It has been a trying few years for everyone with the impact of Covid and related restrictions. During this time, I have been privileged to see some incredible person-centred care. For example, one of the homes I have worked with went above and beyond to ensure that an isolating gentleman with learning disabilities, who had tested positive, had a staff member at his door throughout the day to engage with him and give him someone to talk to. They also supported him by doing activities at a distance and he had thrice-daily supported access to the gardens to get fresh air and a change of scene.
I am sure many readers will have also seen clips online of residents playing ‘hungry hippo’ spaced out around a large social area, or playing virtual bingo. These are just a few examples of innovative, thoughtful practises where staff have banded together to promote quality of life for service users in trying times.
Isolation and seclusion of vulnerable people
While there are certainly many examples of good practice out there, there have also been a number of cases where care teams have perhaps been understaffed, or lack in sufficient understanding of how to grade and adapt to challenges. This has had a significant impact on individuals’ quality of life while in care.
For example, there have been many situations reported where service users have been confined to their rooms ‘for their own good’, whether or not they have tested positive for Covid-19. While Covid guidance for care environments has recently been changed by government from 14 days isolation to 10, there seems to be a general lack of understanding in the care system that this is guidance – it is not a universal rule to be applied without thought. Indeed, risk assessments for individuals can still be carried out under Covid guidelines, in order to ensure least restrictive practice and that we are not being detrimental to residents’ mental health.
This leads me to wonder: how exactly have care homes been encouraging isolation among Covid-positive patients in cases where the individual cannot comprehend or retain information? Is it fair and proportionate that those most vulnerable are being further restricted in their own homes compared to the mass population who now have only 5 days isolation if tests present as clear?
I have seen one particularly poor example of practice in this area, where a home offered an individual with complex mental health issues the choice to move to an empty floor with multiple rooms to isolate in, or to remain in his usual room. After consultation, he was relocated to said empty floor and showed no symptoms of Covid throughout his isolation in this time. However, the team supporting him soon noticed a rapid decline in his daily engagement as he became increasingly withdrawn: not using the available space, laying on his bed all day and declining all activities, even watching TV or listening music. By the seventh day, he was witnessed by several staff members to be whispering ‘help’ as he sat alone in his bedroom. It was only at this point that an escalation was finally raised.
I am sure many readers will agree that this incident is unacceptable, and is certainly not an example of ‘reasonable’ and ‘proportionate’ isolation. Indeed, I suggest that it is actually a case of disproportionate seclusion.
According to the Mental Health Act Code of Practice, seclusion is defined as:
the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to othersMental Health Act (1983), Code of Practice
Considering this definition, there is an argument that any individual in isolation within a care setting is being secluded. For which we all have a duty of care to prevent harm, uphold safety and wellbeing, maintain dignity and respect, and ensure ethical practice. It is therefore essential to maintain professional communication and carry out sufficient action planning with continual review, while also implementing mental health support plans as required.
We must not forget what seclusion is, nor how seclusion can have damaging effects, both short and long term, Therefore we should be taking steps to ensure that Covid isolation does not become seclusion, as it did in the case above. After all, seclusion is a form of restraint that should only be used if absolutely necessary. It should also be proportionate and justifiable under the Mental Health Act for the least amount of time possible.
Seclusion should certainly not be used for anything relating to Covid.