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9.1.7 Observations

SCOPE OF THIS CHAPTER

This policy and procedure applies to Learning Disability and Older People’s Accommodation and Day Services.

AMENDMENT

This chapter was significantly amended in December 2014 as a result of local review. Appendix 1: Intermittent Observations Form and Appendix 2: Within Eyesight Observations Form are new. It should be re-read in its entirety.


Contents

  1. Introduction
  2. Purpose of the Policy
  3. Policy Summary: Ten Key Points
  4. Definitions
  5. Types of Observation
  6. Principles
  7. Applying the Policy
  8. Duties / Responsibilities
  9. Procedure

    Appendix 1: Intermittent Observations Form

    Appendix 2: Within Eyesight Observations Form


1. Introduction

This policy applies to Learning Disability and Older People’s Accommodation and Day Services.

It covers:

  • Keeping people safe;
  • Management and recording of observation;
  • The different intensities of observation;
  • Increasing or decreasing observation intensity;
  • Carrying out and recording observation.


2. Purpose of the Policy

This policy addresses the engagement and observation of service users who are receiving care and support in residential settings provided by ASC Provider Services. It aims to ensure a Human Rights perspective is embedded in all contacts with service users and that practice is compliant with The Mental Capacity Act 2005, upholding the rights of people who may not have Capacity to consent to aspects of their care arrangements.

It is intended to inform staff and managers to ensure that observations are lawfully and appropriately introduced, consistently recorded and understood by staff and service users and /or their families.

The policy is based on and gives credit to the Sussex Partnership NHS Trust “Observation and Therapeutic Engagement Policy”, ratified in October 2012. While the principles of that policy have been adopted, the definitions and types of Observation have been modified in order to better reflect the regulated activity and environment of a residential/supported living services, as opposed to a hospital setting.

The levels and types of risk posed in residential/supported living services is not generally the same as that experienced in an acute mental health hospital setting. The primary objective within the services is to rehabilitate, re-able, promote self-care and to maximise the opportunities for service users to feel in more control of their lives and to have increased independence.

Where staff enable and support service users to become more accountable for their movements both within and beyond the homes this may involve some risk to their safety. Staff need to have regard to keeping people under the care of the Council safe, but also to support those people to take risks that may increase their independence, or give them more control. How this responsibility is fulfilled varies between those people with capacity to make relevant decisions, and those without.   For those with capacity, staff’s role would be advising clearly on the risks and supporting appropriately. Where a person lacks capacity, a person centred Best Interest decision is needed. The second does not imply a lower risk will be tolerated. It might still appropriately accept levels of risk / possible harm in order for the person to achieve a greater ‘good’ of more independence or control. Both processes require transparent and defensible decision making.

The Mental Capacity Act 2005 describes circumstances where decisions about care and treatment can be made in the person’s Best Interests when the principles of the Act have been followed and the person has been assessed to lack capacity to make the decision themselves. A Best Interest decision might include restrictive practices. But if such a practice (or several practices in accumulation) amounts to a Deprivation of Liberty, an authorisation under the Deprivation of Liberty Safeguards must also be requested. 

In March 2014, the Supreme Court judgement on the ‘Cheshire West and Cheshire’ case widened and provided some further clarity as to what might constitute a ‘deprivation of liberty’

‘A person is deprived of his liberty if he is “under continuous supervision and control and is not free to leave’. The Judgment clarified that the following factors are not relevant:

  • The person’s lack of objection;
  • The suitability or relative normality of the placement;
  • The reason or purpose for the placement.

Although all those factors will be relevant to deciding whether or not the arrangements are in the person’s best interests and the least restrictive option

The Deprivation of Liberty Safeguards must be considered where any service user  lacking capacity to consent to the arrangements needs higher levels of observation as part of their care plan, and this will include the primary consideration of whether there is a less restrictive way  to achieve the desired outcome, proportionate to the risk of harm.

Further guidance on DoLs is available on the CQC website. This guidance links to the full judgement, and flags other issues for residential providers to consider in advance of issuing an urgent/ or requesting a standard authorisation under DoLS.

Requests for assessments under DoLS should be made to the Access Point:

Access Point - 295555   
AccessPoint@brighton-hove.gov.uk

See also Deprivation of Liberty Safeguards.


3. Policy Summary: Ten Key Points

  1. Each person residing in the care home, supported living service or attending a day service will have an individual, potentially fluctuating exposure to risk;
  2. A key intervention in managing risk is the use of engagement and observation. Therefore, all people are subject to observation;
  3. There are three intensities of observation, described as set out below:
    • General Observations;
    • Intermittent Observations;
    • Within Eyesight Observations (Specialising).
  4. Observations must always be clearly documented on the appropriate recording forms;
  5. An assessment of risk will underpin all decisions to change the intensity of observation;
  6. Support planning notes must include the rationale for an increase or decrease in intensity of observation level. Evidence of consideration of whether DoLS applies should be documented in relation to the Intermittent and within Eyesight observation levels, and, if so, relevant procedures followed;
  7. A handover which includes updates as to the wellbeing of each service user will always occur between the incoming and outgoing shift at handover times in residential settings. Day services should review recording from previous sessions at the start of the current session;
  8. Observations cover the 24 hour period. This includes times when people may be sleeping or resting. The policy requires staff to enter bedrooms to check on the physical and mental wellbeing of people. Observations for day services are limited to the session time and any transport provided by the service;
  9. Service users should be involved in and agree to the decision on the observations they are subject to. If they do not have capacity to consent to the observation arrangements, they should still be as involved as fully as possible in that decision, alongside their family, significant others, or supporters. (This might include a Lasting Power of Attorney or court appointed deputy who may have some authority in relation to some decisions);
  10. All intensities of observation are an opportunity to engage with people.


4. Definitions

  • Observation is an intervention that is used both for the short-term management of behaviour and to prevent harm to the service user. This involves a two-way relationship, established between the person and the member of staff, which is meaningful, grounded in trust, and can be therapeutic for the service user;
  • Observation also provides an opportunity to collaborate with the service user in managing their risks and to explore the key interventions required to manage those risks;
  • Observation, in this context, must not be confused with physical observations that are conducted when a person is medically unwell and may be carried out, for example in CSTS, by a qualified nurse or other medical professional;
  • Observation (above the level of General Observation which happens in the course of normal working), should be considered as an intervention on the basis of any significant physical health issues being present, because either alone, or in combination with mental health problems, they may indicate the need for increased observation. Some of the conditions / behaviours that may present increased risks to the person’s wellbeing are:
    • Coronary heart disease;
    • Diabetes;
    • Asthma;
    • Blood pressure irregularities;
    • Mobility problems;
    • Loss of spatial awareness or cognition of location (including attempts to abscond);
    • Side effects of medication / medication change.
  • Consent must always be sought to apply observations above General Observations level. Even if the person declines or is unable to give consent, this procedure is applicable to them. They retain the right to ask for a review of the observation to which they are subject.


5. Types of Observation

The following applies to all types of observation:

  • Staff should set aside dedicated time each shift to engage positively with each service user, to assess their current state of wellbeing and any risks arising from the physical and mental state of the individual. This may arise in part of the normal duties of delivering care or support;
  • Engaging with a person whilst carrying out observations can have a positive effect on levels of distress and anxiety;
  • The type of observation must be recorded in full in the person’s notes;
  • Observations cover the 24 hour period, which means going into a person’s bedroom when the person is sleeping/resting to check on their physical and mental wellbeing; Observations for Day Services are limited to the session time and any transport provided by the service;
  • Where appropriate the Restrictive Practice Policy and Procedures should be referred to and used;
  • All observations will be recorded on the appropriate recording forms

5.1 General Observation

General observation is the minimal acceptable observation for all people, which means having sight and contact with the person frequently during each shift to ensure their physical and mental wellbeing is known. General Observation includes those informal interactions between staff and service users in the course of the provision of personal care, such as offering to support with food and drink, playing games, socialising and sitting with people.

Other records required in the provision of care and support are also included in the General Observation category, such as the completion of food and fluid intake charts. Other care activities such as supporting with washing, dressing, mobilising or transfers are included in the General Observation category, in that, while these activities are being undertaken, people are being observed and their wellbeing monitored. General observations must be recorded in the person’s progress notes or other specific record (examples above) at the earliest opportunity. As a minimum, a summary of general observations must be recorded in the person’s progress notes no less than once per shift.

As a minimum:

Accommodation Services: a summary of general observations must be recorded in the person’s progress notes no less than once per shift.

Day Services: if anything of significance been observed during a session a summary of observations must be recorded in that person’s progress notes for that session, and flagged for handover to the following sessions.

5.2 Intermittent Observation

This observation is appropriate when service users are assessed to be potentially, but not immediately at risk. This means that the person’s location and state of wellbeing must be checked at specified intervals ranging from every 5 to every 60 minutes as agreed by managers/lead support staff. On occasions, an alteration to the routine pattern of carrying out observations at the specified times may be considered. If this occurs then no more than the agreed time interval can lapse. For example, if the intermittent observations are agreed at 10 minute intervals, the person could be observed at 7 minutes, 5 minutes and 10 minutes.   

This level of observation can be used as a short-term, temporary measure if someone is medically unwell in a day service session, or their or if their behaviour significantly deteriorates and they are considered to be at higher risk than normal.

Where the person lacks Capacity to consent to this level of observation, consideration must be given to whether the person’s care arrangements may amount to a Deprivation of Liberty and if so the appropriate assessment and authorisation process should be followed - see additional information in Section 5.3 Within Eyesight, below.

5.3 Within Eyesight (Specialing)

This observation is for service users assessed to be at the highest level of risk of coming to harm, either by their own behaviour or physical or mental inability to maintain safety for themselves, but who can be safely supervised within eyesight. The risk level should be seen as significant if the person is left alone for any amount time and there must be a clearly identifiable reduction in risk by having a person present at all times. For example, Within Eyesight observations may not prevent someone falling, however the immediate staff response to a fall, the fact it will have been observed and the ability of the service to assess the immediate impact on the wellbeing of the person and call for any assistance required, will reduce the risks for that person significantly. The person must be kept within sight at all times, by day and by night. Observation will be maintained when using lavatory or bathroom facilities. This type of Observation is a Restrictive Practice and the relevant procedures must be followed. Managers should also consider the effects on liberty of this type of observation based on each individual’s circumstances, particularly where this would add to an accumulation of other limiting measures in their care plan.

It should be anticipated that DoLS will most likely apply to all cases where this level of observation is required following the “West Cheshire and Cheshire” Supreme Court judgement (see Deprivation of Liberty Safeguards). However current DoLS guidance (at March 2014) will not yet reflect the new ruling, so advice may need to be sought via the Access Point. Within Eyesight Observations should be used when this is the least restrictive risk control measure in the circumstances. The need to use this level of observation should prompt an urgent review of the person’s needs and consideration of whether those needs can be met by the service.  

5.4 Learning Disability Accommodation Service and Day Options

A number of service users in Learning Disability Accommodation Service and Day Options have staff allocated to them 1:1 due to needs associated with their Learning Disability. In most of these cases the principle of general observations recordings would apply on a day-to-day basis. In these cases, the need for intermittent/within eyesight observations would only be required when there is as significant change in their health or behaviour that increases risk and therefore requires a higher level of recording.

Examples of this may be:

  • Instability of existing health conditions such as Epilepsy;
  • New health conditions;
  • Risk of leaving where this cannot be mitigated against;
  • Risk of self-harm;
  • Concussion monitoring;
  • Increased level of mental health problems;
  • Affects from medication.
These may be temporary changes where increased recording is required on a short-term basis, or long-term changes where a higher level of recording is required on an ongoing basis.


6. Principles

All intensities of observation are an opportunity to engage with service users and must not be regarded as just another task to be recorded.

The primary aim of observation should be to engage positively with the person. We know that care/support environments which provide interventions founded on a strong culture of staff and service user engagement, diminish risk, disturbance, aggression, violence and boredom. As a result they are safer and more positive environments for people receiving care and for staff providing care.

The primary function of observations is to maintain safety and reduce risk. However, the process of observing service users affords staff the opportunity to monitor and assess behaviour, symptoms, physical wellbeing and interactions.

In Care Quality Commission registered Accommodation Services, where the Council has a 24 hour responsibility for people there is rightly a high expectation that we maintain an ongoing record of observations even when everything is appears to be normal. 

In Day Services, particularly, Learning Disability Day Services, most people are physically and mentally well within ‘who they are’, and are coming in from their normal home to engage in social and other activities. As a result of these different circumstances, and the shared responsibility for those people with their main carers, it is sufficient for general level observations to be on an exception basis i.e. it is only necessary to record significant events. This does not, however, diminish the requirement for staff to actively engage with everyone who attends a day service session and to consider the state of their wellbeing that day.


7. Applying the Policy

Every person is subject to observation. General Observation is the minimal acceptable observation for all persons, which means the member of staff seeing the person at reasonable frequencies during any shift to ensure their physical and mental wellbeing is known. The location of all service users must be known to staff, but not all people need to be kept within sight.

Observation tasks can be undertaken by any member of staff.

The decision to increase or decrease the intensity of observation above the General Observation level, must be underpinned by an assessment of risk, signed off by the Manager and recorded in the support plan.

Explaining the purpose of any observation above General Observation to the person and/or their family is important. Where the person’s ability to understand the reason for and capacity to consent to the observation arrangements is in doubt, the Mental Capacity Act statutory principles should be followed, and any capacity assessment and outcome recorded as appropriate.

The person must be provided with information about why they are being observed, the aims of the observation and how long it is likely to be maintained; the aims of observation must, where appropriate, be communicated with the person’s approval to the nearest relative, friend or carer.

All observations must follow the processes and recording requirements set out in this document.

The privacy and dignity of service users must be considered and maximised. It will always, though, be balanced against the need to maintain safety, at all times.


8. Duties / Responsibilities

Operations Managers/Resource Officers

  • Operations Managers are responsible for the dissemination of this policy and procedure to all relevant staff.   And for ensuring that all those staff are adequately trained in order that they understand it, comply with it, and implement it.

Senior Care Officers/Lead Support Workers

  • Training in observation practice and the use of this policy is essential for all staff working in the services and is provided in-house. Training on observation is provided through local induction to the service and through briefing sessions for working on the floor e.g. after/during handovers. Training and the recording of who has been briefed, is the responsibility of Senior Care Officers / Lead Support Workers.  In some services, where a manager is not present for all shifts, the responsibility for briefing staff will be delegated to the worker leading that shift.  SCOs/LSWs hold the responsibility for deciding on variations to observations. The ways in which such changes can be made, and by whom, are set out within this document.

All Employees

  • All staff have a responsibility to understand that there is an Observations Policy; the three levels of observation and how to complete the relevant recording for each level of observation. All staff should understand that observation is not just a ‘tick box’ exercise but an opportunity to engage positively with service users.


9. Procedure

Risk Assessment Prior to Admission

  • Thorough and careful risk assessment underpins the application of appropriate types of observation. It is therefore important that any referring team provides an accurate, up to date assessment of risk at the point of referral. The thorough risk assessment should detail the level and type of risk, in order that the receiving unit can best assess the immediate level of observation necessary and ensure that the person is admitted to the most suitable setting for their needs, their safety, the safety of other service users and staff. If the person lacks capacity to consent to the arrangements, this will also allow consideration in advance of the placement, of whether a deprivation of liberty may result, which requires authorisation.

Observation Following the Admission

  • Every person will be admitted to the service on General Observations unless the referral risk assessment has informed a decision otherwise;
  • Once a person has been admitted to the service and their care plan and any relevant risk assessments have been completed, a decision can be reached about the appropriate type of observations ongoing and whether they need to be changed;
  • For Intermittent and Within Eyesight observations, the person must be provided with information about the aims of the observation and how long it is likely to be maintained; the aims and type of observation, must, where appropriate, be communicated, with the person’s approval, to the nearest relative, friend or carer.

Carrying Out Observation

Staff undertaking observation must:

  • Be fully aware of the observation policy and procedure;
  • Work to use the time positively with the person;
  • Ensure they are fully briefed about the person’s history, background, specific risk factors, particular needs and any relevant equality and diversity issues – Age, Disability, Gender and Gender Identity, Race, Religion and Belief, Sexual Orientation and Pregnancy.  (This information should be contained within the Support Plan.);
  • Be familiar with the care home or supported living environment and emergency procedures for evacuation and First Aid.

The Duty Officer/Shift Leader in charge of each shift will provide clear and unambiguous instruction, management and leadership to others in the allocation of observation duties and ensure that those duties are carried out.

A handover of observations will occur between the incoming shift and outgoing shift and recorded on the appropriate observation form.

Observations cover the 24 hour period. At night, staff must continue the agreed type of observation. This will require entering bedrooms to ensure that persons are safe.

The least intrusive and restrictive method of observation appropriate to the levels of risk must always be adopted so that due sensitivity is given to a person’s safety, dignity and privacy whilst maintaining the safety of those around them.

When carrying out higher than General Observations it is important that staff also observe and record the person’s presentation and location.

All decisions about the specific type of observation must take into account:

  • The current assessment of risk;
  • The person’s current mental state;
  • Any prescribed medications and their effects;
  • As far as possible, the person’s own view.

The rationale as to what type of observation the person is in receipt of above General Observation must always be recorded in their notes.

The Duty Officer/Shift Leader must ensure at Handover, that there are sufficient staff to undertake any observations of the Intermittent or Within Eyesight level. They must also ensure that these tasks are shared and split across staff who are working. It is inadvisable for one member of staff to be allowed to undertake these levels of observations for a whole shift – consideration must be given for adequate breaks from these duties or transfer of duties to another member of staff at an appropriate time.

The Duty Officer/Shift Leader in charge of the shift is responsible for ensuring that the number of people that any individual staff member is required to intermittently observe does not jeopardise the safety of any of those service users.

Staff members must be aware of and sensitive to the fact that people sometimes find observation provocative, and that it can lead to feelings of isolation and even dehumanisation, and may increase levels of agitation and aggression.

Where possible and appropriate, the handover from one staff member to another should involve the person so that they are aware of what is being said about them.

Recording Observation

In order to ensure the observation procedure is completed and to allow for staff to monitor persons, clear, timely and accurate recording of observations is imperative.

It is the responsibility of the Duty Officer/Shift Leader in charge to allocate members of staff to the observation of persons, ensuring that staff are familiar with those persons, are aware of this policy/procedure.

The recording of observation will be completed on the appropriate observation recording form, for the type of observation the person is subject to.

The following standards will apply to the recording of all observation levels:

  • Carrying out observation, provides an opportunity to therapeutically engage with the person(s), and recording is part of that engagement and should not, therefore, be conducted in a mechanistic way;
  • Persons’ names entered in full;
  • Each recording entry must be legible;
  • The name, role and the signature of the person implementing the observation must be written clearly on the form.


Appendices

Appendix 1: Intermittent Observations Form

Appendix 2: Within Eyesight Observations Form

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