The Crisis Assessment Unit (CAU) became operational July 2015 and provides an alternative acute service for Leeds and York Partnership NHS Trust (LYPFT). CAU is predominantly an assessment unit with overnight facilities and a place of respite for those experiencing acute & complex mental health crisis, for whom in-patient admission is being considered.
What We Did
The Crisis Assessment Unit (CAU) became operational July 2015 and provides an alternative acute service for Leeds and York Partnership NHS Trust (LYPFT). CAU is predominantly an assessment unit with overnight facilities and a place of respite for those experiencing acute & complex mental health crisis, for whom in-patient admission is being considered. It provides 6 beds (3 male and 3 female) in the CAU and 4 rooms in the 136 suite. The unit is gate kept by the crisis assessment service (CAS).
Staffing levels within the CAU are a minimum of 5 per shift.
CAU – 3 staff (two registered clinicians), Section 136 suite 2 staff (including an AMHP). On every shift there will be an identified CAU shift co-ordinator who will liaise closely with the CAS shift co-ordinator to safely manage service demand
Some key groups of service users who benefit from the service are:
Ø Service users presenting in an acute crisis following a significant event who need a brief period of support before their medium term needs can be accurately determined. It would be expected that this could be a community based service rather than inpatient admission.
Ø Service users who are attending Intensive Community Services (ICS) for on-going care however are experiencing an exacerbation of symptoms that requires further monitoring overnight. Without CAU these service users would require admission to an in-patient ward.
Ø Service users with a social related crisis precipitator who can be both treated and safely supported whilst the situation which precipitated the crisis is resolved.
Ø Service users with other mental health problems likely to require short term assessment and treatment in a controlled and safe environment.
Ø Service users recalled using a community treatment order who will receive treatment in a supported environment. Historically these service users have had to be admitted to an inpatient ward to receive treatment.
There are occasions when the CAU is used to help the whole system manage capacity in order to prevent service users having to be accommodated in an out of area provision.
The CAU length of stay is dependant of the reason for the referral being made but generally 72 hours should offer sufficient time to complete a holistic assessment of needs. There may be occasions when the assessment process requires longer than 72 hours in which case the service user and their family are kept updated on the plan of care. Length of stay in the CAU is monitored via the CAS clinical improvement forum
On admission to the CAU the service user needs are identified through concise formulation and interventions will be tailored to those needs.
The CAU aims to provide a flexible range of evidence based care interventions, delivered using a psychosocial approach, along with medical assessment, treatment and monitoring which aims to resolve the current acute crisis. Each service user will have a care plan which will be individualised to their acute needs.
In addition to the main CAU there is a new assessment waiting area and an enhanced section 136 provision the objectives for which are:
Ø Service users presenting at their GP requiring an emergency assessment of their mental health who do not have medical needs requiring treatment.
Ø Service users who have contacted YAS requiring mental health assessment and whose physical health needs have been met by the paramedics.
Service users seen by the police who have no medical needs but who require a mental health intervention will have a suitable environment to wait for a CAS assessment or in initial screening by the Mental Health Crisis Triage Service (Street Triage).
Service Users detained by the police under s136 MHA providing a 4 room health based place of safety with an intoxication pathway to support their physical needs.
Since it has opened the CAU has accepted approximately 30 service users a month with an average length of stay of 3.2 days. This has prevented approximately 2 admissions to the acute wards a week. Majority of the service users are transferred to the alternative to hospital provision in the intensive community services (ICS)
Some examples of recent feedback from service users who have been in the CAU between October 2016 – January 31 2017 and are coded into themes:
Feedback on Staff:
‘compassionate, prepared to go out of their way to ensure I was ok.’
‘Reassuring staff – my first experience of mental health services and I really appreciate the efforts of every staff member’
‘I am astounded by the level of care staff provide.’
‘Approachable helpful Doctors.’
Unhelpful/negative aspects on CAU:
15 minute observations
Noisy corridor and doors
Noise from the 136 suite
What else could have been provided?
‘the most positive input I have ever had from mental health services’
‘A safe place when most needed and where I was understood.’
Everything has been good
Amazing people – the staff have been great and go out of their way to do anything for you.
Have put together a good plan for the future
Staff willing to listen
Chance to slow things down and reflect
Feeling hopeful now
Nice relaxed atmosphere
The following was posted on NHS Choices in relation to the CAU on 31st January 2017:-
Fantastic Staff from the start
My partner was admitted on Friday night to the CAU following a home visit, we had to wait 9 hours for them to come see us but I understand the service is very busy, when the 2 nurses arrived they was very professional and honest about our options. On arrival at the unit we could tell he was in very good hands with the high level of care shown to him and us as a family. The unit nit is very well designed and feels more like a home than a ward, the staff are very honest and do take the time to speak to everyone. This unit is a credit to the NHS in every way in a very challenging and emotional environment. I personally feel the negative reviews are not a reflection on what I have witnessed visiting this unit. All I can say is Thank You! The consultant and their team are fantastic.
Wider Active Support
The operational manager of the Crisis Assessment Service is the chair of the NHS Crisis and Urgent Care forum. This has membership from the acute hospitals, police, third sector, ambulance, children and young peoples mental health services, adult social care and community services. CAU and the health based place of safety are discussed in relation to the system wide support for the people of Leeds who are experiencing a mental health crisis. This meeting is 6 weekly and utilises live cases to review current processes and make suggestions for improvement. There is also a quarterly 136 interagency meeting again chaired by myself that helps promote the services and develop improvements.
The evaluation last year identified areas for improvement which are summarised below.
• Provision should be made for the Occupational Therapist to develop an activity assessment and programmes for meeting individual needs – activity coordinator now in post and has developed more packages linking to the internal therapy suite.
• The OT should be provided with time and support to develop Health Care Support Workers’ knowledge and understanding of the benefit of occupation and activity to enable HCSW to drive this movement forwards – this has been part of the role of the activity coordinator and HCSW’s now feel more confident in providing these interventions.
• A review of the HCSW role should be considered, the role could be expanded to support the service user transition to other services – Team away day last May developed a training needs analysis for HCSW’s which has included the care certificate.
• A CAU team meeting to be held weekly. CAU staff to be given opportunity to make agenda items in the week leading up to the meeting on a board or in a dedicated meeting book. This will allow CAU staff to outline any concerns regarding the day to day functioning of CAU. It is also anticipated that a weekly forum such as this will improve communication and provide an opportunity to offer/receive information with colleagues. Plans to action changes or provide feedback should be identified within the meeting and the minutes disseminated to all staff – This has now been established and is facilitated by the Clinical Team Manager for the service.
• Senior staff to reinforce and encourage the use of clinical supervision for all team members. Furthermore effort should be made to enable CAU staff participation at reflective practice; which is held weekly in CAS main office – Reflective forum on-going and CAU staff are encouraged to attend. Clinical Supervision actively encouraged and compliance monitored monthly.
• Senior management to consider the benefits of CAU having one dedicated psychiatrist for the service – Due to working patterns of the 2 consultants this continues to be a shared responsibility.
• Senior management to identify training needs of staff and enable access to courses which will benefit the staff member and the service, such as assertiveness and leadership training – Some staff now permanently work in CAU whilst others rotate around the different elements of the Crisis services. induction package in place and additional training identified in staff appraisals.
• The Clinical Team Leader or Clinical Team Manager to attend the key interface services, principally Intensive Community Services. This is to participate in clinical discussion regarding referrals to and from CAU, build understanding regarding CAU purpose and establish a clear line of communication. – Clinical lead for CAU has attended the ICS development group to discuss transitions between services.
Looking Back/Challenges Faced
The main challenge was in connection to the CQC visit last year. Even though the local working instructions were left intentionally broad they fixed on the 72 hour length of stay parameters that were specified in the service user information leaflets and the LWIs. They were also critical of the configuration of the environment and how this was compromising the mixed sex environment guidelines. At the time of the inspection urgent remedial work was done on the environment to address this. As part of the CQC action plan the LWI’s and service user information leaflet have been amended to more accurately reflect the broad purpose of the CAU. The potential for the environment breaching mixed sex guidelines should have been more thoroughly considered prior to opening of the unit (even though at the time of the inspection there had been no incidents related to this0. As discussed earlier we are now involved in developing briefing guides for CQC inspectors on this type of provision as they did struggle to understand the service.
System of requested service users to complete a feedback form on discharge and on-going review of these.
Regular monitoring of data associated with the outcomes of the CAU identified in the business case which will be governed by the CAS Clinical Improvement Forum.
The trust are undertaking a financial evaluation of the CAU to ensure that it continues to offer value for money.
Dedicated clinical lead and clinical team manager in post to oversee the day to day operation of the service.
Dedicated staff who work in the CAU who are able to develop the service and provide consistency in its provision.
Evaluation (Peer or Academic)
The service was evaluated last year by a member of the team given dedicated time and there have been 2 separate reports have been conducted to highlight how the service is performing against the key measures identified in the business case.
The evaluation explored the impact that the Crisis Assessment Unit (CAU) is having on the service users, the practitioners who refer in and the staff that work there.
This evaluation explored service user’s experience of the Crisis Assessment Unit (CAU) through a detailed questionnaire. It aimed to explore service user perception of access to the service and the quality of care and environment. The evaluation revealed that CAU is valued by its service users who gave positive feedback about the CAU team, the access to support and the CAU environment. The service user perspective suggests that more could be done to enable activity on the unit and the team could be more explicit when discussing treatment options.
The evaluation also explored staff perception of working on the Crisis Assessment Unit, what works well and what can be improved. There appeared to be a consensus among the participants that being able to assess people for longer than the conventional CAS assessment is a positive investment for the trust and CAU works well as a crisis intervention for service users. The team suggested that improved relations and communication are needed between the CAU practitioners and the internal psychiatrists and that work could be done to shape the role of the Health Care Support Worker.
In addition feedback was sought from interface services within the trust to request an insight into their experience of referring a service user into CAU and if they had any opinion on the role and purpose of it. The feedback also suggests that CAU is a valuable and helpful service. At the time of the evaluation it was identified more work needed to be done to improve consistency and communication among the CAU team, particularly to improve reliability when making referrals which has been addressed as the service has become more embedded into the pathway.
The CAU continues to provide an important pathway for service users experiencing a mental health crisis who need additional enhanced support or assessment as an alternative to a full acute admission. Feedback from service users are mainly positive and it is particularly warmly received from service users who have had limited contact with mental health services as an introduction to the acute pathway. The service has provided an alternative pathway for clinicians to consider which is not as restrictive as an inpatient ward but offers emotional and physical containment to support the service user in the mental health crisis.
Since opening we attended London’s Mental Health Crisis Care Summit, on 25th February 2016 as part of a series of workshops on alternative or enhanced models to standard acute care pathways.
There was a evaluation conducted on the service in 2016 which gathered views from internal staff, stakeholders and service users on the new service. This report was presented at the LYPFT annual research forum in November 2016 and I have been asked to attend Leeds University Mental Health Research day on the 29th June 2017 with 3rd year student nurses.
Recently the CQC have commissioned an independent director of nursing to develop a briefing guide on assessment type units for their inspectors. We have been visited by this director and have been asked to attend a workshop in may to contribute to these guides.
As part of a rolling programme of workshop delivered by the Crisis Assessment Service to various statutory and non statutory agencies the CAU is discussed in terms of this addition to the acute pathway.