Shoreditch Ward – John Howard Centre – East London NHS Foundation Trust – Winners #MHAwards19

Our Quality Improvement Project on Shoreditch Ward is entitled ‘Flip The Triangle’. Flip The Triangle refers to changing the culture on our ward to increase focus on positive and proactive interventions. As a forensic service, we are very good at thinking about our service-users and managing risk when they are in ‘crisis’. Crisis interventions are usually the most high risk for our staff and patients and often involve physical and restrictive interventions. However, we would often notice that those who were at their ‘settled’ and ‘baseline’ behaviours were sometimes overlooked and not receiving the same level of care and attention. Our project is about changing the culture on Shoreditch ward to ‘flip’ our whole team’s thinking into re-focusing our care and interventions to proactively keep our patients at ‘baseline’ in order to improve our patients wellbeing, prevent escalation and reduce our use of physical and restrictive interventions.

Hours the service operates   24 hours a day, 7 days a week

Winners #MHAwards19

Co-Production


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  • From start: No

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  • In evaluation: No

Evaluation


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  • Peer: No

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  • Academic: No

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  • PP Collaborative: No

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Our Quality Improvement Project on Shoreditch Ward is entitled ‘Flip The Triangle’. Flip The Triangle refers to changing the culture on our ward to increase focus on positive and proactive interventions. As a forensic service, we are very good at thinking about our service-users and managing risk when they are in ‘crisis’. Crisis interventions are usually the most high risk for our staff and patients and often involve physical and restrictive interventions. However, we would often notice that those who were at their ‘settled’ and ‘baseline’ behaviours were sometimes overlooked and not receiving the same level of care and attention. Our project is about changing the culture on Shoreditch ward to ‘flip’ our whole team’s thinking into re-focusing our care and interventions to proactively keep our patients at ‘baseline’ in order to improve our patients wellbeing, prevent escalation and reduce our use of physical and restrictive interventions.

The project’s aim is to increase and maintain our proactive and positive interventions to a rate of 95%. This means that of 100 interventions offered, at least 95 of the interventions will be proactive and positive. The ‘Flip The Triangle’ model of care is informed by the evidence-based approach ‘Positive Behaviour Support’. Before our work began we noticed that PBS plans were held by psychology and not developed and supported with the whole team in mind. This presented as a barrier to their implementation to improve the care of our service-users. In order to successfully implement positive behaviour support plans we have developed a process of collaboration across all members of staff who work with the service-user (across professions and bandings) as well as the service-user themselves. Our PBS plans are now ‘live’ documents that are constantly reviewed and updated by all members of the team to inform our care. We recognise the importance of joint and collaborative working across professions and often distribute therapeutic input across disciplines. This has helped the ward develop a model of integrated care across therapeutic and medical staff. Another factor that has been key in implementing PBS plans and change the culture of our ward has been staff support. We recognise the importance of supporting our staff to provide care in very challenging circumstances (for example our staff can sometimes be victim to physical, verbal and racial abuse) and sharing, reflecting and containing their normal human response.

 

The change ideas we have implemented so far: • Blue dots: We capture each instance of providing a proactive and positive intervention with a patient by placing a ‘blue dot’ on a chart with each patient’s initials. This helps up identify how many proactive and positive interventions we are providing each day, identify who are the ‘hidden’ patients that day and offering them care, it provides time to stop, think and reflect about the care we are providing and encourage staff to provide and recognise the positive care they provide. We also capture blue dots for staff support to better understand how our staff team supports each other in challenging circumstances and on a day-to-day basis. • Pedometers: We provided all staff and patients with pedometers to measure steps. This has provided many of our service-users with positive engagements that they would not have otherwise had with staff. It has fostered a sense of ‘community’ with our service-users as it has dismantled the ‘them and us’ culture as we are all building our steps together. It has also encouraged our service-users to care for their physical health. • Wellbeing Traffic Lights: We have added a wellbeing traffic light system to our daily safety huddle. This asks our staff to rate their wellbeing level on a green, amber, red scale. Our staff do not need to disclose any more than the colour that rates their wellbeing to protect their confidentiality. We use the staff ratings to offer informal support to our staff during the day (we have a ‘repair’ box on the ward that contains tissues, caffeine, etc to help staff through the day) and to plan our shifts. For example, if someone is ‘red’ we will try to match them with the less challenging patient on the ward that day. This recognises how important it is for our staff to feel resilient to provide care in the face of significant challenges. • Making our Positive Behaviour Support Plans Live Documents:

 

Our PBS plans are reviewed and updated daily within our existing ‘safety huddle’ structure. They are used to make proactive plans for the day ahead to keep people at baseline, manage potential triggers, de-escalate potential risk incidents and keep staff and patients safe. • Social Tea/Community Meeting: We have developed a sense of community on the ward to model and reward positive, prosocial and appropriate relationships with staff and peers. We now combine our community meeting with social tea to provide service-users with positive engagements and new roles on the ward. • Family Meals: We recognise the importance of regular and positive contact with our patients’ families and carers and are in the process of developing strong working links. We noticed that in the 6 months previous to the project, that 8 service-users had had no face-to-face contact with a family member. We are now setting up a rolling programme of ‘family meals’ that aim to support communication, build links and rapport, and offer a pleasurable experience to the family and the service-user.

 

What makes your service stand out from others? Please provide an example of this.

The tireless resilience and dedication of Shoreditch ward’s staff team to provide outstanding, person-centred care in the face of significant abuse and challenging behaviour makes our service stand out from the others. The compassion, flexibility, collaboration, creativity and enjoyment that our staff bring to their practise is beyond comparison. A recent example that illustrates our staff’s exceptional work describes how our staff have used positive behaviour support in action to connect a Service User (X) to his family in the face of challenging behaviours: As a team, we recognise family contact is vital to help our service-users in their recovery and we wanted to help our service-user, X, to visit his mother. There were several challenges to arranging this visit; ongoing physically aggressive and verbally abusive behaviours, a difficult relationship between the team and the family, anxiety within the team about whether a visit should go ahead. The team decided to promote positive-risk taking and planned to make the family visit safe. The visit home proved to be a success, however, upon returning to the hospital X became highly agitated and a risk incident followed. Before the team started the QI project and change in culture, the team’s response may have been to conclude the visit was a failure and prohibit X from returning home again. However, our team responded by reflecting and learning from the experience. We used the embedded process of PBS in action to first identify the problem; returning to the ward from a home visit and began to try and understand the behaviour.

We came together as a team to discuss and explore what the X might be communicating by his behaviours and what the unmet needs might be. With everyone’s contribution, we generated hypotheses and then developed proactive strategies according to the hypotheses. For example, we wondered whether there may have been sensory issues related to a sudden change in environment, from overstimulation (in the community) to under stimulation (on the ward), or whether rapid disengagement from the team upon returning to the ward could be causing distress. Based on these hypotheses the whole team developed plans such as, increasing the transition time returning to the ward and allowing X to sit in the garden for 30 minutes before returning to the ward, and checking the ward was settled before returning. We also tried to proactively develop positive links between the team and family and held several conversations to try and mend the relationship.

The next step was to implement our proactive strategies and review their impact. After the second home visit, X did not display any challenging behaviours upon returning to the ward. As a team we then came together to reflect on the impact of our proactive strategies and how they had prevented an incident occurring. As part of the review process we added all the strategies identified as helpful (7 in total) to his Positive Behaviour Support plan to document and share our learning. The above example illustrates the amount of effort, collaboration and shared communication it can take to implement proactive strategies, but that our team is not afraid to go the extra mile and always puts our patients and their families first.

 

How do you ensure an effective, safe, compassionate and sustainable workforce?

We are constantly and continually upskilling our staff to develop their repertoire of proactive interventions and why these are important and make a difference. For example, each month at our Team Away days the Clinical Psychologist will lead case discussions that help the team develop their working formulation and hypotheses about the functions of our patient’s behaviours and how their life experiences and diagnoses have shaped their current challenging behaviours. This has helped our staff hold compassion for our service-users and maintain their resilience and ability to provide care in the face of abusive interactions. to We have also provided our staff with more formal training and recently supported the whole ward to attend 2-day Autism & Forensics training. As part of Flip The Triangle, we have invested a lot of time and effort in our staff support. We have fostered strong and support working relationships between our MDT & nursing staff that allows for daily reflective and supportive conversations to take place.

We monitor our staff support by measuring blue dots (as described previously). We also implemented our wellbeing traffic light system to monitor and support our staff on a daily basis. Our team also engaged in monthly reflective practise as a whole team at our Away Days. All of our staff have a robust induction to the ward to our way of working. There are many development opportunities and many of our staff progress up bandings as we aim to promote from within our staff team. We don’t use agency staff and we have a pool of bank staff that we aim to support to the same degree as our regular staff. Our ward has excellent staff retention and we have several members of staff who have worked here since the ward opened.

 

Who is in your team?

Clinical Psychologist 7 1 1 Speech & Language Therapist 7 1 0.75 Occupational Therapist 6 1 1 Ward Manager 7 1 1 Matron 8a 1 0.5 Social Worker 7 1 1 Consultant Psychiatrist Consultant 1 1 Clinical Practise Leads 6 3 3 Staff Nurses 5 7 7 Life Skill Recovery Workers 4 2 2 Social Therapists 3 7 7

 

How do you work with the wider system?

Our ward works with the wider system of the forensic service to try and upskill staff who come into contact with our service-users (for example Emergency Response Teams). We work with external agencies when discharging our patients into the community to help them understand the approach we have taken to our service-users care and think about how they could adapt this for their community placement. Our occupational therapist has built links with local authority and charitable organisations to improve access for our service-users in community based projects, for example employment, leisure and volunteering opportunities. This has helped develop positive engagement opportunities for our service-users and opportunities to explore alternative, prosocial roles in the community. Our Clinical Psychologist also shares our approach with other wards and offers a training package that can be delivered in ward Away Days.

 

Do you use co-production approaches?

Co-production and meaningful service-user involvement is imperative to the evolution of our project. Our service-users can sometimes struggle to engage in large meetings so we have developed creative and meaningful ways to receive their input and feedback to the project. “Dotting the Disc”: We have held several focus groups with our service-users to identify and define what is important to them in terms of the care and support they receive from staff. Through our focus groups, our service-users have identified 10 domains of care that they value: 1. Doing things for myself (independence) 2. Going out (community access) 3. Being together (communication) 4. Trying something new (new experiences and occupational roles) 5. Seeing me (person centred care) 6. Being flexible (least restrictive) 7. Everyday jobs (ADLs) 8. Family 9. Having fun (leisure and relaxation) 10. Being on time (responsive and timely) We are currently creating a 1.5m diameter Perspex ‘disc’ to go on the wall of our ward with words and pictures to illustrate the 10 domains of care. Symbols will sit like a clock round the edge of the disc and patients can ‘blue dot’ next to a domain if they recognise the type of care they value or in the middle if they are unsure. We will then photograph the disc once a month to record where our care is most / least highly perceived and valued. We will then use this data to reflexively inform the care we provide.

 

Do you share your work with others? If so, please tell us how.

We share our work both within and outside of our organisation. We have presented our work within our organisation at Violence Collaborative ‘Time to Think’ forums and DSN Away Days. We were invited to present at the West London Forensic Service “Journey to Outstanding” Conference in May. We also presented to Oxford forensic services who were aiming to learn from our work to address harassment and racial abuse within their service. Our Clinical Psychologist is part of PBS steering group within ELFT that shares and reflects on good practise in PBS. We also have an informal partnership with a medium secure learning disability ward at Fromeside in Bristol, where we share knowledge and learning. We are part of a quality review network which is led by the Royal College of Psychiatry whereby other secure services review our practise, and vice versa.

 

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

We measure the rate of proactive and positive interventions using our blue dot system (as previously described). We collect blue dots weekly, and then compare them to the number of physical and restrictive interventions (Enhanced observations, PRN & sedative medications, Rapid Tranquillisation, Restraint and Seclusion). This gives us a percentage figure. We have improved our rate of proactive interventions from a low of 60% during our baseline, to a maintained rate of at least 95%. We have reduced our use of physical and restrictive interventions (figure 1 is our baseline figure from Oct-Dec and figure 2 is our active phase from Jan-April. We are updating restrictive figures every quarter so please get in touch if you would like updated figures): Number of seclusions: 15 down to 3 Days spent in seclusion: 27 down to 5 Restraint: 9 down to 3 Rapid Tranquillisation: 6 down to 0 PRN & Sedative medication doses: 535 down to 337 Day on Enhanced observations: 127 down to 70. We have measured our staff knowledge and understanding of patients challenging behaviours, confidence knowing how to proactively respond to challenging behaviours and how safe they feel working on the ward. These ratings have increased respectively from baseline to active phase (19.1 to 19.8, 17.6 to 19.9 and 3.9 to 4.4). Staff sickness has also reduced from 118 days of sickness to 32 across the baseline and active phase. There has not been any days of sickness for our ward staff from the beginning of May to now. Additionally, our proactive work has proven to be cost effective. We have reduced the overspend on our budget by £39,696 from baseline to our active phase.

 

Has your service been evaluated (by peer or academic review)?

The Forensic Service is regularly evaluated by the CQC and has received a rating of “Outstanding”.

 

How will you ensure that your service continues to deliver good mental health care?

The success of our project lies within the whole team approach and buy-in across all professions and bandings. We hope the whole team approach and embedded culture change will help the project withstand staff and service changes. To ensure the legacy and longevity of our project, we believe the Quality Improvement framework will aid this. Senior members of the hospital structure are stakeholders in the project and are keen to ensure that adequate funding is in place to support our change ideas. We would like to share our work with commissioners in the future to support the ongoing development of the project.

 

What aspects of your service would you share with people who want to learn from you?

Change within any institution can present a significant challenge. Before our work began, Shoreditch Ward had many entrenched practises and team dynamics that were initially resistant to changes. We understood that implementing change can take a considerable amount of time and can sometimes feel frustrating and hopeless. However, allowing your team to take that time, fostering creativity and curiosity, empowering staff to have a voice and providing strong and inspiring leadership have all been factors that have contributed to the positive culture change. We would like to help other services to develop staff support systems and evidence-based approaches that will in turn benefit service-users, their families and their colleagues. Resource limitations can also present as a challenge to this way of working. It is often resource intensive, however perseverance through the early stages has proved that putting resource into proactive strategies can reduce the amount of resource required to manage crises. For example seclusion observations are very resource-intensive, costly and sometimes unsafe.

 

 

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England):  NHS England

Provided by (e.g. name of NHS trust) or your organisation:  East London NHS Foundation Trust

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status):

Shoreditch ward supports 14 men with a diagnosis of learning disability (with or without Autism) who have committed an offence or their challenging behaviour cannot be managed in lower levels of security. Many of our patients present with varying degrees of challenging behaviours and multiple co-morbidities including ADHD, Psychosis, Personality Disorder etc. Our patient population comprises of multi ethnicities, varying degrees of socioeconomic status and ages range, the minimum age for admission to the Forensic service is 18 years old.

 

Size of population and localities covered:  We are a regional specialist service for men with learning disabilities (with or without autism). We are situated in the borough of City and Hackney and are one of only two NHS specialist medium secure wards for people with Learning Disabilities in London. Our service receives admissions across the whole of London and some out of area patients.

 

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