Calderstones Partnership NHS Foundation Trust

1. Calderstones Partnership NHS Foundation Trust

2. SPECIAL PROJECT (INTENSIVE SUPPORT PACKAGE)  CARE IN CALDERSTONES

3. Calderstones Partnership NHS Foundation Trust is a regional provider for adults with a learning disability with complex needs who cannot be supported by other organisations. There are 218 beds around the main site, comprising 36 medium secure and 182 low secure and open beds in flats and peripheral houses. Some service users have difficulty forming relationships with peers, sharing staff, coping with changes in staff and peers, and with lack of structure in activities. Individuals with autism, autistic spectrum disorder and brain injury fall into this category. They benefit from a skilled, experienced stable staff team, consistent approach and a programme of predictable activities. � I will present seven patients managed with intensive support packages (special projects), detailing brief histories, diagnoses and costs of care. I will then discuss the implications for community care and the challenge to normalisation and inclusion.

4. PATIENT A A 48 year old woman who transferred to Calderstones in 2006 from a general adult psychiatric ward on Section 3, detained under severe mental impairment. She had been admitted following an attack on a child in the street, at a time when care staff reported they could no longer manage her levels of violence.

5. Patient A DIAGNOSES F71.1 - Moderate mental retardation Bipolar Affective Disorder � unclassified Probably Autistic Spectrum Disorder COST OF CURRENT CARE 8.5 staff - �233,883

6. PATIENT B 21 year old woman with moderate mental retardation and pervasive developmental disorder. Transferred to Calderstones in February 2006 on Section 3.

7. Patient B DIAGNOSES F71.1 Moderate mental retardation F84 Pervasive developmental disorder COST OF CURRENT CARE 11 staff - �289,424

8. PATIENT C Transferred, aged 18 years, to Calderstones in 2006 on Section 3. Diagnosed with severe mental retardation and Autistic Spectrum Disorder. Long history of serious aggression (grabbing, biting, scratching and hitting), damage to property, pica and self injury including inserting material into his nose and biting himself. At the time of admission he was doubly incontinent. He would defecate and smear faeces on himself, walls and on staff.

9. Patient C DIAGNOSES F72.1 Severe mental retardation F84 Pervasive developmental disorder Diagnosed with Chromosome 22 q level deletion COST OF CURRENT CARE 13 staff - �338,862

10. PATIENT D 40 year old man transferred to Calderstones on Section 3 from a high secure hospital in April 2006

11. DIAGNOSES F71.1 Moderate mental retardation F07.0 Organic personality disorder COST OF CURRENT CARE 21.50 staff - �588,364 Patient D contd..

12. PATIENT E Admitted to Calderstones at the age of 15 years - over one hundred services having refused admission. No child service felt that they could meet his needs. He had been placed outside his home district at the age of 13 years into the independent sector provision. Due to his difficult and violent behaviours he was admitted into the NHS. He was nursed on his own on an adult intensive care unit for over 5 months.

13. Patient E PRIOR TO ADMISSION TO CALDERSTONES He required a team of 23 staff covering a 24 hour period to provide physical restraint for the entire time he was awake, at a cost in excess of �1.25 million per annum. DIAGNOSES F70.1 � Mild mental retardation Tourettes syndrome ADHD Autism COST OF CARE ON DISCHARGE FROM CALDERSTONES 16.50 staff- �449,460

14. PATIENT F 40 year old man with mild mental retardation, organic personality disorder secondary to head injury, recurrent depressive disorder and undifferentiated schizophrenia. Admitted to Calderstones informally in 2001 following a breakdown in a community placement for a special project care package to manage very high levels of physical aggression and damage to property. He threatened to self harm and had become head injured and paraplegic from jumping off a bridge in a suicide attempt aged 26 years. He was detained under Section 3 in January 2002.

15. Patient F DIAGNOSES F70.1 - Mild mental retardation F07.0 Organic personality disorder Recurrent depressive disorder Undifferentiated schizophrenia COST OF CURRENT CARE 13 staff - �338,862

16. PATIENT G A 35 year old man moderate mental retardation and pervasive developmental disorder, transferred to Calderstones on Section 3 from a temporary placement in the private sector. The community placement has not been able to manage his level of physical aggression and were concerned about his threats to kill staff and stab them.

17. Patient G DIAGNOSES F71. 0 Moderate mental retardation F84 Pervasive developmental disorder COST OF CURRENT CARE 14 staff - �373,040

18. COSTINGS FOR INTENSIVE SUPPORT/SPECIAL PROJECT CARE

19. DISCUSSION Individual intensive support package costs between 2 to 4 times that of other patients in Calderstones. They are funded by the Secure Commissioning Team who set a budget of 2 million, which is closely monitored. Districts are going to have a dilemma to fund expensive individual care or to focus on more general provision for service users. High numbers of staff are involved which can be found from the large pool of skilled experienced workers within the hospital institution. Individual community care packages run the risk of staff burn out and need to use agency or bank staff to cover sickness and holidays. They do not have access to large numbers of experienced skilled, trained staff. The way forward for complex community care packages would be to design services to provide for small numbers, for example 3 to 5 individual staffed flats within one site. One district could potentially sell the resource to other districts ,or there could be joint funding.

20. These facilities could be seen as a step in rehabilitation or, for some individuals, long term providers. All the patients presented lacked capacity to consent to the physical restraint that was needed at times to manage physical aggression. They were in receipt of 24 hour supervision with restriction of their liberty. It is debateable as to how these restrictions could best be legally supported � through the Mental Health Act, supervised community treatment order or Guardianship, or through the Mental Capacity legislation. In all cases there would be concerns about emergency admissions to general adult psychiatric provisions, when a place of safety may be the intervention required. Community care staff would need to be skilled and confident in using physical restraint techniques in the least restrictive way. They would need knowledge and experience in managing individuals with autism or head injury.

21. The current emphasis on normalisation and inclusion does not encompass risk management and mitigation. The patients presented all potentially place themselves and others at risk through their behaviour. They are sensitive to overstimulation and each patient requires their individual needs and risks to be recognised and managed. Intensive support packages can be demonstrated to significantly reduce the harm to patients and to others. Commissioners need to understand that it is not always possible to reduce these risks and reduce costs of care. Some of these packages may be needed for considerate periods of time to maximise the quality of life of the service user and manage risks to the care providers.