Department of Health

Locked areas: staffing requirements within mental health inpatient units

The Chief Psychiatrist has statutory roles and functions under the Mental Health Act 2014 (s.120 and s.121). This includes the power to issue directions to mental health service providers in respect of the provision of mental health services (s. 121 (j)).

In response to recent serious adverse events involving patients when staff were not in attendance in locked areas of inpatient units, the following direction is issued by the Chief Psychiatrist to mental health service providers under s.121 (j).

Preliminary

If a patient is locked or confined in a room or any enclosed space on their own within an inpatient unit, from which it is not within the control of the person confined to leave, this is seclusion and all the statutory responsibilities, including patient support and the required monitoring under Part 6 of the Mental Health Act relating to Restrictive Interventions must occur.

Direction regarding locked spaces where more than one patient is receiving treatment

  • If there is a locked space within the inpatient unit where more than one patient is receiving treatment and care, there must be at a minimum one clinical staff member present at all times.
  • The practice of observing patients through a window of a staff base is not considered an acceptable level of service provision where more than one patient is receiving treatment in a locked space. Clinical staff need to be physically present in the locked area where the patients are receiving treatment.
  • This direction applies to any locked area within an inpatient mental health unit (including high dependency units) where more than one patient is receiving treatment, at all times. In the exceptional circumstances of an imminent risk to staff health or safety (such as an emergency situation) other legislation provides for staff to withdraw in order to maintain their own safety and safety of patients.

Recommendations to ensure compliance with the Direction regarding the use of locked areas for high dependency care

  • Service providers need to ensure adequate responsiveness to the individual needs and vulnerabilities of patients placed in locked areas. Particular attention needs to be paid to the gender needs of the patient, trauma they may have experienced and any cultural considerations.
  • Service providers must support the capacity to increase nursing staff in response to escalation of patient needs, number of patients and for the occupational health and safety needs of staff.
  • Senior nursing staff should be rostered to the skill levels required to assist persons with this level of acute psychiatric need.
  • The clinical practice of high dependency care includes an increased level of nursing observation through therapeutic engagement; and increased treatment and support. Health services should implement the Nursing observation through engagement in psychiatric inpatient care guideline (2013).
  • Assessment, planning, interventions and observations should be clearly documented and communicated.

Background

Victorian public mental health services provide inpatient mental health care across a number of age-specific settings. At times inpatient units may be locked due to assessed level of need of patients, staff and the community.

Sometimes areas within these inpatient units are locked to ensure a secure environment, such as 'high dependency areas'.

High dependency treatment and support of acutely unwell individuals, with a profile of behavioural risk and/or sexual vulnerability, is a component of mental health service provision.

The main purpose of high dependency care is the provision of an increased level of therapeutic engagement, intervention, safety and supervision in an environment with a higher nurse-to-patient ratio. Staffing levels should be consistent within a framework of recovery oriented, trauma informed and gender sensitive practice, and staffing numbers increased in relation to the assessed vulnerability and risk of patients within the environment.

Compliance

Mental health service providers are required to comply with this Direction of the Chief Psychiatrist.

Service providers should include this advice in their local policy and procedure related to restrictive interventions and ensure that it is communicated to staff and ensure that training is provided to make sure practices are consistent with this Direction.

Reviewed 16 October 2022

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