dhulwa mental health unit (dmhu) – use of … › sites › default › files › 20… · web...

CHHS17/213

Canberra Hospital and Health ServicesOperational Procedure Dhulwa Mental Health Unit (DMHU) – Use of Therapy Spaces Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 4

Section 1 – Responsibility for Therapy Spaces..........................................................................4

1.1 On-ward Therapy Spaces................................................................................................4

1.2 Off-ward Therapy Spaces................................................................................................4

1.3 Orientation to therapy spaces.........................................................................................6

1.4 Staff facilitating an activity..............................................................................................6

Section 2 – Accounting for Tools, Equipment and Materials....................................................7

2.1 Counts of Tools, Equipment and Materials.....................................................................7

2.2 Missing Tools, Equipment or Materials...........................................................................7

2.3 Weekly Audits................................................................................................................. 7

2.4 Damaged, broken or work tools, materials or equipment..............................................7

Section 3 – Consumer Access and Use of Therapy Spaces........................................................7

3.1 Approval for Consumer Access to Therapy Spaces.........................................................7

3.2 Risk Assessment..............................................................................................................8

3.3 Safety and Security..........................................................................................................8

3.4 Unsupervised Access to Therapy Spaces.........................................................................9

3.5 Documentation...............................................................................................................9

Section 4 – Booking Therapy Spaces.........................................................................................9

4.1 On-ward Therapy Group Rooms.....................................................................................9

4.2 Off-ward Therapy Spaces................................................................................................9

4.3 Computer devices........................................................................................................... 9

Implementation...................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

Legislation........................................................................................................................... 11

Doc Number Version Issued Review Date Area Responsible PageCHHS17/213 1 05/09/2017 01/09/2020 MHJHADS 1 of 12

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS17/213

Definition of Terms................................................................................................................. 11

Search Terms.......................................................................................................................... 12



CHHS17/213

Purpose

The purpose of this procedure is to provide all staff working in Dhulwa Mental Health Unit (DMHU) with the necessary information about: Responsibilities for therapy spaces Use of storage spaces Accounting for tools, equipment and materials Consumer access to and use of therapy spaces, and Booking therapy spaces.

Back to Table of Contents

Alerts

This procedure should be read in conjunction with the Mental Health Act 2015, the Mental Health (Secure Facilities) Act 2016, the DMHU Control of Tools, Equipment and Materials Procedure and the DMHU Consumer Access to Electronic Devices Procedure.

All staff involved in an activity must be familiar with the location of the fixed duress alarm(s) in the space they are using before taking consumers into the space (see Justice Health Services Duress and Emergency Response Procedure for more information).

Only staff who have received the relevant orientation and induction to a therapy space, including how items may be used and are to be safely managed in the space, will have access to tools, equipment and materials (including sporting and music resources).

Staff wishing to access the space and tools, equipment and materials for use with consumers will need to liaise with the relevant manager of the space (see below) about their training.

Information about the use of equipment, tools and materials in each therapy space is available from the respective therapy space manual, located in the therapy space, generally on the door. In some circumstances posters on display in the room may also be used as an easy reference for example, hand washing in the ADL Kitchen.

Staff facilitating an activity are responsible for completing the Session Inventory Form, located in the Session Inventory Form booklet stored in each therapy space, before and at the conclusion of the activity.




CHHS17/213

Scope

This procedure applies to: All staff working in DMHU, and All DMHU therapy spaces, including the:

o Activities of Daily Living (ADL) Kitcheno Barbeque Areao Basketball Courto Computer Roomo Dining roomso Group Activity roomso Gymnasiumo Multi-Faith Roomo Multipurpose Roomo Sensory Modulation Roomo Vocational Workshop, ando Walking track.


Section 1 – Responsibility for Therapy Spaces

1.1 On-ward Therapy SpacesNursing staff on each unit are responsible for managing the on-ward therapy spaces (see definition of terms). All enquiries about the use of these spaces and associated equipment should be directed to the Nurse in Charge (NIC).

1.2 Off-ward Therapy SpacesAllocated staff are responsible for managing each of the following off-ward therapy spaces:

1.2.1 Activities of Daily Living Kitchen The Occupational Therapist (OT) is responsible for managing for the ADL Kitchen. The OT and Allied Health Assistant (AHA) have overall responsibility for ensuring the

maintenance and cleaning of equipment and the completion and monitoring of documentation e.g. Session Inventory Form, of the ADL Kitchen and for the purchase of appropriate equipment.

1.2.2 Barbeques The Facility Manager has overall responsibility for the maintenance, cleaning of the

barbeque area and for the purchase of appropriate equipment. Cleaning of the barbeques is scheduled for every Monday and additional cleaning can be

arranged on request, through the Facility Manger. Staff facilitating a barbeque are responsible for ordering all stores required.



CHHS17/213

Note: Any tools or equipment taken from the ADL kitchen for a barbeque, must be recorded on the kitchen Session Inventory Form.

1.2.3 Basketball CourtThe Facility Manager has responsibility for the maintenance of the basketball court. All enquiries about the basketball court should be directed to the Facility Manager.

Staff facilitating an activity have responsibility for equipment and the use of the basketball court during an activity.

1.2.4 Computer Room and DMHU owned laptops, iPads, iPods and computersThe Therapy Manager has management responsibility for the Computer Room and DMHU owned laptops, iPads, iPods and computers available for consumer use. All enquiries about the use of these resources should be directed to the Therapy Manager. The Therapy Manager will manage the DMHU iTunes account.

Alert: It is essential that all access to the computer room must follow section 4.1 Access to DMHU Computer Room in the DMHU Consumer Access to Electronic Devices Procedure.

1.2.5 GymnasiumThe Exercise Physiologist (EP) is responsible for managing the gymnasium (gym). All enquiries about the use of the gym and associated equipment should be directed to the EP (or Therapy Manager in absence of EP). The EP and AHA have overall responsibility for ensuring the maintenance and cleaning of

equipment and the completion and monitoring of documentation (e.g. Session Inventory Checklist), in the gym and for the purchase of appropriate equipment.

1.2.6 Multi-Faith Room The Allied Health Team is responsible for managing the Multi-Faith Room. All enquiries

about the use of the Multi-Faith Room and associated equipment should be directed to the Therapy Manager or delegate.

1.2.7 Multipurpose Activities Room The Art Therapist is responsible for managing the Multipurpose Activity Room and the

purchase and replenishment of equipment and materials for art therapy purposes. All enquiries about the use of the Multipurpose Activity Room and associated equipment should be directed to the Art Therapist.

Where the room is used for activities other than Art, the facilitator of that activity is responsible for the management of equipment or materials.

Staff should inform the Art Therapist as art materials become depleted. Sharps are to be kept in the locked knife box in the Multipurpose Storeroom. Staff may

access these with approval from the Therapy Manager, Art Therapist or OT. Only the tools required for the activity should be removed from the Multipurpose

Storeroom.



CHHS17/213

1.2.8 Sensory Modulation Room The OT is responsible for managing the Sensory Modulation Room. The OT and AHA have overall responsibility for ensuring the maintenance, cleaning and

monitoring of the sensory modulation room and for the purchase of appropriate equipment.

1.2.9 Vocational Training Room The OT is responsible for managing the Vocational Training Room. All enquiries about the

use of the Vocational Training Room and associated equipment should be directed to the OT (or Therapy Manager in the absence of the OT).

1.2.10 Walking Track The Facility Manager is responsible for managing the walking track maintenance and

upkeep. All enquiries about the maintenance and upkeep of the Walking Track should be directed to the Facility Manager.

1.3 Orientation to therapy spacesThe staff member(s) with responsibility for each therapy space are available to orientate staff to the space, its manual and associated equipment. Staff seeking orientation should approach the relevant staff member(s) for orientation.

1.4 Staff facilitating an activityStaff facilitating an activity will: Conduct the session in accordance with the therapy space manual located on the back of

the door Use the Session Inventory Checklist to record all tools and materials to be used during an

activity at the commencement of the activity and at the conclusion of the activity, before consumers have left the therapy space (see DMHU Control of Equipment and Materials Procedure for further information)

Ensure all items used during the activity are returned to their respective locations, (e.g. locked cupboards, ADL kitchen)

Ensure the space is left tidy and clean, (i.e. paint brushes are cleaned, the barbeque is cleaned)

Ensure any required cleaning and hygiene guidelines, specified in the therapy space manual, have been followed

Ensure any keys borrowed from a Therapy Manager are returned Advise security control (on ext 79600) before taking consumers to off-ward activities.

This is to ensure that security turns on the relevant Closed Circuit Television (CCTV) cameras in the area during the activity, and

Advise security control (on ext 79600) when the activity has concluded, so that security can turn off the relevant cameras at the conclusion of the activity.


Section 2 – Accounting for Tools, Equipment and Materials



CHHS17/213

Unless otherwise stipulated in this procedure, the following requirements apply to the use and storage of equipment in therapy spaces.

2.1 Counts of Tools, Equipment and Materials At the beginning and end of each activity, staff responsible for supervising the activity

must conduct a count of all tools, equipment and materials to be used, using the Session Inventory Check Form contained in the session inventory check form audit booklet, located in the therapy space (see therapy space manual and DMHU Control of Equipment and Materials Procedure for further information). The count at the end of the activity must occur before consumers leave the room.

2.2 Missing Tools, Equipment or Materials If any tools, equipment or materials are missing, search procedures should commence,

as outlined in section four of the DMHU Control of Equipment and Materials Procedure (see DMHU Search Procedure for more information).

2.3 Weekly Audits Staff with overall responsibility for a therapy space will conduct a weekly audit of all tools

and materials in the therapy space using the respective therapy space audit checklist, contained in the therapy space audit booklet, located in the therapy space.

The Unit Management Team (UMT) will audit Inventory Forms to monitor compliance. The Therapy Manager will table an audit report of inventory forms at the monthly DMHU

Security and Facility meeting.

2.4 Damaged, broken or work tools, materials or equipment The staff member responsible for the therapy space will replace any damaged, broken or

worn out tools, materials or equipment. Before new tools, materials or equipment are taken into the therapy space they must be

engraved with the appropriate identification (see therapy space manual and DMHU Use of Tools and Material Procedure for more information).


Section 3 – Consumer Access and Use of Therapy Spaces

3.1 Approval for Consumer Access to Therapy SpacesAccess to off-ward therapy spaces requires approval of the MDT, based on the consumer’s Security Classification and Leave Entitlement (SCALE) (see DMHU Consumer Leave Management Procedure for more information) and must be documented in the consumer’s Treatment, Placement, Restrictions, Implementation, Monitoring and Review (TPRIM) Plan (see DMHU Clinical Risk Assessment and Management Procedure for more information).

Access to outdoor therapy spaces (see definition of terms) is contingent on approval for ground leave as indicated by the consumer’s SCALE rating. This may be escorted, supervised, or unescorted (see DMHU Consumer Leave Management Procedure for more information).



CHHS17/213

3.2 Risk AssessmentAccess to specific activities and facilities is based on relevant risk assessments. These include:

3.2.1 Activities of Daily Living Kitchen and Barbeque AreasThe OT will conduct relevant risk assessments and document the outcome in the consumer’s electronic clinical file (ECR). Assessments may include the safe use of sharps, fire equipment, and use of tools or implements.

3.2.2 Consumer Computer Room and DMHU owned laptop, iPad, IPod or ComputerConsumers will require MDT approval before having access to the computer room and a DMHU owned laptop, iPad iPod or computer to use for therapeutic activities. Access to a DMHU owned laptop, iPad iPod or computer may be given with or without supervision, based on the consumer’s SCALE and MDT approval (see DMHU Consumer Access to Electronic Devices Procedure for more information).

3.2.3 GymnasiumThe EP will conduct physical and medical risk assessments using the Dhulwa Gym Pre-Screening Tool and the Physical Assessment Form: Dhulwa Gym available on the DMHU forms folder. These will be scanned into the consumer’s ECR.

3.2.4 Multipurpose RoomThe facilitator of an activity conducted in the Multipurpose Room will ensure that consumers have any appropriate risk assessments, e.g. when using tools that may pose a risk.

3.2.5 Vocational WorkshopThe facilitator of an activity conducted in the Vocational Workshop will ensure that consumers have any appropriate risk assessments, e.g. when using tools that may pose a risk.

3.3 Safety and SecurityNotwithstanding the above risk assessments, dynamic clinical factors may govern the decision to approve participation on a given occasion (i.e., leave, mental state, Dynamic Appraisal and Situational Risk (DASA) score, TPRIM updates and group mix). Dynamic factors will be assessed by the staff member facilitating the activity on each occasion prior to providing access to the therapy space. A final decision on access will be determined by the NIC and/or Therapy Manager.

Prior to commencing an activity, staff responsible for supervising the activity should: Be aware of the consumer’s TPRIM Plan and SCALE rating (see Consumer Leave

Management Procedure for more information) and current mental state of each consumer considered for an activity

Check the space for any hazards, e.g., prohibited and restricted items and items requiring approval (see DMHU Prohibited and Restricted Items for more information)



CHHS17/213

When facilitating activities in the grounds, collect a Talk Radio Network (TRN) radio from the staff station to facilitate contact with security or another staff member in the event that staff require further assistance to manage a medical or security incident, and

Note the ratio of staff to consumers required, as indicated by their SCALE and minuted in the TPRIM.

3.4 Unsupervised Access to Therapy SpacesUnsupervised access may be granted to a therapy space, .e.g. the walking track, depending on the consumer’s SCALE and recommendation of the MDT.

3.5 DocumentationAt the conclusion of each activity, a member of staff involved in the activity should record a clinical note in the ECR of each consumer who was involved in the activity and for any consumer who declined to participate in the activity. This note should include information about the consumer’s mental state, participation level and anything else of relevance.


Section 4 – Booking Therapy Spaces

4.1 On-ward Therapy Group RoomsActivities and programs scheduled in the on-ward group activity rooms will be documented on the Lomandra and Cassia Unit timetables, located on the staff station noticeboard and consumer noticeboards.

If there is no activity scheduled in a room, it can be used and accessed as needed (i.e. as a quiet space, for play station, etc), with the prior approval of the NIC.

4.2 Off-ward Therapy SpacesActivities and programs scheduled in each therapy space will be documented on the relevant therapy space timetable, located on the door of the space and on the consumer noticeboard.

If there is no activity scheduled in the space, a member of staff may use the space with a consumer after first seeking approval from the staff member responsible for the space or Therapy Manager.

4.3 Computer devicesBookings for all consumer computer devices can be made via the Computer Room Diary


Implementation



CHHS17/213

The contents of this procedure will be communicated through training provided to DMHU staff and other relevant teams where the procedure applies. New staff will be familiarised with the procedure on their induction.


Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Work Health and Safety PolicyACT Health Work Health and Safety Management SystemACT Health Incident Management Policy ACT Health Waste Management PolicyACT Health Electrical Safety Policy DMHU Search Policy

ProceduresACT Health Incident Management ProcedureACT Health Significant Incident ProcedureCHHS Mobile Electrical Equipment including Clinical EquipmentMHJHADS Director on Call Roles and Responsibilities ProcedureMHJHADS Significant Incidents Reporting ProcedureJustice Health Services Duress and Emergency Response ProcedureDMHU Control of Tools, Equipment and Materials Procedure DMHU Referral, Admission and Transfer of Care ProcedureDMHU Search ProcedureDMHU Consumer Access to Electronic Devices Procedure DMHU Prohibited and Restricted Items and Items Requiring Approval for more informationDMHU Clinical Risk Assessment and Management ProcedureDMHU Leave Procedure

FrameworksDMHU Security Procedural FrameworkACT Health Waste Management Plan

Standards Australian Charter of Healthcare Rights National Standards for Mental Health Services 2010 National Safety and Quality Health Service Standards 2012 Australian and New Zealand Food Standards Code

Legislation Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Children and Young People Act 2008 Public Advocate Act 2005Doc Number Version Issued Review Date Area Responsible PageCHHS17/213 1 05/09/2017 01/09/2020 MHJHADS 10 of 12


CHHS17/213

Human Rights Act 2004 Carers Recognition Act 2010 Health Records (Privacy & Access) Act 1997 Guardianship and Management of Property Act 1991 Crimes Act 1900 Privacy Act 1988 Discrimination Act 1991 Work Health and Safety Act 2011 Corrections Management Act 2007 Official Visitor Act 2012 Territory Records Act 2002 Working with Vulnerable People (Background Checking) Act 2011 Health Act 1993 Workplace Privacy Act 2011 Security Industry Act 2003 Court Procedures Act 2004 Electrical Safety Act 1971 Food Act 2001


Definition of Terms

On-Ward Therapy SpacesOn-Ward therapy spaces include the respective unit dining rooms and Group Activity Room.

Off-Ward Therapy Spaces Off-Ward therapy spaces include the therapy corridor, multi faith room and the outdoor therapy spaces.

Outdoor Therapy Spaces Outdoor therapy spaces include the gymnasium, basketball courts, walking track, barbeque areas and Vocational Workshop.

Sensory Modulation The capacity to regulate and organise the degree, intensity and nature of responses to sensory input in a graded and adaptive manner. This allows the individual to achieve and maintain an optimal range of performance and adapt to challenges in daily life.

Sensory RoomA supervised, therapeutic environmental room equipped with sensory based tools which supports people to recognise his/her own individual sensory preferences, thereby aiming to make the person orientated, grounded and safe. The sensory therapy space allows for the supervised use of the sensory room; to explore the various modalities and/or to use the space.



CHHS17/213

Therapy Corridor The Therapy Corridor includes the Activities of Daily Living (ADL) Kitchen, sensory room and multi-purpose room and computer room.


Search Terms

Activities of daily living kitchen, sensory modulation, sensory room, multi-faith room, gymnasium, gym, basketball court, walking track, art activities, barbeque, BBQ, computer devices, DMHU owned computer, vocational workshop, therapy space.

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



dhulwa mental health unit (dmhu) – use of … › sites › default › files › 20… · web...

Documents