Care in Mind. HC – #MHAwards19

Care in Mind was established in 2008, by a group of front line mental health professionals who had been working in secure inpatient services with young adults with complex mental health needs. There were significant challenges discharging these young adults successfully back into the community and avoiding a pattern of failed placements and readmission. The service aimed specifically to support young adults with an emergent or existing diagnosis of personality disorder and complex risk profiles. Since 2012, we have been offering intensive mental health packages to young adults aged 16-30 in specialist community residential care settings.

Highly Commended - #MHAwards19

www.careinmind.co.uk

Co-Production

  • From start: No
  • During process: Yes
  • In evaluation: No

Evaluation

  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

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

Care in Mind was established in 2008, by a group of front line mental health professionals who had been working in secure inpatient services with young adults with complex mental health needs. There were significant challenges discharging these young adults successfully back into the community and avoiding a pattern of failed placements and readmission. The service aimed specifically to support young adults with an emergent or existing diagnosis of personality disorder and complex risk profiles. Since 2012, we have been offering intensive mental health packages to young adults aged 16-30 in specialist community residential care settings. Our aim has been to repatriate young adults to their home area, often following a long period in inpatient services and often at some distance from their home and existing support networks. Our innovative and evidence-based model of care aims to support young people presenting with high levels of complexity, within a model underpinned by attachment theory and therapeutic risk management. We can also provide an alternative to hospital admission as we are able to manage significant levels of risk safely in a least restrictive community setting. Our unique model provides 24/7 on-call and crisis intervention support, alongside an intensive therapeutic programme, which helps us to support our young people in maintaining their community placement and avoiding readmission. Our consultant-led mental health teams including clinical nurse specialists and clinical psychologists, work out of geographical ‘hubs’ and support both the residential teams and the young adults within the homes in their area.

 

We are able to provide intensive individual and multi-modal therapeutic interventions tailored to meet the individual needs of our young people. We work as one system inclusive of clinical and residential care and our clinicians offer intensive support to the residential teams, including staff support sessions, training, consultation time and reflective practice sessions. This provides the specialist input that is needed to assist the residential teams in managing our complex young people. A culture of involvement is core to our values, ensuring that young people remain central to everything that we do and are actively involved in evaluating and shaping service delivery. We have an involvement lead, an expert by experience, who has led the development and embedding of this culture throughout the organisation, supported by our champions, who are ex- care in Mind service users who are employed to support existing young people, projects, audits, training and other initiatives. We believe that we can positively shift the trajectory for a young person who may have lost hope and/or developed unhelpful coping styles, by breaking cycles of repeat admission or multiple failed placements and offering them hope for the future.

 

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

There are key aspects of our service that are unique and that aim to directly address the challenges faced by young adults with a diagnosis of personality disorder and by the staff who work to support them. Care in mind provide mental health supported residential care as a single organisation, allowing us to work with one common model of care. This is essential in delivering consistency and continuity of approach, both of which are central to ensuring that the team supporting our young people have the best skills to do so, work consistently within boundaries and are able to access the support of the wider MDT and reflective spaces to support decision making and delivery of care. This common model has been a great success and has allowed for more effective care of our young people. Young adults themselves also take a central role in their own care within Care in Mind. We operate as a least restrictive service and we do not restrain young people or restrict their access to everyday items and to a full life. Whilst our young people often present with significant risk profiles, we employ therapeutic risk management, working collaboratively with them to develop risk assessments and management plans and to identify core needs underlying risk to ensure that they are able to develop an identity outside of their risks and diagnosis. Our aim is to support them when taking risks for a more positive long-term gain, helping them to learn the skills to control their own emotions and behaviour and ultimately develop the responsibility to manage their difficulties safely.

 

All our young people are under the care of a Consultant Psychiatrist, who leads on our therapeutic risk-taking model. 24/7 support from our clinical team helps us to manage crises effectively and avert unnecessary admissions by liaising closely with Accident and Emergency Departments and Crisis Teams. We have also developed close working relationships and shared care protocols with local police forces, to offer training and developed a shared understanding of the importance of how incidents are responded to, but that recognises the challenges and processes in place for partner agencies. This has yielded some very significant benefits, with improved consistency and multi-agency collaboration. We have also recently begun to offer a step down from our residential services, offering structured packages of tailored support into an independent tenancy, providing continuity of care from the team both residentially and clinically. Support is gradually reduced in line with individual independence goals, with the aim of moving into complete independence from our services in a gradual and formulated way.

 

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

All of our staff receive a comprehensive induction when they start with Care in Mind, which includes our own innovative training ‘Therapeutic risk underpinned by safe supportive techniques’ (TRUSST). This equips our new starters with the essential skills to support our model of least restrictive practice and includes training on Therapeutic risk, Safewards for Safe Homes, Lone working and Managing Violence and aggression. Clinical staff receive additional training in the specific clinical models, for example SCM-A, leading reflective practice and staff support. Staff are encouraged to engage in CPD and access additional training in new models of care, therapeutic approaches and to achieve additional qualifications and skills in line with personal objectives. We hold 3 monthly CPD events that are topic based and we have both internal and external presenters at these events. All staff then receive a comprehensive 6 month probation period which then leads onto a appraisal which should take place 3 times a year. This is supported by management supervisions that take place every 4-6 weeks and for our clinical team, monthly clinical supervision.

 

All of our staff can also access staff support and reflective practice sessions which run on a monthly basis Care in Mind are Investors in People accredited and also recognised as a Mindful Employer due to the support we offer to staff with mental health difficulties. We have a wellbeing strategy in place to support staff and this has recently meant the introduction of a partnership with Able Futures to provide additional wellbeing support to staff. All employees also have access to 24hours Employee Assistance Service and can access up to 8 free face-face counselling sessions a year. We are keen to involve our staff at Care in Mind . The Managing Director and Head of People hold Team Brief sessions for all staff that run quarterly whereby staff are given updates on changes to the business and can also contribute by asking questions and feeding in ideas. We have recently rolled out a staff Happiness Survey to gauge staffs satisfaction with the company. This resulted in a number of changes to the business based on staff feedback such as advertising more job roles with part times options to support flexible working, introducing rolling rotas so are staff can have better planned shifts, making the team brief more accessible for staff and reviewing technology solutions through the development of better IT to improve communication with staff.

 

We also have a number of recognition initiatives in place such as employee of the month, suggestion email and box where staff can put suggestions in and receive shopping vouchers for those that are implemented, Length of service awards, annual staff awards ceremony, Mid year festival, Christmas Party and Thank you badges on our PeopleHR system where staff can award each other virtual thank you badges. We are also involving staff through focus groups. An example of this was that we have recently revised the Care in Minds values through consultation and review with all staff.

Who is in your team?

Care in Mind Clinical Team Cheshire Hub The Cheshire Hub Clinical team consists of; 1x Clinical Director 1x Consultant Psychiatrist 2 x Lead Clinical Nurse Specialists ,Band 8a 2 x Clinical Nurse Specialists, Band 7 3 x band 8a, Highly Specialised Clinical Psychologists 1 x Consultant Art Therapist (covers across service) 1 x Clinical Administrator Chorley Hub The Chorley Hub is team consists of; 1x Consultant Psychiatrist ( covering Yorkshire and Lancashire) 1 Band 7 Clinical Nurse Specialist 1 Band 8a Highly Specialised Clinical Psychologist Yorkshire Hub The Yorkshire Hub team is consists of; 1 Band 8a, Lead Clinical Nurse Specialist 1 Band 7 Clinical Nurse Specialist 2 x Band 8a Highly Specialised Clinical Psychologists

Within our specialist residential homes, of which we have 10, we have a manager and team leader in each home, senior support workers and support workers, who make up key teams of three for each young adult. We have one waking night and one sleep on every night shift to support young people. We also have bank teams that are based within the hub areas, meaning that a pool of staff work regular bank into any home in that hub, providing consistency and support for services at times of leave/sickness. We do not use agency staff within the service.

 

How do you work with the wider system?

We have worked very hard alongside our multi-agency partners to communicate with them about our service, what we offer and how we support young adults within our service, whilst also working hard to understands the demands and requirements of protocols and systems in place within other services. We make close local links for each home with A&E liaison and rapid response teams/crisis teams, to ensure that we are known to them and to ensure that they have an overview of our model of care. We have 24/7 clinical support available and our on-call clinicians will support discussion with A&E and crisis teams should our young people have significant incidents and or present to their services, and this aids the development of collaborative care planning and prevention of unnecessary admissions. All of our young people have A&E letters describing their current needs and treatment plans and well as any relevant physical health needs.

 

We work with young adults who may also have additional needs around eating disorders, diabetes, substance misuse for example, and in those cases we work closely with specialist NHS services to ensure that the staff have adequate training and we are able to manage the risk collaboratively, developing care pathways for an acute admission for example, with a clear plan for discharge back to the placement as soon as possible. We have also developed shared care protocol with the police to support them in responding to incidents involving our young people, and in reducing the factors that can reinforce unhelpful patterns of responding to risk.

 

Do you use co-production approaches?

At Care in Mind, involving the young adults that we work with in their care and our service development is central to our ethos. We know that often young adults who come to us may have had difficult experiences in services and feel like their voices haven’t been heard. We want a placement at Care in Mind to feel different and most importantly, involvement needs to be meaningful and not tokenistic. Our Service User Involvement Coordinator is an expert by experience. Her role at Care in Mind is to ensure young people’s voices are heard, and that they are truly involved in all aspects of their care. She also ensures young people are involved in our service development and improvement plans. She coordinates a number of projects that young people have suggested or can get involved in while at Care in Mind – Some examples include; Consequences Consultation Project, Recruitment and Selection, Charity fundraising activities, YP Newsletter, Policies, , Improving therapy spaces and service audits.

 

We also employ champions, who are former Care in Mind service users. This is a flexible, paid role, designed to allow young adults to use their knowledge and expertise to improve the experiences of other people being supported by Care in Mind. At Care in Mind we also work hard to engage families and extended care networks, from the earliest opportunity and throughout a young person’s care, where of course this is consented to. We also offer families and carers education events and a chance to learn more about our model of care and how we support people within our services. We offer family therapy and support to families in recognising how best to support and respond to their family member

 

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

We are very proud of the work that our teams do at Care in Mind, and we try to share as much learning and good practice as we can. We offer regular education events where people can come along and learn more about our model of care and how we approach the work with our service users. Recent topics at these events have been presentations on therapeutic risk management, Safewards for Safehomes and case formulations. We had have clinicians, crisis teams, residential providers, commissioners and the police in attendance at these events which supports learning across multi-agency partners. We have regular student nurses within service, from whom we have an average placement rating of 98% satisfaction. We also offer training on clinical psychology training courses. We have offered training to partner agencies when requested, for example to the police, and we regulatory attend local safeguarding network events across the hub/home localities.

We presented at the British and Irish group for the Study of Personality Disorder (BIGSPD) National conference two years ago and we displayed a research poster at the event in April of this year. We have presented at the conference Mental Health in the Young, where we presented data form our service, and explored therapeutic risk management. We have also had posters at conferences organised by the Royal College of psychiatry. We are members of the Restraint Reduction Network and are passionate about communicating and sharing good practice around the reduction of the use of restraint in mental health services.

 

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

We utilise a number of outcome measures to assess both progress and recovery whilst a service user is in our care, and to look at overall recovery upon trasntion out of service. The Mental Health Recovery Star is completed jointly by the young person, a member of the young persons residential key team and a clinician. This tool is completed during transition to identify goals for the first three months of placement, and is then completed every three months following that until the end of placement with goals identified feeding directly into care planning and monthly multi-disciplinary reviews. A goal focused CPA report and process clearly evidence how goals identified on the measure are worked on with the young person. We also complete a number of other patient rated outcomes measures; the Inventory of Interpersonal Problems, brief form (IIP-34), the Fear of Negative Emotions Scale, the Defeat Scale and the Connor- Davidson Resilience Scale (CD-RISC-25). These measures are completed by the young people, with support from their clinicians if required. The measures are completed in transition for the baseline and then every three months after that time.

Young people are able to use these measures to highlight any improvements in their ability to recognise, understand and change their difficulties and they were chosen specifically to target areas of difficulty for the client group; emotional regulation, interpersonal relationships, hopelessness, emotional understanding and recognition. the inclusion of the resilience measure aims to highlight to service users the skills and resilience that they do have despite their difficulties, and that increasing resilience is a key factor in mental health recovery. We also collate incident data for young people that is used, alongside mental health recovery star data currently, to demonstrate service outcomes and highlight common patterns in incidents. For example, we tend to see an increase in incidents after 3 months socialisation when our service users begin working on their core difficulties more, and express feeling more secure in placement. We also complete audits across service that include a YP audit, where our service user coordinator goes out to each home to meet the young adults, and completes an audit with them around their experience of their care. We also seek feedback from young people, carers and staff around their experiences of Care in Mind.

 

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

We have been consistently rated as Good in all areas by the CQC. We have presented research posters at conferences and supported a piece of qualitative research completed for a Psychology masters degree, exploring staff experiences of least restrictive practice within the organisation.

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

We have robust Governance structures within the organisation that support the production of KPI data monthly and trends are reviewed across the organisation in Governance meetings to ensure that the service we deliver is of the highest quality. Our senior management team, including the CEO, Managing Director and Clinical Director are all clinicians by background, complimented by Business Development, Finance and IT Directors. This clinical leadership ensures that the direction and priorities of the organisation, as well as recruitment of new staff into senior posts, remains focused on the highest standard of care delivery possible for our client group. If a senior manager were to leave, this team would be able to maintain the clinical leadership and recruit a suitable alternative to ensure that the organisational values, drivers and care delivery standards were maintained.

Care in Mind builds proactive working relationships with NHS and local authority commissioners within each locality in England to ensure we collaborate to meet the needs of the local population. We are also actively engaging with the newly commissioned New Model’s of Care to ensure that we are part of the Care Pathway for people with complex mental health Needs. We provide detailed Needs Assessments, Prescribed Interventions and Comprehensive Costs breakdown for all commissioned placements to ensure that funding is effectively secured to enable a smooth transition for the young person into the service. Care in Mind attend stakeholder events hosted by Local Authorities and Health Commissioners in the North and Midlands and where there is a need for residential services for young people with complex mental health needs will submit a bid to secure funding to provide quality services within the locality.

 

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

We believe that it is the consistency, quality and breadth of the model that yields the most significant results for our service users. We have found when working with multi-agency partners that the development of shared protocols is most effective in delivering the best outcomes as every service has its own standards and processes to follow but often these can complete and clash in the care of those involved in services. We have found, through working through such clashes and challenges, that learning from each other and understanding others perspectives and drivers, can support everyone to a better outcome. We continue to work right at the edge of what is possible therapeutically in the community, and these challenges offer a significant amount of learning to us as an organisation, which we believe is valuable in considering when and for how long young adults require inpatient services, and when risks and needs can be safely managed in the community. We feel very passionately about least restrictive practice and delivering care in the least restrictive setting, with the least restrictive methods to yield a more positive outcome and long-term gain for people to take increasing responsibility for their own risks. This message is central to all the work that do and why it is central that young people work with us and are active agents within their own recovery. These messages around consistency and therapeutic risk management are core to the model of care and key messages to others services who work with a similar client group, regardless of the setting.

 

How many people do you see?

Care in Mind have received 90 referrals into the service between 1st May 2018 and 30th April 2019, of which 36 were accepted for placement in the service (40% acceptance rate). We operate ten residential homes, with a total of 43 beds.

 

How do people access the service?

Referrals into the service are usually made by a health or social care professional, i.e. social worker, care coordinator, commissioner, placement officer etc. We have a clearly defined referral pathway as follows: Step 1: Referral We will request a completed referral form and supporting documentation Step 2: Screening (within 24 hours of referral) Our clinical team will undertake initial screening to provisionally determine if we may be able to meet the young person’s needs based on the information provided. Step 3: Assessment (within 1 week of referral) Following screening, all suitable referrals will be offered a face to face assessment in their current placement. As part of this process we would also wish to meet with members of the current care team and families/carers where appropriate to enable a holistic assessment. All assessments are undertaken by a clinician and a residential manager. Step 4: Initial Response Letter (within 72 hours of assessment) Step 5: Full Needs Assessment (Within 1 week of assessment) Step 6: Transition

 

How long do people wait to start receiving care?

Under our standard referral process we aim to undertake assessment within 1 week of receiving referral, with a full assessment of needs and prescribed interventions, provided within a further week. Following the issue of our placement offer, the timescales to access the service are dependent on the funding authority approval procedure. The standard process is that the case will be taken to funding panel for review which can take from 2 weeks to 2 months. Transition into our service can commence as soon as signed contracts are in place. Upon the onset of transition all clinical services are immediately available to the young adult and remain available at all times throughout their placement.

 

How do you ensure you provide timely access?

Our services are staffed prior to any young people being referred and at all times staffing levels remain at the level required to offer a full service to all service users at all times.

 

 

What is your service doing to identify mental health inequalities that exist in your local area?

Care in Mind work collaboratively key stakeholders with Mental Health Trusts, Acute Hospital Trusts (A & E liaison). Local Authorities, Police and other Mental Health Charities such as MIND to ensure that the geographical locality population are aware of the complex needs of the young people in our care. We regularly attend stakeholder engagement meetings hosted by the above and have agreed processes and that enable the young people to have their needs met appropriately, at the right time.

 

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

We have a higher proportion of females (71%) to males (29%) within our service.

 

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

Initial assessment document, Mental Health Recovery Star, Physical Health Baseline Screening, MACI/MCMI

 

How do you meet the needs of people using the service and how could you improve on this?

At Care in Mind, our specialist model is designed to provide a unique, integrated approach to mental health support within a residential setting. Every young person has an allocated clinical nurse specialist and clinical psychologist and is under the care of a consultant psychiatrist, which enables timely, individually tailored interventions to be delivered to young people, whilst ensuring robust engagement and involvement with the wider MDT and residential team to ensure continuity and consistency of care for all young people. This approach enables us to support young people with high levels of complexity on their recovery journeys, through safe and clinically effective residential care. We can take young people from Low Secure/ Locked Rehabilitation Services, CAMHs Tier 4 Services, Acute In-patient Services, Residential Services, Secure Children’s Homes and Community Services

 

What support do you offer families and carers? (where family/carers are not the service users)

We work hard to engage families and extended care networks, from the earliest opportunity and throughout a young person’s care, where of course this is consented to. Where appropriate families are invited to take part in CPA’s and to offer us feedback about our services. We also offer families and carers education events and a chance to learn more about our model of care and how we support people within our services. We are able to offer family therapy programmes and we have offered support to families in recognising how best to support and respond to their family member.

 

 

Is there anything else you want to share about what makes you an example of positive practice?

Our position in bridging the gap between CAMHS and adult servcies. Often these young people can struggle with a transition from children’s to adult services and we are able to work with this very complex group and coordinate services and ensure consistency at a time when this is vital in the recovery of these young adults.

 

 

Commissioner and providers

Commissioned by: The Young People within our Care are commissioned by Clinical Commissioning Groups and Local Health Boards, alongside Local Authorities from England and Wales. The young adults currently in service are commissioned by the following CCG’s and councils: Wirral CCG, Warrington Council, Chorley and Ribble CCG, Cumbria Council, Trafford CCG, Blackpool CCG, Lancashire Council, Liverpool Council, Oldham CCG and council, Kirklees CCG and council, Wakefiled CCG and Powys Health Board.

Provided by (e.g. name of NHS trust) or your organisation: Care in Mind

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status): The service users at Care in Mind are aged between 16 and 30yrs. We bridge the gap between CAMHS and adult services for our young people, but our services are wholly or mainly for young adults. Our service operates across the North West taking young adults from diverse backgrounds, both from rural and urban settings. 22% of our young people have been accommodated in Looked after children (LAC) settings, while 20% have come from higher socioeconomic backgrounds, with a higher level of achievement in education, access to housing and their own family support. The remaining 58% come from lower and middle socioeconomic backgrounds.

 

Size of population and localities covered:  We currently have a total of 34 Young People with our Services. The localities covered are Lancashire and Cumbria, Greater Manchester, Cheshire and Mersey and Yorkshire.

 

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