Restricted access and egress policy (G134)

The need to maintain a safe environment for the protection and personal safety of both patients and staff within in-patient areas is of the utmost importance.

This Restricted Access and Egress policy aims to ensure a balance between maintaining both the patients’ human rights and their personal safety.

Any restrictions to an individual’s freedom is always taken seriously and only considered when an individual’s health, safety or wellbeing are assessed to be at risk when they have diminished capacity to judge when and where it is safe.

Restrictions may also be necessary when there is potential risk posed by a member of the public, patient or adverse event, to the health, safety and welfare of other people.

Purpose

The purpose is to provide guidance to staff as to the circumstances in which doors can be locked by the nurse in charge of the shift and to the procedures which must be followed. Advice regarding monitoring of the implementation and record keeping is also provided.

Definitions

• Access and Egress - Entry and exit to a hospital ward or unit.
• Open unit – A clinical area where doors are routinely unlocked during ‘daytime’ hours and patients / visitors can enter and exit as they wish without assistance from a staff member, e.g. University Hospital Ayr (UHA) Station 16 where there is a facility to lock the external station door between the hours of 10pm and 6am for staff and patient safety.
• Locked door area - A ward or unit where access and/or egress is controlled by a key (mechanical or electronic), combination lock or keypad. Access or egress is only possible by a request to a staff member. Patients and visitors therefore have no means of leaving the ward independent of a formal request to staff, e.g.
  • University Hospital Crosshouse (UHC) Intensive Care Unit - access is controlled by visitors using a buzzer system to request entry.
  • UHC Ward 5d –only egress is restricted, using a key pad exit system. Access is controlled by a push button system as with all ward areas in main UHC site.

Scope of the guidance

This policy is applicable to all NHS Ayrshire & and Arran, Acute Hospitals staff but, specifically to the following areas:
UHA – Station 16
UHC - Ward 5D and Intensive Care Unit.

This policy is specifically applicable to the following areas:

• UHA – Station 16
• UHC - Ward 5D, Paediatric Unit and Intensive Care Unit.

Doors to the areas above may be locked in certain circumstances, only if all less restrictive options have been explored in the first instance.
These options include, but are not restricted to:-

• Engagement/distraction with meaningful activities
• Family/carer support
• Increased nursing interactions
• Increased location checks
• Change of placement within clinical environment.

If less restrictive options have been attempted, an Open Unit may be locked if one or more of the following circumstances apply:-

• Risk of harm to self – inability to maintain own safety or suicidal ideation / verbalisation. If continually attempting to leave ensure that assessment for detention under Mental Health (Care and Treatment) (Scotland) Act 2003 is carried out.
• Risk of harm to others or intent thereof.
• Walking with purpose where there is risk of leaving the clinical area and distraction and other attempts are futile - refer to the following local documents:
  • The Absent Vulnerable Patient Absconsion Risk Assessment
  • FP2 Safety Bundle for Vulnerable Patients
  • Higher level supervision (HLS) guideline.
  • Adult Acute Services vulnerable patient/missing inpatient procedure & associated documentation.

In addition to the person specific reasons identified above, the following circumstances may also lead to the Open Unit being temporarily locked:

To stop unauthorised entry where risk involved, for example:

• External security threat
• Infection outbreak.

Any patient who is not formally detained under the Mental Health (Care and Treatment) (Scotland) Act 2003, or who is deemed to have capacity to decide to leave hospital, should be allowed to leave. All patients who require a locked environment must be assessed in accordance with:

• Mental Health (Care and Treatment) (Scotland) Act 2003
• Adults with Incapacity (Scotland) Act 2000 (AWI)

The Mental Welfare Commission for Scotland have produced several reports which provide useful guidance when considering using a locked door:

Mental Welfare Commission for Scotland. Deprivation of liberty

Mental Welfare Commission for Scotland. Rights, risks and limits to freedom.  Section 4.3 Locking the doors.

The decision to lock or unlock the doors to a locked door area must be taken by the nurse in charge (following consultation with others where practical)

Before the nurse in charge decides they must consider the following:

• The issues and risks which require the doors to be locked and any alternatives to this course of action.
• The benefits of locking or unlocking the door.
• Any risks associated with the doors being locked or unlocked.
• Why locking the door is the least restrictive option.
• Whether unlocking the door presents an unmanageable risk, taking into account the presentation of the patient(s)

1. Inform the patient and/or relative about who the decision was regarding, why this action was taken and how long it is likely to last.
2. Inform other members of the MDT, including relevant line manager/duty manager and Responsible Medical Officer (RMO), of the decision.
3. Ensure locked door notice with instructions of how to enter/exit are displayed on both sides of the door in minimum A3 size (Appendix 1c and 1d). Locked Units will display in the same way the locked door notices in Appendix 1a and 1b.

1. Reasons for locking/unlocking door must be clearly documented within the appropriate patient’s health records. Reasons for unlocking UHC Ward 5D would be an extreme exception. 
2. Locked door checklist must be completed and attached to adverse event on safeguard (appendix 2)
3. Complete adverse event report via safeguard.
4. Locked door record must be completed and reviewed after each episode.
5. Where door locked due to the needs of an individual patient, ensure the generic risk assessment and care plan is updated.

The decision to lock the door must be reviewed daily as a minimum and the doors should be unlocked at the earliest opportunity.

During shift handover the nurse in charge should inform the oncoming team of the reasons for the locked door.

Compliance will be monitored quarterly via Care Assurance visits from members of the Clinical Management Teams.

Any concerns should be reported to the relevant line manager.

Poster 1A

Poster 1B

Poster 1C

Poster 1D

Open Unit locked door policy checklist

Locked door record