing a Practice strategy Advice for GP Practices Appendix 2 Risk Assessment Guidance Advice for GP Practices Appendix 3 Expected responses Advice for GP Practices Appendix 4 What happens after the case is Advice for GP Practices reported to the police? Appendix 5 Treatment of Patients Advice for GP Practices Appendix 6 CCTV Code of Conduct in Advice for GP Practices relation to Data Protection Act 1998 Appendix 7 Example poster – Expected Advice for GP Practices Standards of Behaviour Appendix 8 Training Strategy Advice for GP Practices
18 5 Templates
5.1 Written Warning Template
[Practice Address]
[Patient Address]
[Date]
Dear [Patient Name]
Incident date: [Date] Incident location: [Location of Incident] Incident details: [Details of Incident]
I am writing to you following the above incident, which took place on [Date]. This incident made staff of the practice feel threatened/ abused. This is unacceptable. You may be aware of the NHS Zero Tolerance Campaign, this practice operates this system. This means that we will meet your health needs in a polite and professional manner and that we expect you to behave in the same way towards doctors and staff working in the practice.
If you do not behave in this way and continue to behave in the above manner, or if you are aggressive in any way (swearing, abusive, threatening or physically violent) then [insert surgery name] will reserve the right to withdraw our involvement and will remove you, and possibly the rest of your immediate family, from our patient list. [insert surgery name] will also take legal action against anyone making threats or being physically aggressive towards its staff or others. These circumstances are under your direct control.
If you wish to discuss this letter please ring [Tel. no] to make an appointment to see [name].
Yours sincerely
Dr
19 5.2 Incident Report Form
Please complete this Incident Report form for each incident of violence or abuse that happens in your practice.
Copy the entire form and send to: [Primary Care Organisation – Contact details]
Retain a copy for reference
Practice Name: Date: (Stamp) Address:
Staff members involved in incident (Please identify all those present) Doctor Receptionist
Practice Manager Other
Nurse
Type of violence (please identify) Level 1 General nuisance/verbal abuse Level 2 Criminal damage, theft, other inappropriate behaviour Level 3 Threatening behaviour Level 4 Violent behaviour Level 5 Physical assault or attempted physical assault
Action Taken
Additional Comments
Person completing report form: PRINT NAME ………………...………………..… Signed …………………………Designation……………….Date……….
GP or Manager: PRINT NAME ………………………………………………………… Signed …………………………Designation……………….Date……….
20 Details of Individual(s) involved:
Date/ Time of Incident
Exact Location of Incident
Cause of Incident (if any)
Was the incident racially motivated?
Description of Incident (Please include any exact words spoken, any weapons used, any threats made. Specify if any of these were either racist or sexist)
Details of Witnesses
Were the police in attendance Yes…… No……. Officer Details
If not were the police called Yes…… No…… If yes by whom and when
Was the incident recorded? i.e. CCTV footage Yes…… No……. Has this been retained? Yes…… No…….
Details of any Injury(ies)
Did the incident result in staff absence Remember the RIDDOR regulations will apply to any absence over 3 days
21 5.3 Risk assessment form
HAZARD RISK WHO EXISTING CONTROLS HOW MANY HOW SEVERE Potential to Cause How Harm Might Might be Harmed Physical Procedural Training Harm Arise
CONCLUSION
RECOMMENDATIONS
ACTION 5.4 Letter to Inform the Patient has been Identified as being Violent
[Practice Address]
[Patient Address]
[Date]
Dear [Patient Name]
Incident date: [Date] Incident location: [Location of Incident] Incident details: [Details of Incident]
I am writing to inform you that due to the above incident it has been necessary to classify you as a potentially violent patient.
The purpose of this decision is to provide advance warning to staff of your past behaviour, allowing appropriate decisions to be made in relation to your access to health services and to protect the safety of staff and members of the public. Health professionals and social services staff providing you with care, Local NHS Trusts and Northumbria Police will be informed of this decision and where appropriate provided details of the incident(s).
If no further incidents occur, the potentially violent classification will be reviewed in 12 months.
These actions are in accordance with procedures agreed by Northumberland, Tyne and Wear Strategic Health Authority, local Primary Care Trusts and Northumbria Police.
If you believe that the details above are inaccurate please contact [Practice Contact Details].
Yours sincerely
[GP Name] 5.5 Removal of patient from practice list
Patient Name NHS No. DOB
Address
Length of time registered with practice
Please tick as appropriate:
I wish to apply for the removal of this patient from my practice list under the 7 DAY REMOVAL regulation. (I confirm that I am not treating this patient at periods of less than 7 days) □
I wish to apply for the IMMEDIATE REMOVAL of this patient from my practice list □
History of violent or other relevant incident(s) with dates where possible: Including current episode
If no violent incident, reasons for request for removal:
Have you notified the patient of the reason for removal: Yes□ No□ Details of PCT/ Strategic Health Authority/ Police Involvement (with contact names where possible)
24 Details of any other agency involved (e.g. CPN, psychiatrist, social worker) with contact names and numbers if possible:
Current medication, including frequency (i.e. weekly, monthly etc.) and date of last issue:
Known medical problems (including current condition):
Any other relevant comments:
Practice Stamp Signed ………………………………. Registered GP
25 Appendix 1
Developing a Practice Strategy
Services should not wait for a violent incident to happen before developing a strategy for coping with violence. Having patients/clients on the list who are known to be aggressive or having experienced a potentially violent incident would indicate the need for a strategy. All members of the Primary Health Care Team should be involved in the production of the strategy and be given the opportunity to comment upon it during consultation.
1. Key elements of a strategy
Agree a definition of violent or abusive behaviour to ensure all staff have a common understanding. Detail situations which may precipitate a violent incident. Action to be taken to defuse a potentially violent situation. Action to be taken in the event of a violent or abusive situation: - by whom; - within clear line of accountability Action to be taken following a violent or abusive incident. List training requirements Detail the recording and reporting mechanisms
1.1 Patients/Clients
Consider which patients/clients you are identifying. Patients/clients with: - a history of aggressive/abusive behaviour - an unstable psychiatric illness - a history of drug/alcohol misuse
1.2 Patient/Client Services
Consider incidents when violence or aggression may happen: - patient/client unable to see health care worker immediately or health care worker of choice Services requiring payment Prescription requests from chronic drug abusers lost notes/results
1.3 Patients/clients relatives wishing to make formal complaints
Discussing difficult issues with patient/client e.g. child abuse, domestic violence breaking bad news
26 1.4 Premises
Consider risks in the premises: - glass windows/screens - narrow, low reception desk - blocked exits - overcrowding - lack of privacy for patient/reception discussion
27 Appendix 2
Risk Assessment Guidance
1. Practice Risk Assessment
Prevention of violence at work must start with a full assessment of the risks. Risk assessments should be carried out by appropriately trained staff gathering information from a number of sources at both practice and employee level.
2. Environment
Assessing environmental factors can help to ensure that the physicality of a place does not trigger or exacerbate a violent situation. The environment in which staff work, patients are treated and other members of the public visit can have a significant influence on behaviour.
Particular attention should be given to the following:
o that areas are kept clean and hospitable, in particular reception and waiting rooms; o the temperature is controlled during seasonal extremes to maintain an environment which is comfortable, e.g. warm enough in winter and cool enough in the summer (making best use of fresh air); o ensure sufficient ventilation in rooms used for waiting; that space is properly planned to avoid overcrowding and facilitate the movement of people; o that comfortable seating is provided (secured to the floor if necessary); o all signs are clear, simple and suitably visible to direct people to the appropriate location, e.g. treatment rooms, toilets and other facilities; o how to make best use of daylight. Where artificial lighting is used, ensure that this provides enough lighting and is regularly maintained to avoid flickering and failure; o the external environment, e.g. lighting in car parks, concealed areas and unused areas o that access to the building is controlled and monitored, e.g. consider the use of a single entrance/exit where possible; and o using secure lockable doors where patient/visitor access is restricted.
This list should not be considered as exhaustive but illustrative, as there may be factors specific to each building.
The use of CCTV has been well documented as a good disincentive against violent and abusive behaviour. Where CCTV is in use, this should be indicated clearly, along with the reason for its use. CCTV footage is subject to the Data Protection Act and Human Rights Act.
28 CCTV footage should be monitored and retained by employers as it may serve as useful evidence in the event of a prosecution.
Calming measures can help reduce boredom, frustration and anxiety: Consider reducing boredom by;
o providing up-to-date reading material o through the use of other forms of entertainment such as television or radio o adult patients and visitors can be frustrated by noisy children. Try to avoid this by providing play facilities to entertain children o provide patients and visitors with up-to date and easily understood information on waiting times
3. Equipment
o Healthcare records should be stored in a fire proof safe or in an area of the building under lock and key o Store syringes/needles in a locked cupboard o Keep a minimum amount of cash and lock it away in cash box o Store back up computer discs away from the premises or in fire proof safe o Anchor computers to desks, or lock them away each night
4. Drugs and Prescription Pads
o Provide secure storage o Be satisfied of the requirement for medication before prescribing o Keep the office prescription stamp secure o Do not sign prescriptions in advance
5. Home Visits
o ensure the patient’s address is genuine o before undertaking a home visit to a potentially violent situation consider whether the police should be notified of your intention to visit o tell someone where you are going and what time you are likely to return o don’t use vehicle “doctor on call” /”nurse on call” sticker o keep basic drugs in an unobtrusive bag and lock in the boot until reqired o lock car doors, when driving o if you are suspicious about the circumstances of the visit return to the car o if violence is threatened leave immediately unless medical requirements preclude this. Try to summon assistance o carry mobile phone, personal attack alarm
29 6. Additional precautions at night
o ask the patient to put the lights on at the front of the house to help identify the house and reduce risk o take a powerful torch with a long beam o try to park in a well lit area but as close to the entrance of the house as is practicable o don’t carry cash/credit cards etc
7. Other Factors
Other factors, which should be taken into account when assessing risk, are aggravating features such as:
o being unable to get support; o being unable to trace staff; o staff under pressure; o working alone or being in the car alone; o potential weapons to hand; and/or o no staff available.
8. Other Considerations
The receptionist's role. Receptionists take the brunt of verbal abuse and aggression, particularly that arising from the patient's perception of failures in practice administration. Some practices have adopted uniforms for receptionists to increase patients' respect for them. Staff on reception should be appropriately trained and supervised and feel supported in expressing any concerns they have about dealing with angry, abusive or threatening patients.
8.1Recommended communication strategies towards patients include: o trying to be positive, always offering the patient something rather than outright refusal; o referring the aggressive or aggrieved patient to a more senior member of staff (e.g. practice manager or doctor) rather than entering into arguments; o not exceeding one's responsibility by appearing to make inappropriate judgements about patients' needs; and o respecting the dignity of all patients and 'befriending' the vulnerable ones.
8.2 Recommended organisation features include: o more than one receptionist available at all times. This allows for someone to 'take over' if an interaction appears to be getting out of
30 hand, or for a senior member of staff to be discreetly summoned without leaving the desk unmanned; o established routines for unlocking and locking up premises at the beginning or end of the day (and not having to do these on one's own); o being able to communicate quickly but discreetly with doctors during surgery e.g. to alert doctor about aggressive patient e.g. via dedicated phone or message posted on computer; and o electronic signboards or monitors through which patients could be easily informed about doctors running late etc. In the absence of these, reception staff should be trained and aware of the benefits of explaining the causes of delays to waiting patients.
It is recognised that the ability to deliver these features is partially dependent on the size of the surgery.
31 9. Person Risk Assessment Form
The following tool is not intended to replace existing health and safety/clinical risk assessment tools but provides a useful assessment for individuals in their day-to-day practice.
The tool will not be used by the panel assessing patient’s suitability for inclusion into the Violent patient service.
9.1 Two minute risk assessment
Do you know the person? Yes 5 No 10
If yes, does the person have a known history of violence? Yes 10 Don’t know 10 No 0
Has the person become verbally abusive or suddenly become quite? Yes 10 No 5
Has the person said he/she intends to become violent towards you or your colleague? Yes 10 No 0
Does the person have or appear to have a mental health problem? Yes 10 No 0
Is the person under or appear to be under the influence of drugs/ alcohol? Yes 10 No 0
Is the task being undertaken likely to cause the person to become angry? For example, are you giving bad news or doing something the person may find painful or distressing? Yes 10 No 0
Are there sufficient numbers of staff on duty and available to manage a violent situation should it arise? Yes 5
32 No 10
Does your employer/ practice provide safety first for staff? CCTV 9 Personal alarm system 9 Training in aggression management 5 All of the above 3 No 10
Do staff feel comfortable about the situation? Yes 5 No 10
Add up the scores:
13 – 34: Low risk of violence 35 – 84 Medium to high risk of violence 85 – 100: High risk of violence
33 10. Example Risk Assessment Form
WHO HAZARD RISK HOW MANY EXISTING CONTROLS HOW SEVERE
Potential to How Harm Might Might be Harmed Physical Procedural Training Cause Harm Arise Attack/assault by individual staff interview protocols de-escalation client/other member potential for more techniques giving “bad news” ASSAULT/ than one staff to client PHYSICAL member to be layout of building VIOLENCE present no covert method client assessment of raising alarm procedures first contact procedures CONCLUSION
Signage within the clinic is poor resulting in clients accessing certain areas erroneously. An audit of training should be carried out and appropriate de-escalation training set up. Further efforts could be made to better segregate staff and patient areas, particularly the staff facilities adjacent to tIme staff entrance.
RECOMMENDATIONS
ACTION Appendix 3
Expected Responses
The guidance in this section is from the Violence in GP Surgeries Protocol agreed between the Chief Constable of Northumbria Police and the Northumberland, Tyne & Wear Strategic Health Authority and Primary Care Organisations in the Northumbria Police Area.
1. Verbal abuse
Unexpected Anticipated Medical Police Medical Police Trained staff to defuse the As specified under If a repeat incident takes In most serious cases, where situation ‘anticipated’ place then in the most serious there is a repeat incident, the Verbal warning and/or written cases Police will be contacted on warning Call the police, taking account the proviso that: Incident report form of the personal/medical (i) Witness statement will completed and sent to PCO circumstances of the be provided Copy of written warning sent offender. (ii) Action may include: to PCO. If the anticipation is not due Verbal warning
35 The police will only be to previous threats, i.e. no Prosecution informed in relation to the written warning has been Application for ASBO or other most serious cases where it sent, this should be appropriate action depending is a repeat incident as considered prior to the on the circumstances. outlined under ‘anticipated’. consultation. Copy of this letter to PCO IP to make a comprehensive record for use as evidence if needed in the future, using incident report form.
36 2. Threatening behaviour
Takes place – unexpected Anticipated - to take place Medical Police Medical Police Trained staff will attempt to If the police are called they If the anticipation is not In most serious cases or defuse the situation. will consider action under: due to previous threats, where there is a repeat Police to be called via 999 (i) CJS - Criminal Justice i.e. no written warning has incident, the police will be system in extreme cases if the System been sent, this should be contacted on the proviso threat is real and the incident (ii) ASBO - Anti Social considered. (Copy to that: ongoing. Behaviour Order PCO). (i) Witness statement will be If the police are not called as Identify the threat level by provided above at the time of the incident conducting a risk (ii) Action may include: and staff still feel threatened - assessment. Verbal warning the practice will contact the Draft an action plan. Prosecution police using non 999 system to If the threats take place, Application for ASBO make a complaint, providing action to be taken in or other appropriate evidence in order that action can accordance with the action action depending on be taken. plan. the operational Incident report form to be Police to be informed as discretion of the Police completed. per the criteria specified Officers as to the Post incident - Written warning under ‘unexpected’ factors to be actioned, to the patient. If no action has -threatening behaviour. dependent on the been taken as above, this will Incident report form to be circumstances include the fact that: completed. available. the conduct displayed was unacceptable the future implications, action if repeated – Inform PCO and supply copy of warning letter.
37 3. Assault
Takes place – unexpected Anticipated - to take place Medical Police Medical Police Trained staff will attempt to Post Incident GP to contact the police and Consult with GP and PCO to defuse the situation. Action to be taken under liaise with PCO. determine action plan. Police will be called via 999. CJS. A witness statement to Obtain details of past Post Incident Post incident be provided. Earlier events incidents where applicable. The police will be contacted Written warning as to the may be included in the file of Police, GP and PCO to on the proviso that: behaviour. To include evidence. PCO will have an consult and determine action (i) A witness statement will conditions and arrangements index of previous incidents. plan. be provided. for future treatment as Victim, PCO nominee and GP Findings to PCO updated. (ii) Action may be taken recorded in the future plan. to liaise with police (SPOC) Plan implemented. within the Criminal Justice Future Plan regarding intelligence. Police If an incident occurs, police System Copy of warning letter to to assist with the formulating action as ‘unexpected’. PCO or nominated person. of a risk assessment and a future action plan Post Incident Future treatment of patient to (documented). If an incident occurs call be considered by GP police via 999. Surgery. Action under CJS. Liaise with the police post- Review patient care for incident. future. Incident report form to be completed.
38 Appendix 4
What happens after a case is reported to the Police
1. Introduction
The police are responsible for investigating crimes and will charge offenders when there is sufficient evidence to do so.
Alternatively, the police may decide to issue a warning, or to formally caution an individual. A caution is sometimes given by the police where an offence has been committed but they decide not to take the person to court because that person has admitted the offence and agreed to be cautioned.
Whether a caution is an appropriate response will depend upon the seriousness of the offence and will involve consideration of such factors as the offender’s previous record and his/her attitude to the offence. A police caution is not an easy option when dealing with an offender but is serious and will affect how that person is dealt with in future.
Should the person re-offend, the fact that he or she has a previous caution will be a factor in the police decision whether or not to prosecute. In addition, a previous caution may be cited in court and could, therefore, increase any sentence received for the new offence.
If the police decide to charge someone, the case is passed to the Crown Prosecution Service [CPS]. The CPS is a national service, which prosecutes criminal cases in England, and Wales referred to them by the police. CPS lawyers are governed by the Code for Crown Prosecutors.
All cases have to be reviewed to make sure they pass the two tests set out in the Code. The first test is the evidential test – there has to be sufficient evidence for there to be a realistic prospect of a conviction. Criminal cases have to be proved beyond reasonable doubt, so there must be clear and reliable evidence that the offence was committed.
In assault cases it is necessary to prove that the offender either meant to harm someone, or knew that their behaviour created a risk of harming someone, but still carried on.
It is only if the papers pass the evidential test that the second test is applied. This is the public interest test. The Code says “although there may be public interest factors against prosecution in a particular case, often the prosecution should go ahead”.
The Code sets out public interest factors in favour of prosecution. It states that “ a prosecution is likely to be needed if…… the offence was committed against a person serving the public (for example, a police or prison officer or a nurse)”.
Assaults against staff working in the NHS are therefore regarded as serious matters, worthy of prosecution.
2. Where are the cases heard?
All criminal cases begin with a hearing in a magistrates’ court. Assaults are dealt with both in the magistrates’ court and the Crown Court. Some assault charges can only be dealt with in the magistrates’ court where the maximum penalty is six months imprisonment. The advantages of hearings in the magistrates’ court are that they can be dealt with more quickly, the courthouse is likely to be more local to witnesses and hearings are more informal, so it is easier to be at ease when giving evidence.
Most serious charges of assault are dealt with in the Crown Court, where there are greater powers of punishment. Some cases can be heard either in the Crown Court or the magistrates’ court. The alleged offender has a choice as to where the case is heard but the magistrates have to be satisfied that their powers of punishment are sufficient before they agree to hear the case.
3. What happens if I am required to give evidence as a witness?
The police will tell you if you need to appear in court as a witness. All agencies within the criminal justice system work together to provide a co- ordinated service to witnesses, implementing national standards of witness care. Giving evidence in court can be stressful but the people involved - the police, the CPS and court staff - will give you as much information as possible about what is likely to happen.
All Crown Courts and many magistrates’ courts have Witness Service Schemes run by Victim Support and local magistrates’ courts charters set standards of service to witnesses. The CPS has made a public declaration of its principles in the CPS Statement of Purpose and Values: “We will show sensitivity and understanding to victims and witnesses”.
Information about standards of victim/witness care can be found in the following publications:
Statement on the treatment of victims and witnesses by the CPS – explains CPS policies about victims and witnesses and how commitments are put into practice. Home Office leaflet “Witness in Court” – tells witnesses what to expect when asked to go to a magistrates’ court or the Crown Court to give evidence. Home Office publication “The Victim’s Charter” – a statement of service standards for victims of crime.
40 Court Service publication “Court Charter” – sets out important standards which can be expected in the Crown Court. Each Magistrates’ Courts’ Committee publishes their own charter, available from local magistrates’ courts.
4. Sentencing
You may attend the sentencing hearing if you wish, even if you were not present at earlier hearings as a witness. The CPS will keep you informed about the progress of a case and tell you when your attacker is to be sentenced. An unexpected guilty plea at an earlier hearing could however result in sentence being given immediately.
The sentence is a matter for the court alone; magistrates and judges are independent from any individual or organisation. In sentencing the judge or magistrates take into account all the circumstances in which the offence occurred and those of the offender:
the circumstances of the offence will be known to the court if your attacker has pleaded not guilty and a trial has taken place. If they have pleaded guilty the prosecutor will set out the facts of the case. the circumstances of the offender will be available to the court from: the defendant's legal representative when presenting mitigation to the court; the defendants themselves if not legally represented; the probation service, medical or psychiatric reports ordered by the courts.
The sentencing guidelines, issued by the Magistrates Association to its members, make it clear that an assault is made more serious if the victim is a person who is assaulted while serving the public.
The Lord Chancellor, who is also President of the Magistrates Association, has said that it is entirely legitimate for magistrates to respond decisively to a particular form of criminal behaviour, such as assaults on NHS staff, and to impose a sentence, which has a deterrent component.
Magistrate’s courts can impose up to six months imprisonment for common assault or assault occasioning actual bodily harm. If appropriate magistrates’ courts can commit to the Crown Court which can pass a stiffer sentence. The Crown Court can impose substantial periods of imprisonment and, in cases involving the very worst type of attacks, a sentence of life imprisonment may be imposed.
5. Compensation
Magistrates can award compensation for personal injury, loss or damage up to a total of £5,000 for each offence. You can expect the court to consider the possibility of compensation whether or not you make a claim, but if there is
41 any information you wish the court to consider in this respect, you should pass this to the Crown Prosecution Service. If no compensation is given you can expect the magistrates to give their reasons for not making an award. Compensation may only be awarded if the offender has means.
Whether or not a criminal court awards you compensation you may pursue a separate claim in the civil courts either privately or with the assistance of your union/professional association, employer or the PCT’s Chief Executive. Another way of seeking compensation is through the Criminal Injuries
6. Compensation Scheme
If you have been injured because of a crime of violence you can apply for compensation under the scheme. It doesn't matter whether the offender has been caught or not. Copies of the information pack with an application form can be obtained from the Police, Victim Support, Citizens Advice Bureau or direct from the Criminal Injuries Compensation Authority, Tay House, 300 Bath St, Glasgow, G2 4JR. Tel 0141 331 2726
42 43 Appendix 5 Treatment of Patients
This appendix provides a reminder of the National Health Service (General Medical Services) Regulations concerning treatment of patients. This guidance does not cover all eventualities, further information or clarification can be obtained from Primary care organisations.
Patients have a right under the regulations to be registered with a General Practitioner for the provision of medical services. Where a Patient cannot find acceptance by a GP the FHSA can allocate the patient to a GP who, subject to appeal, must accept that patient onto their medical list.
A GP can remove a patient from their list under the following conditions:
Reason Period of responsibility before removal Patient moves outside the practice area 30 days Removal from practice list at doctors request 7 days GP notifies FHSA of wish to remove patient 24 hours (where a complaint has been made to the Police)
Where a patient who is not registered with the GP, requires services in an emergency, or which is deemed immediately necessary, the GP is required to provide such services as he or she deems medically appropriate.
44 Appendix 6
CCTV Code of Conduct in relation to Data Protection Act 1998
1. Location of equipment
It is essential that the location of the equipment is carefully considered, because the way in which images are captured will need to comply with the First Data Protection Principle.
1.1 Standards
o The equipment should be sited in such a way that it only monitors those spaces which are intended to be covered by the equipment. o If domestic areas such as gardens or areas not intended to be covered by the scheme border those spaces which are intended to be covered by the equipment, then the user should consult with the owners of such spaces if images from those spaces might be recorded. In the case of back gardens, this would be the resident of the property overlooked. o Operators must be aware of the purpose(s) for which the scheme has been established (Second and Seventh Data Protection Principles). o Operators must be aware that they are only able to use the equipment in order to achieve the purpose(s) for which it has been installed (First and Second Data Protection Principles). o If cameras are adjustable by the operators, this should be restricted so that operators cannot adjust or manipulate them to overlook spaces which are not intended to be covered by the scheme. o If it is not possible physically to restrict the equipment to avoid recording images from those spaces not intended to be covered by the scheme, then operators should be trained in recognising the privacy implications of such spaces being covered. o Signs should be placed so that the public are aware that they are entering a zone which is covered by surveillance equipment. The signs should contain the following information: - Identity of the person or organisation responsible for the scheme. - The purposes of the scheme. - Details of whom to contact regarding the scheme e.g. "Images are being monitored for the purposes of crime prevention and public safety. This scheme is controlled by the [Organisation Name].” - For further information contact [Contact Telephone number]
2. Quality of the Images
It is important that the images produced by the equipment are as clear as possible in order that they are effective for the purpose(s) for which they are intended. This is why it is essential that the purpose of the scheme is clearly identified. For example if a system has been installed to prevent and detect
45 crime, then it is essential that the images are adequate for that purpose.
2.1 Standards
o Upon installation, an initial check should be undertaken to ensure that the equipment performs properly. o If tapes are used, it should be ensured that they are good quality tapes. o The medium on which the images are captured should be cleaned so that images are not recorded on top of images recorded previously. o The medium on which the images have been recorded should not be used when it has become apparent that the quality of images has deteriorated. o If the system records features such as the location of the camera and/or date and time reference, these should be accurate. o Cameras should be situated so that they will capture images relevant to the purpose for which the scheme has been established. o Users should assess whether it is necessary to carry out constant real time recording, or whether the activity or activities about which they are concerned occur at specific times. For example – it may be that criminal activity only occurs at night, in which case constant recording of images might only be carried out for a limited period e.g. 10.00 pm to 7.00 am. o Cameras should be properly maintained and serviced to ensure that clear images are recorded
3. Processing the images
Images, which are not required for the purpose(s) for which the equipment is being used, should not be retained for longer than is necessary.
3.1 Standards
Images should not be retained for longer than is necessary (Fifth Data Protection Principle). For example – images recorded by equipment covering town centres and streets may not need to be retained for longer than 3l days unless they are required for evidential purposes in legal proceedings. Once the retention period has expired, the images should be removed or erased. If the images are retained for evidential purposes, they should be retained in a secure place to which access is controlled. On removing the medium on which the images have been recorded for the use in legal proceedings, the operator should ensure that they have documented: - The date on which the images were removed from the general system for use in legal proceedings; - the reason why they were removed from the system; - any crime incident number to which the images may be relevant; - the location of the images;
46 - the signature of the collecting police officer, where appropriate (see below)
Monitors displaying images from areas in which individuals would have an expectation of privacy should not be viewed by anyone other than authorised employees of the user of the equipment. Access to the recorded images should be restricted to a manager or designated member of staff who will decide whether to allow requests for access by third parties in accordance with the user’s documented disclosure policies. Viewing of the recorded images should take place in a restricted area, for example, in a manager’s or designated member of staff’s office. Other employees should not be allowed to have access to that area when a viewing is taking place. All operators and employees with access to images should be aware of the procedure which need to be followed when accessing the recorded images. All operators should be trained in their responsibilities under this Code of Practice i.e. they should be aware of: - the user’s security policy e.g. procedures to have access to recorded images; - the user’s disclosure policy; - the rights of individuals in relation to their recorded images.
4. Access to and disclosure of images to third parties
It is important that access to, and disclosure of, the images recorded by CCTV and similar surveillance equipment is restricted and carefully controlled, not only to ensure that the rights of individuals are preserved, but also to ensure that the chain of evidence remains intact should the images be required for evidential purposes.
4.1 Standards
Access to recorded images should be restricted to those staff who need to have access in order to achieve the purpose(s) of using the equipment. All access to the medium on which the images are recorded should be documented Disclosure of the recorded images to third parties should only made in limited and prescribed circumstances. For example, if the purpose of the system is the prevention and detection of crime, then disclosure to third parties should be limited to the following: - Law enforcement agencies where the images recorded would assist in a specific criminal enquiry - Prosecution agencies - Relevant legal representatives
47 - The media, where it is decided that the public’s assistance is needed in order to assist in the identification of victim, witness or perpetrator in relation to a criminal incident. As part of that decision, the wishes of the victim of an incident should be taken into account - People whose images have been recorded and retained (unless disclosure to the individual would prejudice criminal enquiries or criminal proceedings) - All requests for access or for disclosure should be recorded. If access or disclosure is denied, the reason should be documented. - If access to or disclosure of the images is allowed, then the following should be documented: - The date and time at which access was allowed or the date on which disclosure was made - The identification of any third party who was allowed access or to whom disclosure was made - The reason for allowing access or disclosure - The extent of the information to which access was allowed or which was disclosed - Recorded images should not be made more widely available - for example they should not be routinely made available to the media or placed on the Internet. - If it is intended that images will be made more widely available, that decision should be made by the manager or designated member of staff. The reason for that decision should be documented. - If it is decided that images will be disclosed to the media (other than in the circumstances outlined above), the images of individuals will need to be disguised or blurred so that they are not readily identifiable.
5. Access by data subjects
5.1 Standards
o All staff involved in operating the equipment must be able to recognise a request for access to recorded images by data subjects o The manager or designated member of staff should determine whether disclosure to the individual would entail disclosing images of third parties. o The manager or designated member of staff will need to determine whether the images of third parties are held under a duty of confidence. o If third party images are not to be disclosed, the manager or designated member of staff shall arrange for the third party images to be disguised or blurred. o If the manager or designated member of staff decides that a subject access request from an individual is not to be complied with, the following should be documented: o The identity of the individual making the request o The date of the request o The reason for refusing to supply the images requested
48 o The name and signature of the manager or designated member of staff making the decision
6. Monitoring compliance with this code of practice
6.1 Standards
o The contact point indicated on the sign should be available to members of the public during office hours. Employees staffing that contact point should be aware of the policies and procedures governing the use of this equipment. o A manager or designated member of staff should undertake regular reviews of the documented procedures to ensure that the provisions of this Code are being complied with.
7. CCTV Data Protection Notification
When taking part in a process to identify potentially violent patients it is essential that general practices are appropriately notified under the Data Protection Act. The following details must be included in your Data Protection notification:
o Purpose: Crime prevention and prosecution of offenders
o Data subjects: patients (S107) members of the public
o Data classes: personal details (C200); offences (including alleged offences) (C212); criminal proceeding, outcomes and sentences (C213)
o Recipients: the data subject themselves (R400); healthcare, social and welfare advisors or practitioners (R403); employees and agents of the data controller (R406); trade, employer associations and profession bodies (R415); police forces (R416); local government (R418); voluntary and charitable organisations (R420); data processors (R425) 7.1 Actions
You should verify if your current data protection notification includes the purpose and details above. This can be done by:
49 o Checking the details on your current notification (a copy is provided to you when you notify) o Via the Internet at http://www.dpr.gov.uk/search.html. Enter your practice name and address or your registration number o By calling the Office of the Information Commissioner on Tel 01625 545 740 (Notification Line)
If the current notification for your practice does not include the purpose and details above use the attached form to amend your notification. The notification details have been added, you will need to complete:
o Data controller name (on your current notification/ Office of the Information Commissioner website – see above) o Registration number (on your current notification/ Office of the Information Commissioner website – see above) o Security number/user number (on your current notification)
7.2 Completed declaration
Send to the completed from to the Notification Changes Section, Information Commissioner’s Office Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF
50 PURPOSE FORM (for adding a purpose to a notification) A purpose form must be completed for each new purpose You must quote your Security number or the form will be returned Data controller name:
Registration number:
Security number/user number:
Purpose title: Crime prevention and prosecution of offenders See Notification Handbook Section 3.1.8 for full list
Write here a brief description only if none of the standard purposes apply.
Data Subject Codes: S107 See Notification Handbook Section 3.1.9 for full list
Write here additional Members of the Public descriptions only if none of the standard descriptions apply.
Data Class Codes: C200 C212 C213 See Notification Handbook Section 3.1.10 for full list
Write here additional descriptions only if none of the standard descriptions apply.
Recipient Codes: R400 R403 R406 R415 R416 See Notification Handbook Section 3.1.11 for full list R418 R420 R425
Write here additional descriptions only if none of the standard descriptions apply.
Transfers: None outside EEA See Notification Handbook Worldwide page 18 for list of Name individual countries below countries in the EEA If there are more than ten countries indicate Worldwide The declaration overleaf MUST be completed
51 Declaration
To the best of my knowledge and belief, the particulars given in this form and on any continuation sheets are correct and complete. I confirm that I am the Data Controller named overleaf or that I am authorised to act on behalf of the Data Controller.
Signature ______
Name ______
Job Title ______
Date ______
Tel. No. ______
Note:
Once you have notified you must keep your register entry up to date. When any part of your entry becomes inaccurate or incomplete you must inform us. This action must be taken as soon as practicable and in any event within a period of 28 days from the date on which your entry became inaccurate or incomplete. Failure to do so is a criminal offence.
Send this form with your Part 1 and Part 2 if making a new notification
Or
If amending an existing notification send to: Notification Changes Section, Information Commissioners Office Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF
52 Appendix 7
Example Poster: Expected Standards of Behaviour
This practice has signed up to the NHS Zero Tolerance Campaign which makes verbal abuse, threat and physical violence to all NHS staff unacceptable.
The following are examples of behaviour that are not acceptable:
Physical assault, Attempted physical assault or threat of physical assault Threatening or abusive language e.g. swearing or offensive remarks Racist or sexist remarks Offensive sexual gestures or behaviour Abusing alcohol or drugs in practice premises Drug dealing Theft from other patients, staff or theft of equipment Malicious allegations relating to members of staff, patients or visitors Excessive noise e.g. loud or intrusive conversation or shouting Vandalism to the building, furniture or equipment
53 Appendix 8
Training Strategy
1. Introduction
While violence and aggression management training is not mandatory under current health and safety legislation, violence and aggression is a recognised risk in any service that deals with the public. Such training, therefore, must be recognised as a key control in managing violence and aggression. A competency based approach to training should be adopted for all staff, with needs being established by risk assessment. In this way resources are targeted to those at most risk.
2. Risk based competency
The risks faced by staff are broadly determined by the nature of their work and where it takes place. A member of staff who only works in the practice building will face different risks and a different degree of risk from colleagues who undertake home visits.
Similarly the risks faced by practices participating in the Violent Patient Scheme will be greater than those choosing not to. However, risk assessment, training and the circumstances of the service should be designed to reduce these risks to an acceptable level.
3. Purpose of training
Training will not reduce the risk of violence, only its potential consequences to the staff member(s) faced with the aggressive patient. For example, training can enable staff to identify aggression at an earlier stage, before it may escalate to physical assault.
4. Recommended training techniques
Many training agencies teach a range of physical skills and techniques. The drawback of this approach is the physical training requires regular practice for it to be effective. Since dealing with physically violent patients (or their carers) is a rare event, this introduces an inherent risk in use of physical techniques in this context.
Physical training also raises issues regarding the personal fitness/physical abilities of individuals undertaking training.
Given these considerations, it is not recommended that physical techniques form part of the training package, though this should be left open to review
54 especially for those who will be dealing with the aggressive patient on their own behind a closed door. There are however, a wide range of other non-physical interventions that can be used coupled with the physical layout and facilities of the practices involved.
Any training arranged through the VPS scheme should not absolve any practice from the legal responsibility to provide appropriate and adequate health and safety training to its staff. The general training model should however be able to be readily extended to practices outside the scheme as an example of sharing best practice, once scheme participants have been trained.
5. Training model
The training must cover all practice staff who are likely to deal with aggressive patients as part of their job, this will include GP’s, practice nurses and reception staff.
Training should include:
o Recognising aggression, o Verbal and non-verbal communication, o De-escalation techniques o Summoning assistance
The training should be supplemented with advice on:
o Room layout o Developing in-house emergency procedures, o Supporting other staff o Incident reporting
55 6. Identified Training requirements
Staff Group Requiring Training Reception Practice Nursing Medical Training Element Staff Managers Staff Staff Recognising Aggression and Arousal Listening Skills Aggression on the Telephone Verbal De-escalation Techniques Simple Non Verbal De-escalation Techniques Warning Signs and Signals Summoning Assistance Reporting Incidents Local Practice Response Protocols Further Non Verbal De-escalation Techniques Risk Assessment – Room Layout/ Equipment Summoning Assistance Danger Signs and Signals De-escalation Following an Incident Incident De-briefing Staff Support
The above matrix illustrates what training might be offered to any practice wishing to participate on the Violent Patient Scheme. None of the training elements should be seen as rigid, the list is merely illustrative.
56 It will also be important that training reflects the physical environment where treatment will be given and that response protocols are developed for the venue taking into account the availability of other staff or agencies.
7. Training issues
7.1 Introduction This paper sets out a potential approach to training for practices that opt to participate in their Directed Enhanced Service. It is not intended to be extended to all practices and does not in any way remove the responsibility of all employers to ensure their employees receive appropriate health and safety training.
7.2 Physical techniques The risks from providing training on breakaway and other physical techniques outweigh the benefits. Those that would require such training would be the doctors themselves. These skills must be regularly updated and practiced if they are to be effective; fortunately patients being dealt with under the VP Scheme are rare.
Actual use of breakaway and other physical techniques requires anyone using them to be relatively physically fit (or at least have no back, neck or arm problems). This would impose another criterion by which to assess a practice’s ability to participate in the scheme, reducing further the number of practices likely to volunteer.
Training in physical techniques can make staff overconfident leading them to take risks or enter situations that they may not have done otherwise. There is also no guarantee that a particular technique will work on every individual.
If a situation is becoming unmanageable and looks to be escalating towards physical violence to the staff member the most appropriate action is to call 999 for emergency police response. The same action should always be taken if the patient makes physical contact with a staff member.
7.3 Tailored training In any practice opting to participate in the scheme three distinct staff groups will require training: -
Reception staff - will need to be trained how to defuse potential problems and a range of de-escalation techniques (both verbal and non verbal). It is also crucial that they are thoroughly conversant with the scheme and their practice’s participation in it. Reception staff will be the most likely to summon emergency Police assistance. They need to be trained to initiate this response and what information will be required.
57 Practice Nurses (either employed or attached) - may need to deal with LDS patients and will also need to be trained in verbal and non-verbal de-escalation techniques. Practice nurses could also develop other complimentary strategies e.g. peer support when dealing with VPS patients (i.e. 2 nurses always present during treatment).
o Medical staff - need to be trained in a wide range of verbal and non- verbal de-escalation techniques. They need also to know how to summon assistance.
In addition to this training, participating practices need to consider what their own internal response protocols will be. Staff need to be trained in these as well; particularly how to raise an alarm/call for help and who should summon the Police and when.
8. Next steps
Training should be offered to participating practices. Practices should be involved in drawing up the specification for this training.
Participating practices must be assisted in developing appropriate local response protocols and staff trained in these (only appropriate if VPS patients will be seen in practice premises.)
If someone else’s premises are to be used e.g. walk-in centres, A & E, participating practice staff will need to be conversant with the local protocols for raising an alarm and responding to one.
58