HSPOL16 Violence and Agression at Work Policy V8 by Provide Community

Violence and Aggression at Work Policy

Version: V8

Ratified by: Finance and Investment Committee

Date ratified: 04/09/2024

Job Title of author: Head of Health, Safety and Compliance

Reviewed by Committee or Expert Group Property and Health & Safety Steering Group

Equality Impact Assessed by: Head of Health, Safety and Compliance

1. Introduction

Provide Community staff should be able to come to work without fear of violence, abuse or harassment from patients/service users, relatives/carers/friends of patients, and members of the public.

In most cases, people will be appreciative towards those who treat them and respect the work of health and social care professionals, but a minority of people are abusive or violent towards staff.

Provide Community is committed to promoting and improving a safe and secure environment for those who work in or use our services while ensuring we fulfil our duty of care towards our patients.

This policy specifically addresses how all staff should manage such incidents from patients/service user, relatives/carers/friends of patients, or members of the public

The policy is based upon Secretary of State for Health directions to tackle violence against staff and professionals, health and safety legislation; NHS England Violence prevention and reduction standard; National Institute for Health and Care Excellence (NICE) guidelines on violent and aggressive behaviours in people with mental health problems; and Royal College of Nursing (RCN) guidance on work-related violence and managing risk

2. Purpose

The purpose of this policy is to set out a risk-based framework for managing and reducing violence and aggression within Provide Community and supporting a safe and secure working environment for staff. It also aims to safeguard both staff and patients by helping to prevent violent situations and providing guidance to manage them safely when they occur

Provide CIC will not condone or tolerate any aggressive, abusive or violent behaviour towards our employees engaged in their lawful duties from any source - be they service users, visitors or even in incidences when staff verbally abuse fellow or ex colleagues. Violent or abusive behaviour will not be tolerated and action will be taken to protect staff, service users and visitors.

The organisation is committed to providing a safe and secure environment in which antisocial behaviour will not be tolerated. Provide will do anything within its power to support and protect its employees from becoming victims of aggressive, abusive or violent behaviour.

The organisation is committed to supporting criminal proceedings and redress, where necessary and appropriate and withdrawing healthcare services to the perpetrator if an employee is subjected to unwarranted and unsolicited behaviour and/or abuse.

Those service users who, in the expert judgement of the relevant clinician, such as an individual who becomes abusive as a result of an illness or injury and are not competent to take responsibility for their actions may not be subject to this procedure.

The use of this policy will apply to all violent/abusive visitors, relatives and service users, although some of the sanctions may only be applicable to those who are aged

16 or over. Furthermore, this policy will also apply to both current and ex-Provide employees.

The aim of the policy is to describe those behaviours, which are unacceptable, the sanctions available in the face of such behaviour, and a mechanism whereby service users who are extreme or persistent in their unacceptable behaviour can, as a last resort, be excluded from the service. Persistent unacceptable behaviour refers to behaviour both within one admission and/or over a number of separate attendances within period of the sanction.

In situations where current or ex-Provide employees engage in verbal or physical abuse to colleagues, mechanisms are in place to implement formal investigations in line with the Disciplinary and / or Whistle Blowing policy.

Health and Safety Executive

HSE is responsible for the regulation and enforcement of workplace health, safety and welfare, underpinned by the Health and Safety at Work etc. Act 1974. Employers have responsibilities under the act to ensure, as far as is reasonably practicable, the health, safety and welfare of employees at work.

Care Quality Commission (CQC)

CQC was established under the Health and Social Care Act 2008 as the independent regulator for health and adult social care in England. The Act outlines the types of service that must be registered with the CQC and The Care Quality Commission (Registration) Regulations 2009 outlines what service providers have to do to become registered. As part of registration, the CQC will develop a Quality and Risk Profile (QRP) for each provider to assess.

The CQC checks and monitors service providers to ensure that they continue to meet the essential quality and safety standards, including preventing violence against staff

3. Definitions

Work-Related Violence

The Health and Safety Executive (HSE) definition of work-related violence is: ‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work. This can include verbal abuse or threats as well as physical attacks

Physical Assault

The definition of physical assault used for incident reporting purposes is: ‘the intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort.’

Non-Physical Assault

The definition of non-physical assault used for incident reporting purposes is: ‘The use of inappropriate words or behaviour causing distress and/or constituting harassment.’

Unacceptable behaviour

Unacceptable behaviour includes, but is not limited to:

• Physical assaults (including attempted physical assaults)

• Threatening language

• Offensive or abusive language, verbal abuse and swearing

• Racist or discriminatory language

• Negative or malicious comments

• Sexualised language or comments of a sexual nature

• Brandishing of objects or weapons

• Invasion of personal space

• Bullying, victimisation or intimidation

• Alcohol or drug abuse

• Unreasonable behaviour and non-cooperation

• Deliberate destruction of/damage to property

• Stalking

• Spitting

• Presence of uncontrollable or dangerous pets

It is important to remember that such behaviour can be either in person, by telephone, letter or e-mail or other form of communication such as graffiti on a Provide Community property.

Incidents do not need to cause physical harm. Incidents can include.

• Major injury

• Require medical assistance

• Require first aid only

• Involve a threat, even if no physical injury results

• Involve verbal abuse

• Involve non-verbal abuse

• Involve other threatening behaviours

Management of Health and Safety at Work Regulations 1999

The regulations require employers to assess risks to employees and non-employees and make arrangements for effective planning, organisation, control, monitoring and review of health and safety risks. Where appropriate, employers must assess the risks of violence to employees and, if necessary, put in place safe systems of work to protect them.

The

Care Act 2014

This emphasises the duty of care and to protect vulnerable adults from mistreatment and improve their quality of life, care givers must follow the principles of the Care Act 2014.

4. Duties

Provide Board

The Board has overall responsibility for organisational strategy to tackle violence and aggression and ensuring compliance with health and safety statutory requirements.

Additionally, the Board will ensure through the line management structure that these policies and procedures are applied fully and consistently and that all employees are aware of the standards and behaviours required under them.

Designated Duty Holder

The Group Chief Executive is the Dedicated Duty Holder and has the overall statutory responsibility for security management, within Provide Community. Operational management has been delegated to the Group Chief Finance Officer

The Chief Finance Chief Finance Officer has final approval on any exclusion of service users.

Directors and Managers

These senior management roles should take a leading role in promoting and developing a safe and secure environment. They should ensure risk assessments are completed, by liaising with the, Patient Safety Managers, and Health and Safety team to develop arrangements to protect staff from violence and aggression.

When a sanction is issued to a patient/service user/ relative, management roles should ensure the appropriate approval is given prior to issue, and ensure the sanction is recorded on Datix/Access and clinical systems.

Team Leaders/Managers

Will ensure that their staff have access to this policy, and that systems and processes are in place to support staff who are the victims of incidents of violence and aggression. Managers will be proactive in their response to reported incidents and utilise the sanctions available, ensuring that their teams are aware of incidents that have occurred and the action(s) being taken. Managers will offer further support such as employee assistance programmes and / or counselling services to staff who are the victims of violence and aggression.

Health & Safety Oversight Group

This group comprises a group of Managers, Specialists and Staff Side Representatives that under the Safety Representatives and Safety Committees Regulations 1977 (SRSCR), Regulation 9 and the Consultation with Employees Regulations 1996, shall convene regularly to make decisions on the overall health, safety, well-being, efficiency and efficacy of the Trust. The Health and Safety Oversight Group, has responsibility for reporting Health and Safety matters (including violence and aggression against staff) to the Board and Senior Leadership Team.

Health

and Safety Team

Under the Health and Safety at Work Act 1974, the Health and Safety Team should assist the organisation ensure the health and safety of staff. Their role is to assist in the risk management process, including the risk of violence and aggression and the implementation of measures to protect staff.

Patient Safety Team

Will assist in any investigations required alongside the police, assist in gathering / collating evidence for internal and external investigations. Asist in the identification of security breaches and / or failures in systems and processes ensure that events are recorded on Datix/Access and that any sanctions issued are recorded in the outcome of investigation field

Safeguarding

Please refer to the Safeguarding Policy where there is a safeguarding issue identified.

All staff

Employees are responsible for reporting any incidents of violence or aggression through the incident reporting system (Datix/Access)

If deemed necessary, contacts with service users in their own home, day Centre or residential home should be subject to a risk assessment which should include the risk of violence and/or aggression.

All employees (including those on honorary contracts and those working primarily for other organisation’s but on Provide premises) have a duty in the enactment of the policy.

Employees are responsible for complying with arrangements made under this policy.

Security is a management responsibility and the provision of a security service in no way relieves management at any level of its obligations to fulfil the stated purpose of security in the organisation.

All team managers have responsibility for security within their own units. Managers are required to exercise preventative aspects and to take appropriate action where necessary in respect of those who offend against the law, commit misconduct or other breach of security in contravention of the policies of the service.

Staff should ensure that security procedures are observed at all times. Provide Community staff must follow the Department of Health and Social Care’s ‘Reference guide to consent for examination or treatment’; the Mental Capacity Act Code of Practice; Deprivation of liberty safeguards Code of Practice (to supplement the main Mental Capacity Act 2005 Code of Practice).

ICB

On notification from Provide of the withholding of care, the local ICB are responsible for ensuring that care is provided to the service user/s that have been excluded from Provide.

Care must be provided in environments where Provide staff will not be threatened or feel vulnerable by the actions of the excluded service user. All appropriate security arrangements must be considered in accordance with the local Clinical Commissioning Group security related policies.

Alternative care arrangements should be made within 4 weeks of notification of exclusion from the organisation. In most circumstances, a case conference should be held with all interested parties to provide the best alternative arrangements.

5. Consultation and Communication

This document will be published on the Platform and be available to all staff. The publishing of the policy will appear in Weekly Bulletin, H&S Newsletters and communications. Managers will ensure that all staff are briefed on its contents and on what it means for them.

6. Monitoring

The implementation of this policy will be monitored by the Health and Safety Oversight Group.

Compliance with this policy will be measured through management of incidents relating to violence and aggression and the actions taken to address such incidents and recommendations from lessons learned.

Process for Monitoring Compliance and Effectiveness:

• Monitoring of reported violent Incidents.

• Any issues of concern that are raised will be discussed at the Health and Safety Oversight Group.

7. Risk assessments

Risk assessments are intended to reduce the likelihood of incidents involving violence and/or aggression (including verbal abuse). Risk assessments to prevent violence and /or aggression the following should be considered:

• Past: has there been any history of previous incidents?

• Present: the environment and any existing arrangements in place to manage the hazards, e.g. lone workers policy. This includes the availability of equipment designed to improve communication and education of staff in personal security awareness.

• Future: the risk inherent in the task to be carried out such as any threats that have been made as to future behaviour and the process to be followed in the event of an incident.

Managers must take account of the extent that existing controls are being followed. For example in the case of lone working, are lone workers aware of the content of their lone worker risk assessment and the procedures (including who to contact in the event of an incident

Information on the outcome of risk assessments must be fed back to staff as part of the risk assessment process. Staff should be encouraged to seek advice / assistance if they are unsure about a situation or to report any problems / concerns via a line manager.

Managers and staff must discuss, as part of the risk assessment process, what actions they should take in the event of an incident occurring.

Patient/Service User specific risk assessments

Patient specific risk assessments may be needed to monitor the behaviour of the patient/service user. They are created with a view to informing all staff (not just medical) who may come into contact with them. This is for staff’s own personal safety as well as the safety of the patient. In the event of an incident, this (risk assessment) is a document that may be required when the incident is being investigated.

The prevention measures identified by the risk assessment must be recorded in the patient/service users care plan. Where clinical IT systems are in operation e.g., SystmOne, Access, etc. a flag should be put on the system, in relation to the patient, identifying any concerns.

Patient/service user specific risk assessments must be completed or reviewed if:

• the patient/service user has a history of unpredictable, challenging, violent or aggressive behaviour

• the patient/service user displays challenging, violent or aggressive behaviour

• an incident occurs or a patient/service user, relative or visitor becomes aggressive

The patient-specific risk assessment may take into account:

• the mental, emotional and physical condition of the patient/service user

• the patient/service users behaviour related to his or her medical conditions or ingestion of drugs, alcohol or medicines

• whether the person is facing high levels of stress

• whether the person has a history of challenging, violent or aggressive behaviour

• whether the person considers you a threat

Service risk assessments

Service risk assessments are those completed by service leads and used to review operations/locations to identify situations where employees may be exposed to foreseeable risks etc., verbal abuse, physical assault or a work-related safety hazard. Where a risk of violenceor aggression is identified the risk assessment should highlight this and appropriate measures put in place to protect staff.

In certain circumstances it may be appropriate to produce a generic risk assessment e.g., community worker home risk assessment or a risk assessment for a specific environment. These risk assessments apply to a particular activity/environment and summarise the control measures in place that apply collectively to a range of staff or environments.

Having identified any hazardous situations, managers must determine whether existing controls are adequate or whether more needs to be done. This should be formally documented using the risk assessment form to record the risks to which people are exposed.

This assessment must into account the risk inherent in the task, the environment, any other additional risks associated with the building or unauthorised persons and should consider any existing arrangements in place to manage the hazards faced.

Managers must take account of the extent that existing controls are being followed / implemented. In the event that further action is required managers are responsible for developing an action plan. The completion of the action plan will be monitored at local service meetings.

Staff must be encouraged to seek advice / assistance if they are unsure about a situation or to report any problems / concerns via a line manager.

Dynamic risk assessments

A dynamic risk assessment can be defined as a continuous process of identifying hazards and risks and taking steps to eliminate or reduce them in the rapidly changing circumstances of an incident.

The vast majority of risk assessments are carried out dynamically by staff. For example when they arrive at a patient/service user’s home and are met with aggression by the patient/service user and/or the patient/service users family and it wasn’t expected. Staff may need to decide whether they are safe to stay or whether it would be safer to leave and either return another time.

The dynamic risk assessment involves staff:

• being alert to warning signs as covered in conflict resolution training

• carrying out a ’10-second risk assessment’; if staff feel there is a risk of harm to themselves, they should leave immediately placing themselves in a position to make a good escape

• making a judgement as to the best possible course of action – for example, whether to continue working or withdraw. At no point should a staff member place themselves, their colleagues or their patients/service users at risk or in actual danger

• utilising appropriate physical security measures.

• ensuring that when they enter a confined area or room, they make sure they can operate the door lock in case they need to make an emergency exit

• avoiding walking in front of a patient/service user, and not positioning themselves in a corner or in a situation where it may be difficult to escape

• remaining calm and focused during an incident in order to make rational judgements.

Possible causes of unacceptable behaviour

• being in pain

• having to queue/wait to be seen

• waiting times and/or the lack of information

• poor communication,

• poor attitude of staff (or perceived poor attitude)

• lack of facilities, e.g. toilets, food, drinks, etc.

• feeling of not being listened to

• feelings of loneliness

• cancelled appointments

• poorly planned appointments

• poor direction/signage in healthcare buildings

• parking issues/costs

• not being treated by their usual/preferred clinician

• patient expectations differ from what the service is commissioned to provide

• drug and alcohol abuse/dependency

• post-traumatic stress (inc. adverse childhood experiences; domestic violence)

• mental health issues or learning disabilities

• dementia

Immediate actions during/following an incident

• Staff should remove themselves from any situation where they feel threatened; ‘your duty of care starts with you’

• Where communication is possible, staff should utilise conflict resolution and deescalation techniques to politely but firmly challenge the unacceptable behaviour

• Tell the individual(s) the positive option first, followed by the negative consequence if their behaviour continues.

• Any incidents of potential or actual physical assault should be reported to the police and escalated to your line manager immediately.

• Staff must report incidents to their line manager as soon as possible, before reporting the incident on Datix/Access

8. Confidentiality

In line with the Data Protection Act (2018), depending on the nature of the situation, information about cases of violence might need to be restricted to those who have a need to know in order to protect the staff member and to facilitate police enquiries. However, managers will need to ensure that adequate information is conveyed to the wider team to ensure staff safety

9. Training and Support

Conflict resolution training is part of the annual Statutory Mandatory training which all staff must complete. The content of the module meets the national syllabus for conflict resolution. Additional training is provided over and above this, depending on the risks faced and individual needs.

Provide Community Freedom to Speak Up Guardian and Champions provide an independent, impartial and non-judgmental source of support and guidance to everyone who works for Provide They will listen to anyone who approaches them with concerns freedomtospeakup.provide@nhs.net.

10.Provide Care Solutions – Supported Living

Higher tolerance levels of violence and aggression can be expected within this service due to the complex needs of individuals. With this in mind, incidents reported within the Supported Living Team are assessed on an individual basis and in consultation with the Supported Living Team Manager and the wider team.

Support plans will be reported and additional measures implemented if felt this is necessary. If required, the team will seek advice from physiatrist, social care and other medical professionals before any further sanctions are implemented.

In situations where behaviour significantly effects other individuals living in the properties, consideration will be given as to whether the site is the best place for resident and this will be review as above.

Ultimately, the safety of both our staff and other service users is of paramount importance and, if necessary, the organisation will seek to have individuals re-housed at alternative location more suitable for their individual supported need

11.Animals

It is not uncommon for service user’s to have pets (dogs, cats, snakes etc.) in their home. In the majority of cases the animals do not pose a threat to staff and staff are happy to treat service users with pets in the vicinity.

However as an organisation we respect the fact that some staff may feel uncomfortable about providing care with an animal in the same room. With this in mind, if staff feel uncomfortable then they have the right to request that the animal be securely placed in an alternative room whilst treatment is being carried out. If the service user refuses to do this, then staff have the right to refuse treatment.

12.Premises

Violent, Aggressive or Abusive Visitors - Provide reserves the right to refuse admittance to any person deemed undesirable due to their conduct by either words or actions and may be requested to leave by any staff member. Support for this exclusion can be sought from the police.

Violent, Aggressive or Abusive Behaviour towards staff at other premises - Provide reserves the right to refuse treatment to any person deemed undesirable due to their conduct by either words or actions and any member of staff may refuse

treatment/services and withdraw from the premises / home this includes acts of verbal or physical abuse carried out by relatives and or carer’s.

Violence, aggression and abusive conduct extends also to behaviour demonstrated towards work colleagues.

13.References

• NHS England Violence prevention and reduction standard 2020

• Health & Safety Executive (HSE) work-related violence guidance

• Secured by Design (SBD) official police security initiatives

• Royal College of Nursing guidance - Violence in the workplace

• NICE guidance - Violent and aggressive behaviours in people with mental health problems

• Department of Health & Social Care: Reference guide to consent for examination or treatment

• Mental Capacity Act Code of Practice

• Deprivation of Liberty Safeguards Code of Practice

• Freedom to Speak Up (FTSU) Guardian and Champions

Health and Safety at Work Act 1974 Employers must:

• Protect the health and safety at work of their employees

• Protect the health and safety of others that might be affected by the way they go about their work.

Management of Health and Safety at Work Regulations 1999 Employers must:

• Assess the risks to the health and safety of their employees and identify the precautions needed

• Make arrangements for the effective management of precautions

• Appoint competent people to advise them on health and safety.

• Provide information and training to employees

Appendix 1: Prevention and abuse assessment tool

Prevention and management of violence and abuse assessment tool

This assessment tool is designed to help staff achieve a consistent approach to the assessment of patients/service user with a potential for violence or a history of violence and abuse against staff.

Intervention

Assess patient/service users’ potential for violence and abusive behaviour through history, patient interview (or interview with family and friends, if patient is unable to communicate). Where possible, refer to medical and medical notes and information provided from other relevant organisations or individuals, such as Social Services, patient’s GP etc.

Assess whether patient/Service User has any communication difficulties and explore possible reasons for this (e.g. sensory impairment, learning disability or English not being their first language).

Guidance Note

Before meeting with the patient/service users, examine their medical and medical notes to check for any incidents of violence and abusive behaviour that have been documented and how they were managed.

Introduce yourself and explain any procedure in plain and simple terms. Try to build a rapport with the patient/service user to put them at ease during the assessment interview.

If appropriate and safe to do so, explore the patient/service users history with them and explain Provide Community policy regarding violence and abuse against staff.

If there are communication difficulties, try to arrange for a family member or significant other person to be present to assist during the assessment. You should always try to obtain the patient/service users consent for this first.

If the patient/service users hearing is impaired, ensure that hearing aid equipment is set and working properly or arrange for a BSL interpreter to be present for the assessment.

If the patient/service users first language is not English, it may be appropriate to arrange for an interpreter to be present. It may be useful to engage with family and/or friends to establish if there is any history of violence or abusive behaviour within the family. To maintain patient/service user confidentiality, establish whether or not the patient/service user has advised any significant persons/family, of their condition. However, be aware that family dynamics may be a cause of patient/service users violence and judge whether or not to proceed with engaging with family. Establish level of support available to the patient/service user from family or other significant person.

Encourage family members and significant persons to enforce message that violence or abuse is not tolerated within the healthcare environment.

Assess patient/service users attitude to treatment and medical condition.

Assess patient/service user current physical and mental health, current medication and any substance use and misuse.

Answer any questions the patient may have concerning their admission, treatment or diagnosis and try to alleviate any anxiety.

Arrange for the patient’s doctor, or other relevant members of the multidisciplinary team (MDT), to discuss their condition with them if necessary.

If there are any concerns about the patient’s mental health, refer to the oncall psychiatrist, psychiatric liaison nurse or mental health team.

If there are any signs of substance use or misuse, discuss with the patient the health body policy on the use of substances. Refer the patient to the substance misuse team, if appropriate. If appropriate, set boundaries with patient and employ the use of a behaviour agreement

If there are any organic or other physical health concerns, refer to the appropriate member of the MDT.

Explain policy regarding prescribed medication.

Assess whether patient/service user has any previous known episodes of violence and/or abuse, including any trigger factors or antecedents such as a recent bereavement.

If known history of violence or abusive behaviour, establish whether there is a history of using weapons, hostage taking etc.

Establish from medical records/nursing notes whether patient has had any previous episodes of violence and/or abuse against NHS staff. When engaging with the patient, be alert to any information that they disclose about incidents in their personal life that may have precipitated previous violent behaviour, such as medical/psychiatric diagnosis, change to marital status, bereavement, redundancy etc. This can be achieved through general conversation rather than a direct questioning process.

Ensure that all staff, including the multidisciplinary team, new staff and agency/bank staff are aware of patient’s history and how to care for them in a safe manner.

Observe for warning signs and triggers, and manage appropriately on the scale of de-escalation and resolution to calling for assistance.

Promote an environment that provides safety and reduces agitation.

Ensure that all staff, including the multidisciplinary team, new staff and agency/bank staff are aware of

As regards any previous episodes of violence or abusive behaviour, establish the following if possible: how previous incidents were managed; which interventions were successful and which were not; how long the episode of violence or abusive behaviour lasted; if medication was used to resolve the situation; if the police were involved; and what sanctions, if any, were applied.

patient/service users history and how to care for them in a safe manner. Ensure that all staff are aware of what to do in the event of a violent or abusive incident.

Observe for warning signs and triggers, and manage appropriately on the scale of de-escalation and resolution to calling for assistance.

Staff may wish to consider previous incidents recorded and decide whether it would be helpful to discuss known trigger factors and any preferred intervention with the patient/service user

Staff may wish to consult their mental health colleagues for advice before engaging in such a discussion with the patient.

Appendix 2 : Incident Management Process

Initial support to staff

Following a report of violence or abuse towards staff, the line manager must provide immediate support to ensure the employee is safe. This could be through an immediate visit to their location and/or advice over the phone.

Where appropriate, a referral to employee Occupational Health Service must be considered to ensure the best available support is given to the member(s) of staff. Support should also be provided if the incident requires reporting to the police

Reporting of incidents on Datix/Access

An incident report must be completed on Datix/Access by the victim as soon as possible, selecting the ‘Violence & Aggression’ category. If they are known, the perpetrator’s name (i.e. patient; patient’s relative) must be added to the record to enable tracking of incidents over time.

Line managers should support their staff to complete incident reports if necessary, and should be selected as the incident handler.

Reporting of incidents to the police

Staff can report incidents of violence and aggression to the police if they believe a crime has been committed. The individual(s) affected must personally report the incident. The line manager/Health and Safety team will support them in doing so if required.

The following is a list of possible aggravating factors which should be considered when deciding to report an incident to the police.

• The effect on the victim and/or others present (however, the fact that none of the individuals present are adversely affected does not mean that a criminal offence has not been committed or that the incident should not be reported to the police).

• The assailant’s behaviour is motivated by hostility towards a particular group or individual on the ground of race, religious belief (or lack of), nationality, gender, sexual orientation, age, disability or political affiliation

• A weapon, or object capable of being used as a weapon, is brandished or used to damage property

• The incident was an attempted, incomplete or unsuccessful physical assault

• The incident involves action by more than one assailant

• The incident is not the first to involve the same assailant(s)

• There is an indication that a particular member of staff or department/section is being targeted

• There is serious concern that threats may be carried out

• There is a concern that the individual’s behaviour may deteriorate or that other NHS/social bodies should be advised or alerted

• The response to the incident has caused significant additional expenditure.

All incidents involving firearms or other weapons must be reported to the Police.

Reporting the incident to the police could result in:

• Criminal prosecution and police bail conditions

• Civil injunction, Community Protection Notice ( CPN ) or Criminal Behaviour Order ( CBO ) as punishment for antisocial behaviour

Investigation of incidents

Line managers are responsible for the investigation of incidents involving their staff and updating them on the progress and outcomes of those investigations.

When speaking with the perpetrators of incidents it is important to listen to their side of the story while also being clear that nothing excuses the unacceptable behaviour.

The safeguarding team should be contacted for advice and guidance if the violence and aggression might lead to a vulnerable adult or child not receiving the appropriate care.

Mitigating risks and de-escalation

Use of the sanction process is a way to mitigate risk and prevent future occurrences of unacceptable behaviour. During the meeting to discuss the sanction, managers can listen to the perpetrator’s side of the story and assess their attitude to the unacceptable behaviour, while also clearly communicating that the behaviour will not be tolerated and any conditions of further care.

Managers have several options available to mitigate risk and de-escalate ongoing situations with individuals demonstrating unacceptable behaviour:

1. Arrange for patients to visit Provide premises for treatment that is currently provided at home

2. Contacting patients the day of a visit to assess their state of mind and to reiterate any sanctions previously implemented

3. Arrange for staff to only visit premises in pairs (this should not be routine and only applied in extenuating circumstances).

4. Assigning care to a different individual within the team or to a different team.

A de-escalation arrangement, such as assigning the care to a different team or clinical staff, is to avoid the trigger of such aggressive or unacceptable behaviour. This behaviour can be based on personality clash between the service user and clinical staff, or based on negative, malicious or stereotypical comments and behaviour including racist and discriminatory language.

The main objective of such de-escalation step is to protect the staff and prevent any further emotional or physical harm, at the same time providing legally defensive care to safeguard and protect vulnerable adults, especially if they lack capacity, and children.

The consideration and implementation of any de-escalation steps MUST NOT be seen or considered to condone such behaviour or actions. It has to be made very clear to the service user that such steps are part of the formal resolution process

Identifying a sanction and how to issue

A range of sanctions are available for consideration by incident handlers (usually line managers) for issue to patients, their relatives/friends/carers or members of the public:

• Words of advice – informal resolution

• Verbal warning – formal resolution

• Written warning – formal resolution

• Acknowledgment of Responsibilities Agreement – formal resolution

During any meeting or conversation about a sanction, managers should listen to the perpetrator’s side of the story and assess their attitude to the unacceptable behaviour, while also clearly communicating that the behaviour will not be tolerated and any conditions of further care.

Words of advice – informal resolution

Worries about an individual’s health and the care they receive are often triggers for unacceptable behaviour. In most cases, this lapse in acceptable behaviour is of a minor nature, e.g., shouting at staff due to panic or use of swear words that are not directed at a staff member. These are usually, though not always, followed by a form of an apology.

In the most minor of incidents, appropriate words of advice can be given to the individual. This could take place in the moment if possible, or afterwards with an informal conversation by the member of staff or line manager. This has the effect of:

• maintaining good communication between staff, the patient and/or relative(s). It is important to listen to the individual’s point of view as part of the conversation.

• putting firm boundaries in place as to what behaviour is expected

• giving an opportunity for staff to educate the individual as to why the behaviour is deemed unacceptable and the impact it has on people around them

The ability to apply good conflict resolution techniques is essential, so as to not escalate a situation that is benign. No formal record is required in these cases, but the sanction must be selected in the ‘outcome of investigation’ field on the Datix/Access incident record.

Outcome of incidents on Datix/Access

In line with the Incident Reporting and Management Policy (QSPOL01) the outcome of all incidents must be recorded on the Datix/Access incident record

When a sanction is applied, it should be selected accordingly under the 'outcome of investigation' field on the incident record before it is approved for closure. This field is mandatory and is used to monitor the application of this policy.

Recording incidents on the patient’s electronic clinical record

When a formal sanction is undertaken, it should be logged on the patient’s electronic clinical record.

If the sanction is issued to a relative or carer, the entry should still be placed on the patient’s record as it directly relates to the care being provided to them.

The purpose of logging the incident in this way is to make the incident visible to all clinicians/carers within the service and to other healthcare and social care professionals using the same system. To both warn of the potential for further unacceptable behaviour and to give context for subsequent interactions with the patient.

It is important to state that the updating of the patient’s electronic record is a warning of potential risk to staff by this person. It is not a guarantee that a person will be aggressive and should only be used as a guideline. Patients who have historically received a sanction must be treated the same as any other patient.

Appendix 3: Guidance and script to use for patient/relative contact by telephonePrint out and have at hand if useful

REMAIN CALM AND DO NOT ENTER INTO AN ARGUMENT OR DISCUSSION, it is often useful to let the caller articulate their concerns before responding and let them know that their concerns are being listened to by letting them know you are making a note of their concerns.

“Please do not swear/shout. I cannot help you if you continue to shout/swear. This call is being recorded”.

If the person continues to be abusive….

“I ask you again to please stop shouting/swearing as I cannot help you if you continue to do so and I will terminate this call”.

If the person again continues to be abusive….

“I have asked you twice to stop shouting/swearing. I am terminating this call”.

“I have asked you to moderate your (language/lower your voice/), on two occasions. You have not done so I am terminating this call. “

Appendix 4: Verbal Warning Example process

When do you issue a verbal request?

Where do you make the verbal request?

What is discussed?

How is this recorded?

To address unacceptable behaviour and try to find out why this behaviour is occurring and how this can be stopped

In a safe and private area when all parties are composed

Only give a verbal warning if you feel this is a safe action –a colleague should be present

Use a translator/interpreter if necessary

Understand the reasons for the unacceptable behaviour and find solutions

Explain that this behaviour is unacceptable

Explain the Provide’s position on protecting staff and other patients/service users/contractors and visitors

Explain what will happen if the abusive behaviour continues

Length of time for which the verbal warning will be valid

Document in the notes/on EPIC

In the patient’s notes with date, time and details incident reporting system Datix/Access

Next steps Behaviour improves – no further action Behaviour does not improve –Issue Written Warning

Most people who have worked in a job that involves dealing with the public either face to face or over the phone will have experienced an exchange with an abusive caller at some point or another. If you're ever face with such a scenario, maintain your professionalism and try to work toward a resolution.

Manner

Always maintain a polite and professional manner during any exchange with a service user. If you are verbally abused or exposed to personal attacks on your character, resist the urge to retaliate.

Explain

Ask the abusive service user / carer to calm down in a respectful manner and explain that you're there to help. Tell them it's going to be more difficult to resolve the issue while tempers are flared and that you're more likely to be able to address any concerns if any discussion is conducted in a civilised fashion.

Empathize

Tell your abusive service user that you can understand their frustration and that you would be upset if you were in their position, if they have a valid complaint.

Honesty

Be honest about what you can do. If you're unsure about how to deal with the caller, don't try to bluff your way through the situation. This will only serve to enrage the caller further and you could end up facing disciplinary action. Explain that you're unsure of how to deal with the situation and find out from your Manager or colleagues.

Refer to Policies

If a caller is complaining about an issue respectfully refer them to our Complaint Team.

Escalate

If it becomes clear that you are unable to deal with an abusive caller effectively, don't be afraid of passing the problem on to your Manager or a colleague who is more experienced at negotiating with angry callers.

Issue a Warning

If your caller repeatedly uses abusive language and / or threatens you, advise them that you do not have to, nor will you, tolerate being spoken to in such a manner. Explain again that you are there to help, but warn them that you will terminate the call if you're on the phone or call the Police if you're discussing the situation in person.

Silent Treatment

Don't try to talk over or interrupt your abusive caller when they are in mid-flow. This is only likely to make the caller angrier. Let them finish what they are saying. If this involves a long, drawn-out rant, so be it. Remain silent for a few seconds after they have run out of things to say and then state your position. If the caller interrupts, tell them that you have listened carefully and would be grateful if they could extend you the same courtesy.

State Your Position

If the discussion is going nowhere, state your position firmly but politely and advise your caller to make a complaint.

Terminate the Conversation

If all else fails and you're unable to get through to your abusive caller, end the discussion. If you're on the phone, explain politely that you feel you can go no further with the conversation and that you're going to hang up. If you're dealing with the service user face to face, ask them to leave your premises.

Appendix 5: Written Warning Example process

When do you issue a written warning

To address continued unacceptable behaviour where a verbal request has not been complied with or where initial behaviour is too serious to be addressed by a verbal request.

Line Manager to initiate and lead

Who needs to be advised of the situation Head of Service, Health and Safety Safeguarding, Safety and Quality

What should be included?

• Reason for issuing a written warning

• Examples as to why the patient’s / service user/ visitor’s behaviour is unacceptable.

• A clear explanation that the behaviour must stop.

• The consequences of a failure to stop the behaviour.

• Explain Provides position on protecting staff and other patients/service users and visitors

• Length of time the written warning remains in place, usually 6-12 months

How is this recorded?

Next steps

• One copy of the letter is given to the patient/service user and one filed in the notes

• On Datix if visitor

• On the Datix incident reporting system (attach letter)

Behaviour improves – no further action

Behaviour does not improve:

• Consider exclusion from Provide if there are no situations which would make this inappropriate. ALL EXCLUSIONS MUST BE APPROVED BY THE GROUP CHIEF EXECUTIVE

• Civil or criminal proceedings (escalate to the Health and Safety Team to manage)

Appendix 6: Example warning letter

Dear

Written Warning between [patient/service users name] and provide Community

It is alleged that on [date] you behaved in an unacceptable manner whilst a patient of [where incident occurred].Specifically you [describe specific behaviour].

Behaviour such as this is unacceptable and will not be tolerated. Provides firmly of the view that all those who work in or provide services have the right to do so without fear of violence or abuse. [This was made clear to you on [date and location of verbal request to moderate behaviour] by (person(s) who made the request) to acknowledge responsibility for your actions and to agree a way forward.

I ask you now, in writing to agree to comply with the following conditions when attending any Provide services for treatment in the future or staff our visiting you at home.

[list the conditions these must include all behaviours that the staff do not expect from the recipient]

If you fail to comply with these conditions and continue to demonstrate what we consider to be unacceptable behaviour, Provide Community will have no choice but to take one of the following actions [can be amended as appropriate]:

• The matter will be reported to the Police with a view to Provide Community supporting criminal proceedings or other sanctions. Any legal costs incurred will be sought from yourself.

• Consideration will be given to obtaining a civil injunction. Any legal costs incurred will be sought from yourself.

• As a last resort, Provide Community will consider exclusion from our services

• This agreement will remain in place for 6/12 months [length of time of agreement]

Yours sincerely

[Name of senior member of staff]

EQUALITY IMPACT ASSESSMENT

TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”): Violence and Aggression Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

The aim of this policy is to describe those behaviours, which are unacceptable, the sanctions available in the face of such behaviour, and a mechanism whereby service users who are extreme or persistent in their unacceptable behaviour can, as a last resort, be excluded from the service

Project/Policy Manager: Head of Health, Safety and Compliance

Date: June 2024

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age