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Canberra Hospital and Health ServicesOperational ProcedureDhulwa Mental Health Unit (DMHU): Valuables, Property and Access to MailContents

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

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

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

Scope........................................................................................................................................ 3

Section 1 – Valuables and Property of Consumers....................................................................3

1.1 On Admission..................................................................................................................3

1.2 Updating Consumer’s Property.......................................................................................5

Section 2 – Storage and Audit of a Consumer’s Valuables........................................................6

Section 3 – Lost Property..........................................................................................................6

Section 4 – Electrical Safety – Testing and Tagging...................................................................7

Section 5 – Prohibited, Restricted and Items Requiring Approval.............................................7

Section 6 – Consumer property limits.......................................................................................8

6.1 Consumers Room............................................................................................................8

6.2 Cassia and Lomandra – Food Storage (Dry Goods)..........................................................8

6.3 Cassia – Food Storage (Fridge Items)..............................................................................8

Section 7 – Access to Mail.........................................................................................................8

7.1 Mail Search......................................................................................................................9

7.2 Documentation.............................................................................................................10

Section 8 – No Contact Requests – Consumer to stated person/stated person to consumer 10

8.1 Consumer advises they do not want contact with a stated person..............................10

8.2 Stated person advises they do not want contact with a consumer...............................10

Section 9 – Discharge or Transfer...........................................................................................11

Section 10 – Releasing Valuables and Property of a Deceased Consumer..............................12

Implementation...................................................................................................................... 12

Related Policies, Procedures, Guidelines and Legislation.......................................................12

Definition of Terms................................................................................................................. 13

Search Terms.......................................................................................................................... 14

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Purpose

This procedure provides directions for the management and tracking of all consumers’ personal property at admission, during the course of their admission and at transfer or discharge from the Dhulwa Mental Health Unit (DMHU).

Alerts

Staff should always refer to the Mental Health Act 2015 and the Mental Health (Secure Facilities) Act 2016 for the most definitive understanding, interpretation and explanation of the applicable legislation, particularly when making any decisions under these Acts.

Scope

This document applies to all staff working at the DMHU. This can include: DMHU clinical staff DMHU administrative and DMHU Security Officers.

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Section 1 – Valuables and Property of Consumers

1.1 On AdmissionAll items of consumer property will be x-rayed and examined by Security Officers prior to being transferred to the Property Officer.

A consumer’s property, including valuables and money, will be received and recorded by two DMHU staff, one being a Security Officer. This process will be conducted in the presence of the consumer, where possible.

All property must be recorded on the Consumers Clothing, Property and Valuables Form, located on the clinical forms register. Both staff will counter-sign the form. Once the admission process has been completed and the Consumers Clothing, Property and Valuables Form is completed, the consumer must sign the form when able to. A copy of the signed Consumers Clothing, Property and Valuables Form will be provided to the consumer for them to retain and an updated form can be provided upon request. The Form is to be scanned into the consumer’s Electronic Clinical Record (ECR).

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1.1.1 Clothing and EquipmentEach item of the consumer’s property should be described on the Consumers Clothing, Property and Valuables Form. Staff completing the form should describe brand names and general condition of all items, e.g. Blue Shorts, red ‘Billabong’ shirt, good condition.

The quality of the property will be recorded as follows:

N NewBR BrokenS SoiledT TornWT Wear and TearM MarkedSC Scratched

When itemising the consumer’s property, include the following: Personal clothing and shoes worn on admission Items which the consumer has permission to take to the Unit. (These will be recorded by

the Property Officer and then provided to the consumer’s primary nurse so they can be returned to the consumer on the completion of the admission process.)

Please note: ACT Corrective Services (ACTCS) clothing does not need to be documented and can be returned to ACTCS during transfer of custody.

The Property Officer, or primary nurse when the Property Officer is not present, must ensure that the consumer’s property is placed in the allocated property storage unit for that consumer.

Excess items refer to items that cannot be stored in the allocated space for that consumer due to it being full. Excess items must be stored with the consumer’s property or transferred to their carer or family, or following alternate arrangements made by the Social Worker. If a consumer wishes to have an additional item in their room they may need to exchange this item with one that is already in their room. Excess items are to be stored in property until transfer to the consumer’s family can be arranged, if possible. This would be arranged by the Property Officer in collaboration with the DMHU Social Worker.

1.1.2 MoneyMoney should be described as follows: ‘$125.00 in Australian currency comprising 2 x $50.00, 2 x $10.00 notes and 5 x $1.00 coins’, or, ‘13 foreign currency banknotes apparently Euro in origin comprising 10 notes bearing the number 100 and 3 notes bearing the number 5’.

All cash is to be placed in the consumer’s security bag and sealed with pre-numbered tamper evident security seal / zip lock. The Property Officer or primary nurse, with a Security Officer,

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will check the Consumers Clothing, Property and Valuables Form, the integrity of the security seal and verify the seal number recorded on the form.

The cash may be stored securely by the Property Officer or the consumer may elect to transfer cash to the DMHU Trust account (see DMHU Consumer’s Money Procedure). Evidence of any transfer of cash should be attached to the Consumers Clothing, Property and Valuables Form.

Consumers may require money for approved leave, please refer to DMHU Consumer’s Money Procedure and DMHU Leave Procedure.

1.1.3 ValuablesUpon receiving consumer’s property, DMHU staff should determine whether it contains valuable items. A valuable item includes but is not limited to money, passports, debit/credit cards, jewellery, Medicare cards and personal documents.

Watches, rings and other items of jewellery should be described with no reference to ‘gold’ or ‘silver’ or any other precious metal. Instead describe all items as ‘yellow metal’ or ‘white metal’ or ‘clear stone’.

Place all valuable items in a security bag and seal it with pre-numbered tamper evident security seal / zip lock.

Enter the security seal number on the Consumers Clothing, Property and Valuables Form.

A consumer label should also be affixed to the security bag for identification purposes.

All security bags are to be stored in the Consumer Valuables Locker.

A minimum of two staff members, one being a Security Officer, are required to complete the following steps to check in valuables: The Property Officer or primary nurse, with a Security Officer, will check the Consumers

Clothing, Property and Valuables Form, the integrity of the security seal and verify the seal number recorded on the form.

The Property Officer or Security Officer will enter relevant details into the Consumers Clothing, Property and Valuables Form and place the security bag containing consumer valuables inside the Valuables Locker.

A copy of the Consumers Clothing, Property and Valuables Form is placed in the Consumer Valuables folder. The folder is to be maintained by the Property Officer.

A copy of the signed form will be provided to the consumer for them to retain.

1.2 Updating Consumer’s PropertyIf a consumer’s storage reaches capacity (i.e. exceeds the allocated space for the consumer), all new requests for property will be deferred until existing items are removed (e.g. donated, discarded or transferred to a family member, friend or carer).

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If a consumer donates or discards their property or gives it to a family member, friend or carer to take home, the Consumers Clothing, Property and Valuables Form must be updated and signed by the consumer, Property Officer and primary nurse.

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Section 2 – Storage and Audit of a Consumer’s Valuables

The Consumer Valuables Register is maintained by the Property Officer.

The keys for the Valuables Lockers are to be stored and accessible by Security Officers and Valuables Lockers are only to be opened with two staff present, one being a Security Officer. Security Officers must note in the Security Log when Valuables Lockers are opened.

There will be a weekly audit of the Valuables Lockers and consumers’ valuables.

The audit will be carried out by the Security Supervisor and Facility Manager; the Property Officer may be present. The audit will consist of checking the integrity of security seals, quantity of consumer valuables and record keeping in the Consumer Valuables Register and Consumers Clothing, Property and Valuables Forms.

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Section 3 – Lost Property

If a consumer reports a missing item, staff need to investigate this fully, clarifying when the item was last seen and from where the item went missing.

Though discouraged, consumers do trade and give away items. Property may deteriorate over time and may be discarded. All of these avenues are important to explore when a consumer reports a missing item. Lost or stolen items may be recovered by way of a unit search or, where necessary, a search of an individual room or consumer. The dignity of all concerned must be maintained if searches are conducted (see DMHU Search Procedure).

If valuables that the unit has taken responsibility for storing and safe keeping are reported as missing this needs to be investigated by the Security Supervisor and Assistant Director of Nursing (ADON) and reported to the Operational Director Justice Health Services (JHS) for appropriate management.

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Section 4 – Electrical Safety – Testing and Tagging

All electrical items brought into the DMHU must appear to be in good working order on visual examination and have a current tag attached. The responsibility is on all staff, reinforced by managers and supervisors, to verify that all electrical devices brought on site comply with this requirement.

There will be various DMHU staff trained in the procedure of Testing and Tagging. Consumers are unable to be accessed or use electrical items until Testing and Tagging has been completed and based on approval from MDT.

The length of any cable/lead designed to be attached to or connected to any electrical item, must be the subject of a risk assessment by the Multi-Disciplinary Team (MDT), dependent on the consumer’s SCALE.

Refer to the ACT Health Electrical Safety Policy.

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Section 5 – Prohibited, Restricted and Items Requiring Approval

See DMHU Prohibited, Restricted and Items Requiring Approval Procedure for further information.

To ensure the safety and security of consumers, staff and visitors certain items are regulated within DMHU. These items include: prohibited items as declared by the Director-General restricted items, which are by their nature or properties, potentially hazardous or illegal

(for example, access to electronic media, including the bringing of DVD’s, CDs and Electronic Games into the unit, is restricted within DMHU)

items which require approval.

Consumers will be made aware of prohibited and restricted items and items requiring approval on admission and via the DMHU Welcome Handbook. Consumers wishing to bring a restricted item or item requiring approval into DMHU will require approval from the MDT and should initiate this through their primary nurse.

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Section 6 – Consumer property limits

6.1 Consumers RoomTo minimise fire risk and facilitate room searching, the amount of personal correspondence retained in a consumer’s room should only be contained within one file storage box. A maximum of three soft toys will be allowed in individual rooms.

To minimise damage to wall coverings, all photographs and posters must be displayed on notice boards which will be provided in rooms.

Items of sports equipment (excluding sports leisure wear and training shoes) are not to be stored in a consumer’s room.

Perishable food must not be stored in a consumer’s room.

6.2 Cassia and Lomandra – Food Storage (Dry Goods)There are locked cupboards available for consumer’s to store their own dry goods food items. Access will be facilitated by a DMHU staff member.

6.3 Cassia – Food Storage (Fridge Items) Any fridge items within Cassia must be labelled. Labelling is to include the date the food was brought into the unit and name of the consumer to whom the food belongs.

Food may be disposed if there is a risk of the food product not meeting food safety standards. The consumer is to be present when food is disposed. This can be done by any DMHU clinical staff member.

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Section 7 – Access to Mail

Consumers will be provided with a reasonable quantity of writing materials and envelopes and the DMHU will facilitate posting one standard mail item per week. Any posting in excess of this will need to be funded by the consumer.

All mail addressed to DMHU via the PO Box or street address will be collected from Australia Post by ACT Government Records Services. Mail will be processed in accordance with the ACT Government Shared Services Record Services Procedure One Treatment of All External Mail Items: Action Undertaken by Mailroom Staff prior to its delivery to DMHU.

It must be noted that this examination will not identify potential biological or chemical hazards. For this reason, all recipients must continue to exercise caution when opening mail, particularly mail from unknown sources.

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substances. Stamps will be removed in a respectful and careful way that still allows the consumer to have the experience of opening their own mail.

If there are no concerns that a consumer’s mail contains prohibited, restricted items or items requiring approval, the mail will be provided to the consumer’s primary nurse for opening with the consumer. This is to be done in a timely manner, usually the same day the mail arrived.

Staff should be aware of consumer behaviour and any changes in their clinical presentation on receipt of mail. Content may trigger agitation or destabilisation of the consumer’s mental state and behavioural presentation. Refer to DMHU Clinical Risk Assessment and Management Procedure.

7.1 Mail SearchIf there are concerns that a consumer’s mail may contain a restricted, prohibited item, item requiring approval or items that may affect the security or good order of the Unit, these concerns should be discussed with the Nurse In Charge (NIC). The NIC may direct an Authorised Health Practitioner (see definition of terms) to search, but not read the consumers mail (s. 25 of the Mental Health (Secure Facilities) Act 2016) (see DMHU Search Procedure).

Note: Any mail sent or received between consumers and accredited people (see definition of terms) cannot be searched (s. 25(2) Mental Health (Secure Facilities) Act 2016).

Prior to searching a consumer’s mail, the Accredited Health Practitioner must advise the consumer of the belief that the mail may contain a restricted or prohibited item, or item that may affect the security or good order of the Unit and that the mail must be searched. The consumer, or a representative of the consumer, must be offered the option of being present while their mail is being searched.

If no prohibited, restricted items or items requiring approval are found after a search of a consumer’s mail, the consumer’s mail must be delivered to the consumer as soon as practicable.

If any prohibited, restricted items or items requiring approval or items that may affect the security or good order of the Unit are detected, these must be removed and reported to the ADON and the Security Supervisor (see DMHU Search Procedure).

If a search of a consumer’s mail reveals information about the commission of a serious offence, this information, including the mail itself, must be given to the Chief Police Officer (s. 26(3) Mental Health (Secure Facilities) Act 2016). The ADON or the Security Supervisor would be responsible for notifying the Chief Police Officer.

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7.2 DocumentationWhenever a consumer’s mail is to be searched, the consumer must be given: a Reviewable Decision Notice – Search of Mail and the Dhulwa Mental Health Unit Reviewable Decision Notice: Information for Patients

Brochure, available in the DMHU Forms Folder.

Any search of a consumer’s mail must be documented in the: DMHU Mail Search Register In the consumer’s ECR, including:

o A description of the evento A description of any items found

Any information passed on to the Chief Police Officer, including a copy of documentation passed (see DMHU Search Procedure).

If Items are forfeited the consumer must be provided with A Reviewable Decision Notice and Receipt of Seizure of Property (see DMHU Prohibited, Restricted Items and Items Requiring Approval Procedure).

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Section 8 – No Contact Requests – Consumer to stated person/stated person to consumer

8.1 Consumer advises they do not want contact with a stated personA consumer can request that they do not want contact with a stated person. DMHU staff will take reasonable steps to prevent contact. These steps would include not delivering mail to or from the stated person. The name and known contact details of the stated person will be recorded in the consumer’s ECR. If the stated person sends mail to the consumer, the consumer’s primary nurse will advise the ADON, who will return the mail to the stated person with a letter advising them that the consumer has indicate that they do not want to have contact with them, available in the DMHU forms folder. The consumer may, at any time, advise DMHU staff that they want to resume contact and DMHU staff will support the consumer's request.

8.2 Stated person advises they do not want contact with a consumerA stated person known to the consumer may advise DMHU that they do not want to be contacted by a consumer. If the MDT is satisfied that there are good reasons why the consumer should not contact the stated person, e.g. inappropriate or threatening behaviour, the MDT will advise the consumer of the request and take all reasonable steps to prevent the consumer contacting the stated person.

Mail from the consumer to the stated person will be kept with the consumer’s property in the property room, until the stated person tells the DMHU in writing that the contact conditions may change. When the consumer is discharged from the DMHU any mail should be handed over to the consumer.

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Prior to handing the mail over to the consumer, MDT will consider and plan how mail is provided and the potentially destabilising nature of this process and how it may impact on a consumer.

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Section 9 – Discharge or Transfer

It is the responsibility of a consumer’s primary nurse to notify the Property Officer of the discharge or transfer of a consumer at least 24 hours prior to the consumer’s planned discharge or transfer.

The Property Officer will assist with the preparation and packaging of property and will inform security. The Property Officer will access and release valuables from the safe at the time of discharge.

Once the consumer and staff are satisfied that all property is accounted for, two members of staff, one being a Security Officer will sign the discharge section of the Consumers Clothing, Property and Valuables Form, which will be countersigned by the consumer.

If the consumer is returning to a correctional facility, property (including mail) will be packaged and given to ACTCS Transport Officers at the Secure Vehicle Entry (SVE) with the transfer documentation (see DMHU Transfer of Custody Procedure).

If the consumer is transferred to another mental health care facility, property will be packaged and given to the relevant staff at the point of transfer with the transfer documentation.

If the consumer is returning to a community setting, property will be packaged and given to the consumer on discharge, unless an alternative arrangement has been made.

Money, up to $500.00 can be withdrawn from the consumer’s Trust Account on the day of discharge to ensure the consumer has funds to live on. A cash withdrawal form is to be completed and given to the Property Officer at least two working days prior to the discharge date. The DMHU Social Worker will assist the consumer with this process.

Remaining funds will be provided to the consumer in line with the DMHU Consumer’s Money Procedure.

If property belonging to the consumer is found or mail arrives after the consumer is discharged, the Social Worker will mail the property or redirect mail to the consumer.

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Section 10 – Releasing Valuables and Property of a Deceased Consumer

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The releasing of valuables or property to a third party is governed by strict criteria.

If a consumer dies while in the custody of ACT Health, staff should follow the ACT Health When Death Occurs Policy and When Death Occurs Procedure in releasing the consumer’s possessions and any money held in their trust account.

If a consumer dies, the unit will make all reasonable attempts to contact the next of kin to inform them that the unit holds property of the deceased consumer.

If the unit is unable, after making a reasonable attempt, to locate the deceased consumer’s next of kin, then the unit will refer the matter to the relevant Social Worker for the deceased consumer. The Social Worker will liaise with whomever has been appointed the Legal Representative for the deceased consumer, to decide how the possessions should be distributed.

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Implementation

The contents of this procedure will be communicated through the following means to DMHU staff and other relevant teams where the procedure applies: Education Orientation documentation and sessions Leadership and governance expectations regarding adherence to policy, procedure and

legislation. This is monitored when reviewing staff performance plans.

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Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health When Death Occurs Policy ACT Health Electrical Safety Policy DMHU Search Policy

Procedures ACT Government Shared Services Record Services Procedure One Treatment of All

External Mail Items: Action Undertaken by Mailroom Staff ACT Health When Death Occurs CHHS Mobile Electrical Equipment including Clinical Equipment MHJHADS Significant Incidents Reporting Procedure MHJHADS Director on Call Roles and Responsibilities Procedure DMHU Consumer Use of Electronic Devices and Access to the Internet Procedure DMHU Consumer’s Money Procedure DMHU Search Procedure

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DMHU Prohibited, Restricted and Items Requiring Approval Procedure DMHU Transfer of Custody Procedure

Frameworks DMHU Security Procedural Framework

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

Legislation Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Public Advocate Act 2005 Human Rights Act 2004 Health Records (Privacy & Access) Act 1997 Guardianship and Management of Property Act 1991 Work Health and Safety Act 2011 Official Visitor Act 2012 Territory Records Act 2002

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Definition of Terms

Authorised Health Practitioner: is an Australian Health Practitioner Regulation Agency (AHPRA) registered health practitioner providing care or treatment for consumers who is authorised by the Director-General under the Mental Health (Secure Facilities) Act 2016.

Accredited People: in relation to a consumer, means each of the following: if the consumer has a guardian under the Guardianship and Management of Property Act

1991—the guardian; if the consumer has a nominated person—the nominated person; if the consumer is a child or young person—the CYP director-general; a lawyer acting in a professional capacity; an official visitor; the health services commissioner; the human rights commissioner; the public advocate; a police officer acting in a professional capacity; a member of the Commonwealth Parliament; a member of the Legislative Assembly; or a person prescribed by regulation.

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Consumer's Property refers to any item/article belonging to a consumer that is held by that consumer, or by DMHU on the consumer’s behalf.

Property Officer refers to the staff responsible for the management, storage and documentation relating to items held centrally in the Property Storage Room in accordance with the detail of this procedure.

All Staff refers to all other staff involved in the management of a consumer’s property and they are responsible for ensuring that their practice with regards to a consumers’ property is carried out in accordance with this procedure.

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Search Terms

Dhulwa Mental Health Unit (DMHU), DMHU, Property, Valuables, Mail

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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

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