The Lotus Assessment Suite is an innovative nurse led service that offers in-depth assessments of people assessed by Street Triage, Home Treatment Teams or Liaison Psychiatry services as potentially requiring inpatient admission following initial community based assessment. The service recognizes that informed decisions on whether hospital admission may be required or not is often affected by the circumstances of the assessment
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The Lotus Assessment Suite is an innovative nurse led service that offers in-depth assessments of people assessed by Street Triage, Home Treatment Teams or Liaison Psychiatry services as potentially requiring inpatient admission following initial community based assessment. The service recognizes that informed decisions on whether hospital admission may be required or not is often affected by the circumstances of the assessment. The ability to undertake an in-depth assessment in a more settled, therapeutic environment outside of statutory waiting time standards (4hr A&E waits) will enable a significant number of people to be supported in the community and prevent ‘avoidable’ admissions to hospital.
The service is made up of 5 reclining chairs and the existing two-suite Section 136 service. Reducing admissions through prolonged and informed assessment and enabling the right community support Over its first eighteen months of operation, Lotus has been successful in reducing the demand for inpatient beds through providing an in-depth assessment for patients in crisis, which has resulted in a cumulative total of 63% of assessments (and consistently more than 75% since April 2018) being followed up in the community rather than inpatient settings. Since Lotus has opened there has been a substantial reduction in total informal admissions; nine months after opening there was a 17% reduction, and in the last three months (June-August 2018) the mean figure was 48% below the 2015/16 baseline. Of the 534 informal admissions in the first nine months since Lotus opened 219 were via Lotus but 295 were via other routes. The Trust has since audited the admissions that bypassed Lotus and found the vast majority to have been appropriate. In the first nine months since Lotus was opened there was a 28% reduction in 0-5 day admissions; there has been further improvement and in the last three months (June-August 2018), the mean number of 0-5 day admissions was 37% lower than before Lotus opened. It should be noted that some brief crisis admissions are necessary and appropriate to manage risk. The Trust has developed strategies to reduce length of inpatient admissions i.e. Purposeful Admission Project, which is likely to have an impact on increasing short stay admissions. Lotus has also carried out an analysis of short stay admissions, in relation to patients with a diagnosis of Borderline Personality Disorder.
Following this analysis the trust has implemented new measures (including virtual risk meetings) to try and prevent brief/unnecessary admissions for this population of patients. Similarly, during its first nine months Lotus contributed to a reduction of inpatient bed days by approximately 7 per day, and continues to reduce acute bed use substantially despite persistently increasing demand for acute beds. Lastly, and arguable most importantly, the patient feedback has been exceedingly positive. Patients reflect they favour the ability for a prolonged assessment within a more calming conducive environment. They have also consistently praised the support, compassion and individualized care they received from Lotus staff. The further reductions in informal admissions and short (0-5 day) admissions have resulted in the gradual shift of the Lotus model by the team from simply assessing patients for admission, to assessing patients and attempting to contain and manage their crisis, within 48 hours. This report recommends that this be formally adopted as the new Lotus model.
What makes your service stand out from others?
Key Strengths Nursing Leadership Lotus is a nurse led service. Presently we have a strong qualified and non-qualified nursing establishment comprising of a unit manager, two deputy managers, four charge nurses, two senior nurses, nine staff nurses, two nursing associates and ten health care facilitators. We also have one part time 0.50 consultant. With the support of the unit manager and consultant nurses are empowered to lead on patient care including; assessment, formulation, implementation of agreed interventions and discharge planning. Senior nurses lead the nursing workforce out of hours to undertake thorough risk assessments and are empowered to discharge patients safely to the community independently with the option to discuss complex cases with the on-call team. This improves the patient pathway and prevents unnecessary delays, therefore, improving service user satisfaction. The quality of the clinical team led by the unit manager and consultant sets a culture of continuous improvement as well as continuous professional development. The unit manager and consultant recognise the value of supporting and developing a nurse led service. They have implemented two monthly teaching sessions which are responsive to the needs of the service for example ‘assessment of suicide risk’. This improves nursing confidence and competence to lead the service out of hours.
Furthermore, all nursing staff have monthly supervision, in addition to, bi-weekly complex case reflections to problem solve collaboratively on challenging areas of practice. Collaborative Crisis Plans Lotus Assessment Suite is a patient centred service putting the patient at the heart of all we do. All service users that are transferred to Lotus Assessment Suite are supported to create/review a collaborative crisis plan. Service users have responded very positively to this tangible plan they can take home with them following discharge. The crisis plan uses a RAG rating system which is easy to use and understand. It also includes a useful contact list to help service user’s identify who they can contact when a crisis is looming. Furthermore, the crisis plan aids the service user to identify things that have been helpful and not helpful previously. This aids professionals to support someone when in a crisis. Situation, Background, Assessment, Recommendation (SBAR) The Lotus Assessment Suite Team have embraced the SBAR technique. SBAR is recognised by the Institute for Healthcare Improvement as an effective and efficient way to communicate important information. SBAR offers a simple way to help standardise communication and allows parties to have common expectations related to what is to be communicated and how the communication is structured. The nursing team use SBAR when handing over during multidisciplinary and nursing handover meetings. They also use SBAR to structure when handing over to other teams i.e. HTT and also when recording referral information. Lastly, SBAR is used when completing 18 hour quality reports. Band 6 Nurse Development Framework Lotus Assessment Suite offers a supportive and safe platform for nurses to develop into band 6 practitioners.
The service has a Competency Framework to support the senior nurse’s development into band 6 posts. The competency framework focuses on the following domains; communication, management of risk, assessment and crisis planning, capacity consent and legal issues, collaborative working, management, medication and personal development needs. Following successful completion of the competency framework the band 6 development nurses will be appointable to a substantive band 6 community post. Often nurses struggle to transition from inpatient to community nursing. Lotus Assessment Suite is able to bridge this gap and offer a more streamlined pathway into the community. Service User Feedback All service users assessed at the Lotus Assessment Suite are asked to complete an anonymous service user real time feedback (RTF) questionnaire at time of discharge. The questionnaire asks a range of questions against which, patients are asked to give a rating of their level of satisfaction. We have received a huge amount of compliments since opening and very few complaints. Please see three examples of service user positive feedback to date: 1. THEY TREATED ME WITH KINDNESS AND DIGNITY. THE STAFF WERE VERY EFFICIENT AND KNOWLEDGABLE ALL MY CONCERNS WERE DEALT WITH PROMPTLY. 2. THE CARE HAS BEEN EXCELLENT. SOME OF THE BEST CARE IVE HAD IN A LONG TIME. I FEEL A LOT MORE POSITIVE LEAVING HOSPITAL THAN I HAVE BEFORE. 3. BERORE YOU HAD TO SIT IN A,N,E WAITING FOR HOURS SO NOW ITS A REALLY GOOD THING THEY HAVE THIS KIND OF UNIT AS SITTING IN CASUALTY ILL FOR ALL THEM HOURS AND IT IS NOT A PLESANT EXPERIENCE SO AT LEAST WITH A UNIT LIKE HERE YOU KEEP YOUR DIGNITY We recently had a service user present their experience of being on Lotus to the trusts executive board.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Nursing Leadership Lotus is a nurse led service. Presently we have a strong qualified and non-qualified nursing establishment comprising of a unit manager, two deputy managers, four charge nurses, two senior nurses, nine staff nurses, two nursing associates and ten health care facilitators. We also have one part time 0.50 consultant. With the support of the unit manager and consultant nurses are empowered to lead on patient care including; assessment, formulation, implementation of agreed interventions and discharge planning. Senior nurses lead the nursing workforce out of hours to undertake thorough risk assessments and are empowered to discharge patients safely to the community independently with the option to discuss complex cases with the on-call team. This improves the patient pathway and prevents unnecessary delays, therefore, improving service user satisfaction. The quality of the clinical team led by the unit manager and consultant sets a culture of continuous improvement as well as continuous professional development. The unit manager and consultant recognize the value of supporting and developing a nurse led service. They have implemented two monthly teaching sessions which are responsive to the needs of the service for example ‘assessment of suicide risk’. This improves nursing confidence and competence to lead the service out of hours. Furthermore, all nursing staff have monthly supervision, in addition to, bi-weekly complex case reflections to problem solve collaboratively on challenging areas of practice. We also have monthly team reflective practice and monthly staff/service user mindfulness. We have lead roles whereby nurses lead on a role for example therapies and will introduce new interventions to the team. All of our nurses are prioritized for the psychosocial interventions masters.
Who is in your team?
Presently we have a strong qualified and non-qualified nursing establishment comprising of a full time B7 unit manager, two B6 deputy managers, four B6 charge nurses, two B5 senior nurses, nine B5 staff nurses, two B4 nursing associates and ten B2-B3 health care facilitators. We also have one part time 0.50 consultant. We also have expert by lived experience volunteers and a full time administrator.
How do you work with the wider system?
Since opening the staff on Lotus have carried out significant research into community support services both NHS and Voluntary sector services that are available to patients. They have collated information on services form a variety of providers covering a wide range of topics which is now accessible on a shared drive for all staff. This has been invaluable in allowing staff to devise community support packages for patients which have prevented inpatient admissions. The resources are sourced for all 5 CCGs the trust serves. The team work closely with the community mental health teams and home treatment team, often arranging collaborative professionals meetings for service users on Lotus to help with discharge planning. We also help to address service users social stressors by referring them to the local housing department for emergency accommodation, signing posting to women’s refuges and providing benefit, debt and relationship support. We work closely with service users families and carers by providing family interventions and often facilitating mediation.
Do you use co-production approaches?
The Lotus assessment suite was co-produced with service users and service users are still very much a part of our day to day functioning. We receive regular feedback from service users and have recently worked with service users to form our mission statement: ‘Lotus provide holistic, person-centred, nurse-led assessments and care for your health, welfare and social needs’. We have also recently co-produced our mutual expectations and created a welcome pack for service users and carers based on service user feedback. We are working closely with our involvement team to have a service user representative on our recruitment panels.
Do you share your work with others? If so, please tell us how.
Yes – we share our assessment and discharge planning knowledge with all of our referring teams. We recommend that staff from other services spend time on Lotus so we can share our exceptional practice. Based on service user feedback the trust are currently looking into how the ethos of Lotus could be taken into acute ward settings.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The service Key performance indicators are: No of assessments (LAS) not accepted due to capacity. 67% of LAS assessments to result in non-hospital admission. 36 hours average length of assessment 84% of assessments to be completed and patient transferred within 36 hours Any assessments lasting more than 48 hours reported as a Serious Incident. The lead nurses complete monthly audits of the HBPoS (health based place of safety), risk assessments, capacity assessments, physical health, crisis planning and the outcome of these audits are fed back to staff both individually and as a team in business meeting.
Has your service been evaluated (by peer or academic review)?
We have recently completed a review of the service and the following recommendations were made: Recommendation 1) Review of Lotus Psychiatry Decision Unit Operational Policy: a) To include information regarding all breaches and steps to be taken for each one of them via a Decision Tree: Anticipated 48 hour and 72 hour breaches need to trigger an immediate discussion with the most senior nurse on duty (unit manager, Matron or on-call manager out of hours) regarding the reason for why the breach could take place, and agree on the steps to be taken. 48-hour breaches cannot be allowed to occur without the prior agreement of the Matron or on-call Manager. 72-hour breaches cannot be allowed to occur without the prior agreement of the Director of Nursing & Quality or the on-call Director. When reporting 48- and 72-hour breaches on Lotus, the Team need to ensure that reason such as lack of beds is classified as Serious Incidents. The 18 hour report should be replaced by a 24 hour report. This will allow nurses more time to spend working with the patient before the 24 hour period. The 24 hour report will be a Quality Assurance Report, not a breach report. This affects only the timing of this report, and not the overall length of stay on Lotus. b) The target for Assessment to be completed within 24 hours should be amended to reflect the revised Lotus model. The new target for assessment should be that 80% should be completed (and the patient transferred/discharged) within 36 hours. This should be reviewed after six months. (NB. This does not represent an increase in length of stay on Lotus, merely matching the metric to the established length of stay, so that it can be used as a meaningful management tool.) c) The Lotus team manager to commission a QI project within the team focussing on those reasons for breaches identified within this report that may be amenable to reduction by team members (such as the use of medical reviews out of hours, referral to emergency accommodation/use of B&B etc.).
This should commence in November after integration of the team’s new staff, and take no longer than three months. d) To include a Reviewed Nurse Led Section, including specific skill sets. Manager and Matron to discuss with Nursing Development Team in terms of bespoke psychosocial intervention training aiming at specific tools that the nursing team on Lotus have found helpful to help clients and carers to manage crisis. e) To review the referral criteria so as to allow the assessment on Lotus of patients who have had a MHA assessment and have been referred for informal admission (including clients from the S136 suite). Referrals should however been screened for: 1. Discharge summary completed if from Acute Trusts– NEWs chart assurance of medical clearance. 2. Referrer to consider whether patient’s physical condition will impact on their ability to engage in gatekeeping/further assessment on Lotus 3. Where there is evidence of withdrawal understanding the potential to impede on assessment and guiding on timeframes required for admission to contain risk ahead of objective assessment f) The PDU pathway flowchart will need to be reviewed in line with the reviewed Operational Policy. g) Access to external facilitator for regular reflective practice h) Share data on frequent attenders with 136 data, street triage data, A&E presentation data and develop working processes with the SIM Project and ED FA CQUIN teams. i) The PDU to establish a Lead Homelessness Nurse who will attend meetings across the five boroughs covered by lotus in order to build relationships with the Housing Departments and build upon current homelessness resources. j)
The PDU to build a stronger relationship with ACPs to tackle barriers to discharge upon arrival to the suite for more proactive approach to identify barriers and early completing of relevant housing paperwork. k) The PDU to build a working relationship with Housing Support Workers and Hospital Discharge Teams once those roles are in post. l) Lotus & S136 staff to be empowered to request ACCC authorise use of B&B accommodation to facilitate discharge of patients who would otherwise have to wait to present to HPU, particularly over the weekend. m) Staffing to be increased to three registered mental health nurses and two (currently one) unregistered to allow both the HBPoS and PDU to be safely staffed, with the proviso that whenever activity in Lotus/S136 is low, the additional HCA will be deployed to other areas of the Trust that may be in need. n) The Lotus team manager, in conjunction with the Matron, to review the skill mix and banding of the Lotus establishment, as part of the submission for the April 2019 Safer Staffing round. This should include comparison with the staffing models for teams such as Home Treatment and Liaison Psychiatry, which also include a significant element of independent decision-making by nurse practitioners. 2) Staff Development a) Staff to have access to management days for development, completion of clinical audit and QI facilitation. b) To provide opportunities for the team to create and implement internal training, with input from QII leaders. c) Agreement with Nurse Development and Training regarding Budget provision for structured training such as Masters, Maudsley Simulations etc. and shared learning via train-the-trainer events.
How will you ensure that your service continues to deliver good mental health care?
We complete a 6 monthly review of the service and within this review we check we are meeting our services aims and objectives. We are funded by the CCG and are currently exceeding expectations. The service is continuously being rigorously evaluated and reviewed both quantitatively and qualitatively. The review process has and continues to involve patients, carers and key stakeholders. Furthermore, the lead nurse is currently working collaboratively with the CQC to create regulatory guidance for similar types of new and innovative services.
What aspects of your service would you share with people who want to learn from you?
Lots of trust are setting up unit similar to the Lotus assessment suite, we often have trusts visit the suite and we are very honest and open about the challenges we have encountered. We always share the challenges we have had in getting the correct establishment and the correct amount of senior nurses. We also share incidents and learning from incidents.
The following questions are an opportunity for you to provide further details on how you implement positive practice in your service delivery and how you ensure your service is advancing access and equalities. Answers to these questions will not influence how your PPiMH awards application is assessed, however any responses received may contribute to the potential inclusion of your service/team as a positive practice example within published guidance developed by NCCMH and NHS England.
How many people do you see?
721 service users admitted to Lotus in the past 12 months 04/2018 – 04/2019
How do people access the service?
Service users are referred by psychiatric liaison, home treatment team or street triage. They are referred via telephone, the Lotus nurses screen the referral against our inclusion criteria and decide whether the service user is appropriate for the service.
How long do people wait to start receiving care?
The assessment commence upon arrival to the Lotus assessment suite. Demanding on capacity there might be a short wait in the community before accessing a chair on Lotus.
How do you ensure you provide timely access?
Our bed managers have a pending list which all service users are placed on whilst awaiting a chair on Lotus. When capacity is created Lotus staff inform the bed managers who decides which service user is transferred to Lotus and in which order. Our staffing levels are 3x RMNs (1x B6, 2x B5) and 2x HCAs on every shift.
Assessing needs and providing care
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
We complete a gatekeeping assessment which covers the following We also use the PDQ-4, BDI, WEEKLY STRUCTURING PLANNER, CHAIN ANALYSIS WORKSHEETS, DISTRACTION TECHNIQUES
How do you meet the needs of people using the service and how could you improve on this?
Strengths. One-to-one time and Communication Skills: Patients find the access to one to one time extremely beneficial on Lotus. They feel nursing staff are more available than for example on an acute ward, and have time for longer periods of engagement be it during assessments, reviews, crisis planning, building distraction techniques and coping strategies or discharge planning. All staff have developed high levels or communication skills, with active listening, empathy, asking open and closed questions, clear explanations and reassurance which has enabled the one to one sessions and assessments to be even more effective. Risk Assessments and Collaborative Crisis Plans: Staff on lotus will review existing risk summary’s and risk management plans on Rio when the patient arrives. Following their initial assessment the risk assessment will be updated and again on discharge as well as following an incident on the unit. Staff have developed and improved their skills in completing and using the risk assessment form as an essential component of the overall patient care plan. 99% of service users have had a completed and updated risk assessment during their time on Lotus to date. Capacity Assessments: Staff have developed their skills in completing and documenting capacity assessments for patients on the unit. All patients are routinely assessed with regards to having capacity to consent to stay on the unit when they arrive and this is regularly reviewed. Nursing staff have also improved their skills and knowledge and practice for managing patients who are deemed not to have capacity or are not consenting to stay on the unit. They are now very confident in making decisions for such patients using the appropriate legal framework and following trust protocols to detain or restrain people on the unit if necessary.
Similar to collaborative crisis plans, capacity assessments are audited qualitatively and quantitatively every month. Drug and Alcohol Misuse: Staff have become very skilled in detailed assessments and management of drug and alcohol misuse. All patients have a detailed drug and alcohol history and a variety of assessment tools are used as part of this. Appropriate management will be started on the unit if required and brief interventions with onwards referral to appropriate community services. This has reduced the amount of patients entering hospital for inpatient detoxes when the appropriate care can be provided in the community. MDT
What support do you offer families and carers? (where family/carers are not the service users)
iii. Carer Feedback Lotus recognises that the input of carers is invaluable in recognising early signs of relapse, engaging clients in timely support and improving long term recovery following discharge from the unit. Lotus also recognises that carers can feel very isolated when their loved one enter services and it is important for their feedback to enable services to be inclusive and responsive. The specialist carers RTF survey, noted in the last 3 month review, is routinely offered to carers/friends/relatives when they visit the service. However, due to the nature of the short-stay variable acuity environment, it is not always possible for staff to have face-to-face contact with clients’ family and carers. Subsequently, RTF via the current unit tablet is estimated to have collected less than a quarter of the carers involved with our service users. With input from the Trust RTF Lead, the team now utilise resources on how to submit feedback away from the unit (via the online SWLStG portal and Care Option). Details for these services are available as information cards which can be distributed alongside mental health support line and other quick-reference guides. Lotus Carers Welcome Pack Feedback mechanisms are also incorporated into the new Lotus Carers Welcome Pack, which provides information on the structure and function of the unit, contact details for relevant staff and details of carer specialist support services (from across all 5 boroughs) to improve the wellbeing of clients and carers alike. Self-Assessment Triangle of Care The Triangle of Care (TOC) Self-Assessment Tool is regularly completed due The Lotus Carers Lead will be spearheading the completion of the audit and will disseminate the findings via Monthly Business Meetings. In conjunction with the unit manager, an action plan will be developed demonstrating how improvements will be made and a set timeframe for when each action plan will be achieved.
NCCMH mental health care pathways
Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?
Emergency Mental Health Care
Brief description of population (e.g. urban, age, socioeconomic status):
Size of population and localities covered:
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): CCG
Provided by (e.g. name of NHS trust) or your organisation: South West London and St Georges Mental Health Trust.