Trust project site presentations 2 July 2015

1. Trust project site presentations2 July 2015

2. Cambridgeshire & Peterborough NHS FT (CPFT) Older people inpatient services Ramesh Subbiah Presented by Safer Care Pathways in Mental Health

3. Project sites • Willow ward is an 18-bed purpose built assessment ward for people who have an acute mental health need who require treatment in hospital. • Denbigh ward is an 14 bed purpose build acute assessment and treatment unit for people with behavioural and psychological disturbance who living with dementia. • We provide comprehensive mental health assessment and intensive treatment in a safe environment. • Within a framework of individualised patient care by which we identify the needs of each service user, through collective commitment from the multidisciplinary team.

4. Patient Flow – High Level Care & Treatment Decision Care & Treatment Admission Assessment Self Care, Physiotherapy, Dietetics, Pharmacy, Discharge Planning, Therapeutic Assessment Investigations e.g. X-rays, CT Scans, DOLS Assessment Re-assess Discharge Plan TTOs, Accommodation, Home Visits, Transfers, OT Assessment, Relatives, Service User Input Handover (Willow) Discharge Planning Discharge Yes/No Transport Organised, Carers Aware, Handover complete Discharge

5. Admission (First 24 hours) Admission Welcome & Orientation Patient Interview Carer Interview Medical Exam Patient Activity MEDS REC OBS. Tests Nursing Assessment New Prescription Risk Screen/Assessment Inc. Falls Initial Care Plan 1 WK Fluid + Food Assessment

6. Care and Treatment Questions: Why are we dong this? When – Timeframe Who and What do they do How are will this be delivered? WHO: Doctor Physio/OT SALT/Dietician Nurse/HCA Servive User/Carer/Family Advocates WHEN: Timeframe HOW: Intensity of the Input Planning Psychological Delivery & Treatment • Psychological • Anxiety Management (1:1) • Talking Therapies • Physical • OT; Activities of Daily Living • Physio; Exercise, Mobility Pharmacological Physical Interventions ECT Review Observations Intended Outcome Discharge Planning

7. Discharge Discharge Priorities Health Care Professional Service User If not improved Ref. to PDSA Min- MH State TTOs Home Essentials e.g. Bread, Milk Notes/RIO Transport Home Leave Fax Disch. Info to GP/CMHT Belongings Hand over plan date/time Money Follow Up Care Package e.g. Dentist, Dietitian, Diabetic Clinic Referrals Informing Family/Carer If not improved Ref. to PDSA Mobility Aids s117 Meetings Home Assessment Housing

8. Chosen patient safety improvement project • We have chosen Falls prevention and management as the patient safety improvement project. • Following the review of the inpatient service risk registers and the Datix trends, we decided to concentrate more on the falls prevention and management

9. Rationale – Falls • Number falls in the OPMH inpatient services 2013 & 2014 – 733 • Number serious incidents 2013 & 2014- 13

10. Rationale – falls

11. Time of the – Falls

13. Since the project • Every person admitted to older adult inpatient service to have compulsory falls risk assessment and no need to complete falls risk screen. • Falls lead to feedback in the team meeting about the latest trust wide initiatives and changes. • Falls prevention and management e-learning has been made mandatory for OPMH inpatient staff. • Patients were involved in the pathway mapping process • Patient input via Patient forum. • Easier access to the COSHH cupboard- spill kit

14. Plan • More staff trained in frontline staff human factors training • Analyze the data further identify the environmental cause, i.e where the fall took place. • Install the grab rails in the shower rooms • Explore other assistive technology equipment support with falls prevention • Access to mobility aids over the weekend and bank holidays.

15. Hertfordshire Partnership NHS Foundation Trust Acute day Treatment Unit(ADTU), Crisis Assessment and Treatment Team (CATT), Helen Dudeney and Sarah Biggs Presented by Safer Care Pathways in Mental Health

16. About the service CATT • 24 hour crisis service • Crisis solution and Home Treatment • Gate keeps admission • Facilitates early discharge • Works in A & E at night • Work in to the wards and assessment unit. • Works with the Host Family Scheme • Runs the Mental Health Helpline • MDT • Third level

17. About the service ADTU • Alternative to Admission • 7 day Acute support and Treatment • Offers a therapeutic group programme • MDT • Facilitates early discharge from Wards • Third level

18. About the chosen risk focus • Medication issues • Communication with family members & friends • Decision making after assessment – no further follow up • Service user involvement – did not always understand what was going on All pointed to the transfer between service so this became our main focus.

19. About the chosen patient safety improvement project • Care call for people not continuing care in HPFT. • Next Step Planning

20. Project progress so farCare Call • Plan in place: We are 1 month into a 3 month pilot • Engagement: fairly successful need to revisit all teams to ensure they understand it. • Early successes: 40 % of people couldn’t get hold of and 60% appreciated it. Service users and carers felt it positive – all wanted it in other services eg Child and Adolescence mental health services (CAMHS) • Problem solving: Revisit it with all teams – may misunderstand what it is about. Chinese whispers. • Barriers: Getting the message out, using forms properly, collating the data. • Measure(s): Evaluation forms (summarise), looked at serious incidents post assessment as baseline data – people seen who did end their lives , not sure it will make a difference but people think its positive and reassuring.

21. Project progress so farNext step Planning • Plan in place: Algorithm in place • Engagement: Service users and carers fully engaged need to introduce to the teams • Early successes: Service users wanted to change language and make it recovery orientated/Shared document/coproduced • Problem solving: Repeating work already done in paperwork on electronic systems – want to work in a different way. Really include service user & have more information so when they leave to next step they can tell other professionals what the next step is so not waiting for the services all the time. • Barriers:Difficult in engaging all professionals – don’t just want another document • Measure(s): We still need to collate at the data around transfer and incident s

22. Future plans • Looking at care call – roll out into other areas • Piloting next step planning in ADTU but will be good in CATT too • Revisit and look at pathway and see if we have missed anything • Feed into the service review

23. Key learning points from your experience of the SSA process • Vital for it to be collaborative with service users and carer’s to ensure rounded viewpoint and thinking, to appreciate lived experience, to avoid assumptions. • We found we identified same hazards i.e. discharge transfer but from different perspectives • Needed to keep revisiting the pathways and SSA documents to keep focused and to ensure all thoughts captured/can’t solve all the complaints and unhappiness in the system . • Recovery language and what this means to people – language can create a risk. • If people do not understand what is happening it is not good for self esteem and therefore their whole recovery. • We can’t make improvements without service users and carers.

24. General learning points about your improvement work • Good base line data • Getting everyone on board • Keeping momentum • look at ways in which project profile can be raised with other teams trust wide • Having the support of the organisation has been vital • Be patient with the process – felt like we weren’t getting anywhere but can see how it all works • Keeping the human factor element alive in our planning

25. North East Partnership University NHS Foundation Trust Benita Christie - Operational Services Manager Denise Cracknell - Matron Julie King – Ward Manager Angie Butcher – Area Chief Nurse

26. About the service Two Wards at Kingwood Centre in Colchester • Henneage Ward – Functional Older Adults, 16 beds • Bernard Ward - Organic Older Adult , 14 beds • Recent transformation of Community services – impact on service • Changes in Senior Management – resulting in two parallel projects

27. About the chosen risk focus Henneage Ward - self harm • Changing service user population with increased risk profiles • Discharge planning and aftercare • Staff confidence Bernard Ward - Violence & Aggression • Personal care interventions • Patient – patient incidents • Leadership and co-ordination of clinical team

28. About the chosen patient safety improvement project Henneage • Increase staffs’ confidence via training, KUF & STORM, • Review handover process Bernard • Review systems for gathering key life story information on patient’s normal routines at the point of admission • Detailed analysis of incidents to inform areas for improvement • Review ward communication systems, personal development plans for staff focusing on leadership

29. Project progress so far • Staff engaged in project – Human Factors training • Patient Safety Champions in place, and trained • Dedicated medical leadership – one consultant working with the teams • Care plans for personal care interventions being signed off by Matron • Detailed analysis of incidents started • Virtual dementia tour training 6.7.15 • New STORM trainers trained w/c 29.6.15

30. Future plans Henneage • Role out STORM training • Provide KUF (knowledge and understanding framework) training internally • Develop Trust personality disorder pathway incorporating Henneage Ward

31. Future plans cont. Bernard Ward • All staff virtual dementia trained • Set up staff focus group to review patient – patient, and patient - staff incidents • Review staff competencies and training needs • Agree 5 key pieces of information required for each new patient on admission re their routine

32. Key learning points from your experience of the SSA process • Helped to focus on what the issues were • Broadened thinking about the whole system and root causes • Whole team could participate which supports ownership of the issues identified, and finding solutions

33. General learning points about your improvement work • Involves the whole team • Promotes reflective practice • Support a culture of continuous improvement

35. Norfolk and Suffolk NHS Foundation Trust Dementia and Complexity in Later Life - Inpatient wards Presented by Debbie Thompson and Sarah Nichols Safer Care Pathways in Mental Health

36. About the service Julian Hospital • Hammerton Court is the inpatient element of our mental health services for service users with dementia and complexity in later life (DCLL), within Norfolk and Suffolk. • Hammerton Court opened in March 2012 for service users with continuing health care needs. It is a hospital environment purpose built for service users with dementia. Service users requiring admission for assessment and treatment have been accommodated in Hammerton Court since May 2015. • Our patients have complex needs which cannot be met in a community, nursing or residential setting. • Beach, Rose and Reed Wards have a philosophy of person centred care to facilitate. • Discharges from our services can be home with a package of care, to residential or nursing care facilities.

37. About the chosen risk focus Initially there was a very broad focus on the care pathway through our services from initial referral through to discharge with a desire to improve the patient experience. •High incidence of falls and violence and aggression relative to other services in the Trust - Decision - to focus on the DCLL inpatient services. •Our overarching aim was to create a safer pathway for patients within the DCLL Inpatient Services • FOCUS Reduction of falls, major contributor to patient harm in our service, extensions to length of stay •FOCUS Reduction of violent incidents, high levels reported low levels of significant harm but major contributor to patients feeling unsafe in our services. •How could we prevent the above incidents and reduce the level of harm when incidents do occur?

38. About the chosen patient safety improvement project • The Lead for the project is the Deputy Director of Nursing. • Key individuals identified for implementation of the project, stakeholders identified • Appointment of a SCP Coordinator to collate data and coordinate project • Focus to reduce falls / harm from falls and reduce incidence of violence and aggression decided upon. • Meeting Schedule for project • Leads for the three wards identified • Beach Ward modified the role of one of it’s Band 6 nurses to drive the project • Safer Care Pathways embedded into Ward Staff Meeting Agendas • SSAs for the two subjects undertaken

39. Project progress so far SSAs Admission procedure, Boredom, Reactive practice, Lack of sense of control/ coordination of shift, Environment - poor observation, dead ends, long narrow entrance corridor frequent incidents. •Engagement of staff, LMS, Appraisals, allocation of link roles building on interests, constructive feedback, clarity of expectations, skills development •Unexpected admissions – development of systems to reduce frequency •Person centred admission procedure developed by staff •Increased engagement with relatives – carer support group •Ward Move – approved by Trust Board •Introduction of SBAR communication •Focus on increased level of Therapeutic Interventions and patient engagement.

40. Project progress so far Barriers – •Staffing, vacancies, sickness •E Rostering, source of discontent for staff •Lorenzo electronic patient records, introduced the week of the ward move •Ward having to respond at short notice transferring / discharging/ admitting patients with little notice and little pre admission information – unpreparedness and frequent poor communications with significant others •Original ward environment, not suitable for people with dementia, ‘hotspots’ where incidents occurred •Frequent anxiety and incidents on arrival, processes and procedures especially regarding personal possessions and clothing. •Falls- not been a focus only one change to practice

41. Future plans Project group to continue meeting •Evaluation of the changes to the Role of Band 6 •Focus onto Falls •Project Coordinator presenting data to project group and ward staff, regular feedback •Measures for Falls and V&A (including within first 72hours of admission) to continue and monitor impact of changes. Baselines for incidents (V&A) in the first 72 hours to be reviewed in August 2015, then 3monthly thereafter. •Human Factors to be cascaded throughout teams by those attending training to enable facilitation. •Patient Safety training to be cascaded to staff by Patient Safety Champions Early 2016. •Embed into Hammerton Court as a whole

42. Key learning points from your experience of the SSA process Process implementation has worked splitting up the processes – original document completed at project team level •The project team identified at a ‘higher’ level challenges, areas for development •The ward team being able to modify the above and work out their own solutions has lead to some really creative workarounds •Removing the data collection requirements from clinicians has ensured that the data has been collected! •Having an identified link between the project team and ward team has maintained the focus •Will provide feedback for the staff of how their changes to practice have reduced incidents, often the data is lost when incidents are prevented

43. General learning points about your improvement work Within our services the identification of a lead on the ward with a remit for implementation of SCP has facilitated change at a much increased rate •Engagement of key staff •SSA meetings at project lead level then brainstorming the detail at ward level has ensured ownership •Staff devised workable solutions – admission procedure •Staff want to improve their practice and the patient experience •Implementation of other major changes throw all progress off schedule •Demonstrable support from the Trust Board validates the efforts of staff •Change management is hard work!

44. South Essex Partnership NHS FT (SEPT) Declan Jacob Presented by Safer Care Pathways in Mental Health

45. About the service • Acute and Crisis Pathway • Crisis Resolution and Home Treatment Team (west locality) • Mental Health Assessment Unit (Basildon MHU) • Recent strategic review and redesign of service model

46. About the chosen risk focus • Points of entry • Interface with other parts of the mental health system • Referrer expectation • High case loads • Throughput and risk • Handover

47. About the chosen patient safety improvement project • Cohort of complex service users • Decision to admit • Variables and presenting risk • User led approach

48. Project progress so far • SSA 1 & 2 complete • Difficulties in linking to mainstream • Need to underpin and support service teams • Revisit assumptions

49. Future plans • Revalidation and appraisal • Operational focus • Quick wins • Short/medium term initiative • Workshop planned for 20th July 2015 • Dedicated service user and carer event early August.

50. Key learning points from your experience of the SSA process • Good discipline • Structured • Applicable to operational and clinical processes • Transferable