About the service: Heather Close Rehabilitation Service offers intensive inpatient recovery and rehabilitation service for people with complex and long term mental health conditions (severe mental disorders) and multiple co-existing conditions. The ethos of service is to enable service users to recover from their illness, achieve optimal functioning. Many of the individuals have experienced previous relapses of their mental illness and had multiple hospital admissions often under the mental health act. The project’s aim is to ensure that all care is service user centred and care decisions are patient-led. The project originated from a movement to improve the experience of care and to enable individuals who have experienced long term illnesses to become more autonomous and for care to be more person centred.
Highly Commended - Mental Health Rehabilitation Category - #MHAwards18
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
About the service: Heather Close Rehabilitation Service offers intensive inpatient recovery and rehabilitation service for people with complex and long term mental health conditions (severe mental disorders) and multiple co-existing conditions. The ethos of service is to enable service users to recover from their illness, achieve optimal functioning. Many of the individuals have experienced previous relapses of their mental illness and had multiple hospital admissions often under the mental health act. How the project originated: Involving service users in their care planning has been highlighted by national reports and CQC inspections and this formed the basis for our project. The project’s aim is to ensure that all care is service user centred and care decisions are patient-led. The project originated from a movement to improve the experience of care and to enable individuals who have experienced long term illnesses to become more autonomous and for care to be more person centred. We wanted to change the culture to one of co-production and enablement and a plan was made to support service users to chair their CPA meetings and for interventions to be co-produced and collaborative. Pilot Project and stages of delivery of the actual intervention
The project was piloted in December 2016with 10 service users, who co-produced a prompt sheet (agenda) to help them chair their CPA. The CPA meetings were guided by service user goals. Service users had time and support (coaching) before the meetings and the atmosphere was friendly and informal. Early feedback and data informed further refinement of the approach. Conversations were focused around improving ‘health’ rather than illness. The team members were encouraged not to interrogate service users, but to use enabling language and offer positive feedback, as well as to avoid stigmatising language and jargon. Issues surrounding risk of violence were reframed as ‘improving safety’. For instance, the service user was encouraged to ask others “do you feel safe around me?”.
This allowed for discussions that could help to reduce aggression and violence. At the end of the CPA steps are agreed for further interventions, support and social inclusion activities. Treatment decisions are also made collaboratively. Debriefing is included in each meeting asking everyone how they felt, before the service user ends the meeting (usually last item on the prompt sheet that they produce). Measuring outcomes A bespoke feedback sheet was designed to capture whether the service user felt listened to and in control, and whether they felt the right issues were discussed and the meeting helpful overall. This feedback along with informal feedback was used for each person to plan their next CPA meeting. Overall feedback collected over time was positive, with 75% of service users wanting to chair their next CPA. Roll-out and dissemination Currently all CPA meetings are chaired by service users on the unit. A coproduced prompt-sheet meant that the staff member who co-chairs the meeting with the service user can ask the question if the service user felt anxious or tense in the meeting.
Team members are more skilled to reduce anxiety in meetings through using more conversational style and relaxed manner. Staff felt more able to have discussions and offer suggestions when asked by the service user. This approach has been rolled out to other aspects of care, including support to co-produce all care plans, safety plans, and social inclusion planning. Staff and patients attend our Recovery college in pairs for coproduction training and obtain certificates. We also used shared decision-making approaches and the team was able to apply strengths-based approaches in their interventions. The new developments also include service user co-produced personal health passports as well as a recovery group where service users plan their programme (supported by occupational therapists). The service works closely with community services, local recovery resources, the Maudsley Recovery college and supported housing services to ensure that individuals are supported to recover and the work is disseminated.
What makes your service stand out from others? Please provide an example of this.
Many services offer traditional formats of CPA and clinical meetings where staff members (often consultants) chair the meetings; on our unit all CPAs are chaired by service users. Since CPAs are the cornerstone of inpatient care our initiative has meant better involvement and a change in culture to Co-Production. We have evolved a system that can be used in other settings and a method of evaluation that can help improve on this work. Enabling patients has also meant that the whole team use a strengths based approach – this is reinforced in all clinical meetings and handovers. One service user who had been on an acute ward and nursed under restrictive settings (1:1 observation) started engaging more when he was supported to chair his own meeting. At the time of referral it was expected that this man would need to move to a nursing home. His carer, wife, gave feedback that having control of his care made a difference to his experience of care and this led to a recovery and return to his home and she was “happy to get her husband back”.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The staff on the unit are supported to reflect on the nature and impact of their approach to care. Team reflection meetings are facilitated externally. Feedback from service users is discussed and applied as a team. The team make use of community meetings which are co-facilitated by service users for learning. Many team members attended a bespoke comprehensive, active and vibrant training programme in recovery based care, which included role-play and simulation among other means (the DECC programme of SLaM Trust). The overall aim is to establish a continuous learning culture. Our team has used Quality Improvement approaches to embed patient centred care and co-production. This is further reinforced through obtaining patient feedback and quality and safety metrics. The team are also aware of compassionate leadership and its importance in enabling all individuals; in practice we are working towards leadership that is devolved, and individuals are the leaders in their care with other having the role of enablers. We aspire to reduce hierarchy in care and foster a culture of coaching and mentoring.
Who is in your team?
Team leader = 1 Practice development nurse =1 (currently vacant) Rehabilitation nurses= 16, (dual diagnosis trained =8) Clinical support workers = 23 Activity coordinator =1 Occupational therapists =2 psychologists +1 trainee Psychiatrist =1 Trainee psychiatrists =2 peer support workers Mental Health advocate =1 Physiotherapist =1 Pharmacist (part time)
How do you work with the wider system?
The team work closely with care coordinators in the community to ensure that there is due consideration of support and resources in the community to enable a timely discharge. As part of our co-production work we also have a GP shared care program which enables good access and self-management for physical health disorders. The GPs visit service users on the unit and also tailor the appointments (flexible scheduling) to ensure that the have timely care The team maintain good relationships with all community based recovery resources, local colleges and specific projects such as the Sydenham Garden project.
Do you use co-production approaches?
Our whole program of patient led CPA meetings is based on Co-Production as described earlier in this form. Individuals with mental illnesses are in the driving seat in their CPA meetings; the plans made are implemented collaboratively. We also support carers through carers meetings and one to one sessions. Occasionally some carers have volunteered to co-chair meetings to support service users.
Do you share your work with others?
Our work has been disseminated to all the other rehab teams via the Complex care Quality Improvement programme, of the trust. It has been presented to the trust-wide Continuing Professional Development (CPD) for consultants Many staff are invited to shadow or observe sessions with consent from service users. We have provided teaching sessions to other local services. We have presented this work as posters at Royal college national rehabilitation conference and Royal college international conferences in 2017 Service users share their experience through the (fully coproduced) Heather close magazine We are also launching a Recovery college course on patient led care which will be available to all service users and the staff in the trust.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
We measured feedback using a specialist measure with 10 items which were refined over time in consultation with service users. The items were 1. It is important for me to lead and chair my own CPA meeting. 2. I felt well-supported by my team and doctor to prepare for my CPA. 3. People I wanted to be at my CPA were present. 4. I had enough time in the CPA meeting to cover things that are important to me. 5. I felt able to speak openly in the meeting about how I felt about things. 6. I felt able to ask staff to contribute to my care planning during the meeting in a helpful way 7. I felt that I had choice and control over the treatment and care plans made during my CPA meeting. 8. I feel I understand clearly the decisions and care plans that were made at my CPA. 9. Chairing the CPA meeting has helped me to focus on my recovery goals and increasing my independence. 10. I would like to chair my next CPA.
Individual feedback informed the changes needed to support service users better and collated feedback allowed us to evaluate the program. Between 70-80% of service users said they felt in control and that the decisions taken at the meetings involved them. The team also measured service user satisfaction using Friends and Family Tests, PEDIC Measure and DIALOG (PROM). Individual sessions to debrief after each meeting helped to understand what worked and what didn’t, and this informs our future work. All of the care plans audited monthly for completion rates as well as quality and patient involvement. Care pathway which ensures timely care and service users involved at all stages of care, and each stage is explicit.
Has your service been evaluated (by peer or academic review)?
The Heather Close Rehabilitation Inpatient unit received a rating of ‘Good’ from the CQC. We are currently in the process of accreditation with AIMS-Rehab from the Royal College of Psychiatrists CCQI.
How will you ensure that your service continues to deliver good mental health care?
The impact of this work has been a significant shift in culture and all CPA meetings are now chaired by service users and this has become standard. Staff have appreciated that every individual has the potential to lead on decisions pertaining to their care. This culture shift is much more likely to be maintained over time with the right support, data and oversight. Funding for this has not been sought and this is programme is built into the way we work using quality improvement programme and not as an add on. The importance of this is that this is cost neutral in many ways, (but involves more time commitment early in the care which reduces the time and resources spent later through the enabling process which is beneficial to staff and service users). Excellent systems and care pathways are in place for the programme to be maintained even if senior staff change.
What aspects of your service would you share with people who want to learn from you?
We have demonstrated that even for people with long term serious mental illness (SMI), it is possible to transform the approach of care to one of enablement and co-production. We learned that staff attitudes and beliefs such as “Service user is not engaging” or “Service user does not have insight” leads to paternalistic approaches and coercive care. By believing in the recovery potential of each individual it is possible to get past “Assumptions that hinder recovery and collaboration”. Enabling individuals to chair their meetings takes more time initially (than if a clinician chaired their meeting without any involvement). We illustrated that though there is more time needed to co-produce agenda and coaching individual to chair meetings, there are significant gains in reducing lengths of stay and also in engagement and recovery.
Through our work we truly appreciated that “No one size fits all”, and personalised approaches to care are central in recovery. More engagement meant that there was less need for restrictive care. The unit does not use IM injections or seclusion as part of their policy. Training in shared decision making skills for all staff using the three talk model is beneficial in ensuring that co-production approaches can be delivered for complex medication treatment planning.
How many people do you see?
How do people access the service?
all referrals from other inpatient units
How long do people wait to start receiving care?
3weeks to 2 months
What is your service doing to identify mental health inequalities that exist in your local area?
Working with trust and borough level data plus monitoring equality
What is your service doing to address and advance equality?
All staff attend E&D training. The consultant delivers E&D training for the trust
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Integrated whole MDT assessments
How do you meet the needs of people using the service and how could you improve on this?
Rehabilitation is vital for people with long term SMI, and often resources are lacking
What support do you offer families and carers? (where family/carers are not the service users)
individual and group support for carers and families
Brief description of population (e.g. urban, age, socioeconomic status):
Lewisham borough has a population of 292,000 and is the 31st most deprived borough in England. Prevalence of mental illness is high in Lewisham. Factors such deprivation, a diverse population and being an inner city location all contribute to the high levels of poor mental health. Severe Mental illness (SMI) describes a range of disorders characterised by psychosis and include schizophrenia and bipolar disorder. Service users are referred from acute and forensic services with long duration of psychosis and other co-occurring mental and physical health disorders. Many of the service users have had multiple admissions and have been admitted under the mental health act. The service is for the adult population, and the age range is 24 to 69. Of the 24 beds on the unit 16 are for men and 8 for women. 85% have a diagnosis of schizophrenia or psychosis and 80% have (long term) medical conditions
Size of population and localities covered:
292, 000 for Lewisham Borough plus boroughs of Southwark, Lambeth and Croydon
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Of the 24 beds, Lewisham CCG fund 19 beds which are for residents of Lewisham and 5 beds are funded by the CCGs of Southwark, Lambeth & Croydon for service users whose needs are not met in their boroughs.
Provided by (e.g. name of NHS trust) or your organisation: *
South London and Maudsley NHS Foundation Trust
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