Therapeutic observations are used on all mental health wards as part of a wider care plan to support your loved one and reduce any risks that have been identified by the clinical team.
Everyone admitted to a ward will be on ‘general’ therapeutic observations in order to support them on their recovery journey.
The aim of any observation is to engage people in a constructive way to try and build a rapport with staff and help them to address their difficulties by engaging them in activities that are beneficial to them.
Enhanced observations
‘Enhanced observations’ (sometimes called ‘Obs’) indicates any observations more frequent than general observations (intermittent/continuous/close).
A person may be placed on a period of enhanced observations due to risks relating to themselves or others, physical health concerns, or vulnerability.
Enhanced observations might be considered if the person you care for is actively suicidal, confused and therefore might be at risk of coming to harm through wandering or interactions with other people, or physically unwell.
Observations are carried out throughout the day and night. During the night, staff will use a torch to ensure proper observation is made of each person.
This will not be shone at the person's face, so it won't disturb their sleep, but will be shone into the room, possibly at the celling or their chest to ensure they are safe and well.
When someone is on enhanced observations they are still able to utilise time away from the ward with staff support; however, this must be discussed with the multi-disciplinary team, the person themselves, and their carer to consider whether leave can be managed safely.
Occasionally it may be appropriate for people on enhanced observations to go on leave with family or friends. This should always be discussed with you in advance and if you are not sure, or do not feel able to support the person off the ward, you do not have to agree to take the person away from the ward environment. If there are any doubts about safe management of risk, leave will not go ahead.
Who decides observation levels?
Observation levels for each person are set and reviewed by the multi-disciplinary team through ward rounds. This will include all the people involved in the care of your loved one. The consultant psychiatrist and nursing staff are always present, and junior doctors, occupational therapists, social workers, psychologists, and activity co-ordinators may also attend. The decision to implement enhanced observations will be based on the risk assessment completed by the ward team and balanced by the opinions of the person in hospital and their carer. Levels of observations should always be based on the least restrictive level necessary, for the least amount of time necessary, and won't be used as a routine part of someone’s care and treatment.
Care plans
Any time a person is placed on enhanced observations, a care plan will be written by the clinical team.
The care plan will state the reason for the enhanced observations, what the aim of the observations are, and when they might be reduced.
It will also include information about prescribed medication and when to use it, things that are known to work well in supporting your loved one when they are struggling, and things that might trigger distress/confusion/illness.
There is space within the care plan to reflect both your loved one's views and your views as a carer, so you should be asked about this by the team caring for you loved one. A copy of this care plan is kept by staff and a copy will be given to your loved one for them to keep.
Observation levels and what they mean.
General observations
The lowest level of observation for people admitted to inpatient care. This means that the person is checked on by staff every 30 minutes throughout the day and night. On some wards, such as in rehabilitation settings, general observations are completed hourly.A specifically allocated member of staff will ensure they see, and during the day, speak to the person, this might be a registered nurse, nursing assistant or other health care professional. At night staff will ensure that the person is breathing, but will not disturb them unless it is necessary to do so.
Intermittent observations (sometimes called '15/30 min obs')
This means that a person is checked on more regularly than every hour, at agreed intervals specified within their care plan. This is normally at intervals between 30 and 15 minutes.
Continuous supportive observations (sometimes called ‘max obs’ or ‘1:1’)
This might be used when a person is at risk of self harm, is a potential risk to others, or if there are risks relating to their physical health. It might also be due to issues not specifically relating to someone's own presentation, such as maintaining the safety and wellbeing of a person under 18 temporarily admitted to an adult inpatient ward.
It indicates that a person is within the eyesight of specifically allocated staff at all times throughout the day and night. There will be an agreed plan in place to maximise a person’s dignity at times when they are completing personal care, such as using the toilet or shower.
Close supportive observations
This type of observation is only utilised when there serious concerns for someone's physical health. It means that the patient will be within arm's reach or in very close proximity of a member of staff at all times. There will be times when staff need to go into the toilet or bathroom with the person and this will be a same sex member of staff. On some very rare occasions, because of someone's risk to other people, it may be necessary for people to be observed by more than 1 member of staff. 2:1 indicates 2 members of staff will be present for observations.
Seclusion
Seclusion is when someone being treated on the ward is in an area of confinement away from the rest of people on the ward. This helps to manage severe and immediate risks of harm to others. It will only ever be used when all other attempts to support a person or manage their behaviours have been exhausted. It will only ever be used where the risk of harm to others greatly outweighs the risk of harm to self.
Only people detained under the Mental Health Act will be treated in a seclusion space. If at any time a person who is on the ward informally requires this level of support, they will be considered for emergency section under the Mental Health Act. (Use this link to a carers guide to the Mental Health Act for more information about this).
The decision to seclude someone can be made by the psychiatrist, on call doctor, or nurse in charge. A care plan will be completed like for any other level of enhanced observation, and every attempt will be made to make sure the voice and opinion of your loved one is recorded within their care plan.
Seclusion rooms are specifically designed spaces which enable staff to monitor your loved one closely and for the member of staff to be sitting outside the room observing them at all times. Your loved one will be told why they have been placed in seclusion, and when or under what circumstances they will be able to leave.
There are rules about how people requiring seclusion are managed, such as having access to a toilet and washing facilities within the space and always being able to see a clock. Your loved one will be seen regularly by a doctor and/or a senior member of the nursing team during their time in seclusion.
As a carer, you be informed if the person you care for is being nursed in seclusion at any time. Throughout the time they remain in seclusion, you will not be able to visit or speak with them directly; however, the care team will keep you regularly updated on how your loved one is and the clinical plan.
