Wainwright Respite and Recovery Service (WRRS) is an innovative service which is unique to Sheffield and, as far as we are aware, is unique nationally as well. The service operates a 12 bed citywide service 24 hours a day, 7 days a week to support adults with mental health needs. It provides high quality specialist respite including planned respite and over recent years the service has piloted and then introduced a step-down service.
Wainwright Respite and Recovery Service (WRRS) is an innovative service which is unique to Sheffield and, as far as we are aware, is unique nationally as well. The service has evolved over time to meet the needs of vulnerable adults.
The service operates a 12 bed citywide service 24 hours a day, 7 days a week to support adults with mental health needs. It provides high quality specialist respite including planned respite and over recent years the service has piloted and then introduced a step-down service.
Wainwright provides an essential function in the acute care pathway. This service is well received, has good outcomes and supports flow through the acute care pathway.
It is well known that admission to an acute adult in-patient ward is, for many service users, a traumatic and distressing experience. During their admission people are at their most vulnerable and fragile. Often the thought of returning to their local community can be frightening and stressful. Depending on individual circumstances, prior to admission service users can have experienced discord and distress in their local community and the anticipation of returning ‘home’ whether to a new location or a previous location can be overwhelming. WRRS, in the words of one service user, can be ‘a mini oasis of hope in a barren landscape’.
The step-down service takes people from their most traumatic and vulnerable episodes, moving them out of acute wards where situations can be highly aroused and, at times, chaotic, and moving them to a tranquil, supportive setting which builds resilience and promotes recovery. It is a very different environment to the acute wards and has a different approach to working with service users. The focus is on building resilience and confidence. It is a bridge back into the community for service users, a stepping stone on the way to recovery.
WRRS aims to help service users find a sense of purpose. At WRRS service users have regular access to the internet and are assisted to search for local groups and support networks which can aid their recovery. Activity programmes run throughout the week offering opportunities for both group activity and individual activity both during the day and in the evenings. Service users are encouraged to re-engage with hobbies and interests that they enjoyed in the past, helping them to build resilience and enhance their wellbeing.
All service users self-cater while at WRRS, however, nutritional and hydration education is provided to encourage service users to consider how what they eat and drink can impact on their wellbeing. Education regarding medication is also provided to assist service users in managing their recovery and maintaining their wellbeing.
WRRS aims to provide a safe, friendly and relaxed environment, treats everyone with respect and empowers people to make their own choices. WRRS supports and assists individuals to manage their own mental health and wellbeing, develop skills and confidence to maintain living in the community and prevent relapse/hospital admission.
The staff at WRRS are committed to giving service users a real opportunity to build on their strengths. WRRS doesn’t discriminate on a service user’s pathology, the staff work in the here and now with the focus very much on individual service users’ strengths. Service users relish the fact that they come to WRRS with no ‘baggage’ and feel empowered by the approach which focuses on recovery. Staff at WRRS ask service users ‘how can we help you?’ – an approach which is both effective and empowering.
WRRS does not work in isolation, it reaches in to the acute wards and out into the community. If WRRS is at the centre then the spokes of the wheel include the wards, the community mental health teams, Care Co-ordinators, Key Workers, Access Workers, housing (both Sheffield City Council and Housing Associations), community groups, the Sheffield Mental Health Advocacy Service, Sheffield Citizens Advice Bureau, the Recovery Education Programmes offered by the Trust’s community services and local third sector organisations such as MIND, Rethink etc.
WRRS has a dedicated link worker who works with the Discharge Co-ordinators and Discharge Facilitators on the in-patient wards. Their role is the gather the service user’s history, smooth the transition and ensure that the service user’s needs are met. Service users come to WRRS through personal choice – WRRS only works with service users who want to come to the service and service users are able to visit in advance to see if they feel the service offered would be beneficial to them and meet their individual needs.
The main issue affecting all service users of the step-down beds at WRRS is housing. Nationally, there is a shortage of suitable housing for vulnerable people and the picture in Sheffield is no different to the national situation. Step-down is offered for a standard 28 nights but staff at WRRS have built flexibility into their systems so that a longer stay can be offered dependent on mental health need or housing need.
Recently WRRS has instigated a pilot by creating a Discharge Facilitator role within their own service. The Discharge Facilitator at WRRS picks up the responsibilities of the Discharge Facilitator on the ward and supports each service user to return to their own accommodation. This may include assigning an outreach worker to help a service user reintegrate back into their community, a graded discharge to help a service user settle back into their home, supporting a service user to find alternative accommodation including putting bids on properties, arranging visits and assisting with the mechanics and paperwork of moving. The Discharge Facilitator can also refer service users on to the Floating Support Service offered in Sheffield which provides ongoing support and assistance for people living in the community. Early feedback is that this pilot is working well and that service users are benefitting from this additional dedicated support.
It is not uncommon for service users who use the step-down facility, to take the opportunity to utilise individual budgets (or Self-Directed Support) to establish planned respite stays at WRRS. This is a true testament to how valuable service users find the service offered at WRRS.
If WRRS did not exist the only alternative for service users would be temporary Bed and Breakfast accommodation which we believe is unsuitable and unstable for vulnerable adults. We believe WRRS is a model which should be replicated nationally for the benefit of service users throughout the country.
WRRS prevents institutionalisation by ensuring that service users are not stuck on acute wards when, clinically, they are fit for discharge. WRRS provides a more therapeutic environment which benefits recovery.
WRRS is also proven to prevent service users from becoming ‘revolving door’ clients, those who are frequently re-admitted to hospital due to deterioration in their mental health, a breakdown in their care or a general lack of support and resilience.
The introduction of the step-down service has coincided with a reduction in the number of service users the Trust is having to send to hospital out of city. Having the step-down service means that service users are not bed-blocking on the acute wards while waiting for appropriate accommodation.
The service provided one step-down bed for a number of years. This bed has been available to those who are ready to be discharged from adult acute in-patient wards and who have identified independent accommodation where that accommodation is not immediately available for the service user. A number of different factors may create these circumstances, but a particular example would be an individual who has been granted a Council tenancy but further essential work on the property needs to be completed before they can move in. This can create delays of several weeks.
This proved so beneficial to service users that a pilot was undertaken to look at whether the provision of step-down could be increased and enhanced. WRRS now offers a mix of step-down and respite provision.
Experience of the service suggests that providing both step down accommodation and respite care is an appropriate mix of uses and does not create issues arising from significantly different needs amongst the service user population.
Wider Support
The service is part of Sheffield Health & Social Care NHS Foundation Trust. The service by WRRS is widely supported across the Trust.
To ensure effective collaboration and partnership working with the acute in-patient services WRRS have organized and manage weekly referrals meetings between themselves and the In-patient Discharge Co-ordinators.
Supported discharges are enhanced by partnerships with Community Support Services who work with service users during their stay at WRRS to help to reintegrate them into their community and refresh their confidence in carrying out activities of daily living (which can be affected by long admissions to the acute in-patient wards). The work undertaken by WRRS and the Community Support Service in partnership promotes independence and autonomy for service users. WRRS also has strong links with the Community Mental Health Teams, assisting in a smooth transition from in-patient care to community care.
WRRS also has strong links with local community and support groups and facilitates service user access into these groups which aids in forming resilience and promoting recovery as well as reintegrating service users back into their local communities.
Co-Production
Service users are at the heart WRRS. WRRS consistently and constantly review and assess what it offers to ensure that it is meeting the needs and requirements of service users.
Service users consistently express the view that the transition from the acute wards to WRRS provides an opportunity to gain confidence to return to live within their local community. This arrangement gives an opportunity to build on individual service users’ strengths and address any areas for development while helping to develop renewed hope and motivation on their journey to recovery.
For example, this can mean regaining skills in all aspects of daily living which many clients feel they can lose during delays on acute in-patient wards. Living skills such as budgeting, shopping, cooking, self-medication, and using transport can be affected.
WRRS operates as a communal living entity. Community meetings are held weekly and a development forum (led by service users) takes place every three months. The service users chair, minute and organise the forum.
WRRS embraces the whole person view and offers individualised care. Service users are supported to write their own plans which are created and owned by them. While they are at WRRS they have a ‘My Safety Plan’ in which they outline what will help them keep themselves safe, ‘My Step Down Care Plan’ and, if they chose to purchase respite from WRRS through Self-Directed Support, ‘My Respite Plan’.
Service users are involved at the heart of all discussions about the service and any possible changes. When the step-down pilot ran, there was intensive and regular communication and dialogue with current respite service users as well as those service users using the step-down beds.
Quotes from service users who have used the step down service:
‘This experience helped build up my confidence with my level of independence.’
‘I had been on the ward for 8 months, being in hospital can make a person quite institutionalised, if I had gone straight back into the community I may not have coped.’
‘My time at Wainwright introduced me back to a normal life in a more gentle way.’
‘It was good to meet and chat with others in the unit and staff were always available if I had any problems.’
‘It was so relaxing and calm, so different to the ward setting.’
‘My experience at Wainwright gave me confidence and skills to be more independent and less reliant on my family. I now am able to make my own decisions.’
Many service users who have used the step-down beds have gone on to use Wainwright Crescent for planned respite care as they have been so impressed with the service that they have received. Other service users have used the planned respite care service for many years and we consistently receive positive feedback indicating how much the service provided is valued and how it contributes to maintaining people’s recovery.
Recent compliments received from people who use the respite service include:
‘Knowing that I am coming to Wainwright every couple of months gives me reassurance and helps me to cope.’
‘I look forward to my respite stays. The staff are so friendly and welcoming and it feels like a home away from home.’
‘I don’t know what I would do without Wainwright . . . There is no pressure when I am there. I can stay in my room and relax or I can join in with the activities. Staff are always around to talk to.’
Looking Back/Challenges Overcome
In January 2011 the Trust agreed a 6 month pilot project for the development of 5 additional step down beds at WRRS (only one was currently designated a step-down bed prior to this). The aim of the pilot was to improve the effectiveness of in-patient care, assist in reducing length of stay on the in-patient wards and reduce expenditure and associated costs in out of town placements.
The pilot period was identified to:
• To ensure that WRRS was suitable for the provision of step down accommodation;
• To assess the impact on acute in-patient beds;
• To assess the level of savings achieved from a reduced use of out of town placements in acute in-patient beds;
• To assess the impact on existing service users of planned respite;
• To allow time for the Commissioners involved to reach agreement on future funding for the elements of service provided at WRRS.
The remit of the step down accommodation was set as:-
• Service users ready for discharge from hospital who were able to move to independent accommodation but have not yet secured a tenancy;
• Service users whose mental health had improved considerably during their in-patient admission, have independent accommodation or are in the process of accessing it, but whose recovery is not yet at a stage where they could be safely discharged to independent living. Such service users may benefit from a period of step down and staffed accommodation but do not necessarily need nursing care within an in-patient unit;
• Service users who are ready to be discharged from acute in-patient care who are not moving to independent living but have an identified place in residential care or supported accommodation which is due to become available shortly;
A ‘Discharge to Wainwright Questionnaire’ was introduced in collaboration with the discharge co-ordinators to collate service users’ experience and expectations involving both transfer to and discharge from Wainwright. The feedback from service users who used the step down service during this pilot period was positive.
The pilot was reviewed by the project team, which included 2 service user representatives.
On reflection it would have been helpful if we had promoted the initiative and pathway earlier with the Community Mental Health Teams. We worked closely with the acute in-patient wards but it would have been a positive step to get involvement and ‘buy in’ from the Community Mental Health Teams at an earlier stage.
We could also have linked in with the older adults mental health teams and the rehabilitation services from the beginning of the project rather than making those links part way through. This would have offered more opportunity for their needs and ideas to better inform the project.
The main challenge faced was a concern that by reducing the respite beds to increase the step-down beds this would impact on the feel of the unit, which might adversely affect the mental health of the service user base. It was also a concern that the mix of service users (respite and step-down) would cause problems as they might have very different needs and be experiencing very different problems.
Therefore, as part of the pilot, staff and service users involved in the project group undertook a number of pieces of work to ensure that the project worked as effectively as possible. These included:
• Developing a clear process pathway for identifying potential service users who would benefit from step-down care;
• Establishing a clear referral criteria for access to Wainwright Crescent;
• Appointing a link worker to both act as the link with the acute in-patient wards and to undertake a discharge facilitation role at Wainwright Crescent (ensuring that service users are able to access accommodation and move on from Wainwright as quickly as possible);
• Communicating with existing service users of respite care to ensure that they were clear why the changes were taking place, what the changes were and the reasons for the changes;
• Ensuring that the project group involved service users throughout the pilot.
All service users admitted to Wainwright Crescent either for respite or step-down care have an up-to-date risk assessment in place.
An impact assessment was developed in respect of all existing respite care service users as it was anticipated that due to the rapid nature of the service changes, it would impact on frequency of stay due to reduced bed capacity.
Service user representatives in the project group raised concerns, that while they appreciated that the step down provision is positive for recovery, there were concerns about the respite service and difficulty in meeting previous levels of respite frequency (e.g. where respite may have previously been available to a service user every 8 weeks this is now more likely to be 10 -12 weeks).
To address concerns about the mix of service users, a communal weekly meeting was established for all current users of the service which includes a communal meal afterwards to bring all the service users together.
The staff team are also ensuring that they are working collaboratively with other services, attending and taking part in road shows and attending the acute in-patient wards to raise their profile.
Sustainability
The staff team and the senior leadership within the Directorate are fully committed to ensuring that the high quality service provided by WRRS continues and that continuous quality and service improvement is part of the ongoing programme of development. The Directorate has succession plans in place to ensure that the team continues to function should the current management leave.
We are committed to delivering on the Five Year Forward View for Mental Health services, which includes a requirement to develop evidence based clinical pathways and strive to provide high quality care and support as close to service users’ homes as possible. We are committed to a collaborative recovery based approach to mental health care and genuine co-production with staff and service users. Through our Trustwide Service User Experience Monitoring Unit and our Trustwide Service User Engagement Group we ensure that our service users can be heard and heeded.
Evaluation (Peer or Academic)
The service is evaluated annually and continues to evolve. A service user forum meets very three months to ensure that feedback from service users is heard and actioned.
The service has recently implemented a microsystems approach to quality improvement with a service user representative to help drive improvements forward. The focus is on improving the service and experience for service users.
The Trust has found that the provision of the step-down beds at Wainwright Crescent has contributed to reducing the length of stay (admission) to acute in-patient wards for service users and has also impacted on a reduction in the use of out of city acute in-patient beds.
Outcomes
The introduction of the step-down service has coincided with a reduction in the number of service users the Trust is having to send to hospital out of city. Having the step-down service means that service users are not bed-blocking on the acute wards while waiting for appropriate accommodation.
Quotes from service users who have used the step down service:
‘This experience helped build up my confidence with my level of independence.’
‘I had been on the ward for 8 months, being in hospital can make a person quite institutionalised, if I had gone straight back into the community I may not have coped.’
‘My time at Wainwright introduced me back to a normal life in a more gentle way.’
‘It was good to meet and chat with others in the unit and staff were always available if I had any problems.’
‘It was so relaxing and calm, so different to the ward setting.’
‘My experience at Wainwright gave me confidence and skills to be more independent and less reliant on my family. I now am able to make my own decisions.’
Many service users who have used the step-down beds have gone on to use Wainwright Crescent for planned respite care as they have been so impressed with the service that they have received. Other service users have used the planned respite care service for many years and we consistently receive positive feedback indicating how much the service provided is valued and how it contributes to maintaining people’s recovery.
Recent compliments received from people who use the respite service include: ‘Knowing that I am coming to Wainwright every couple of months gives me reassurance and helps me to cope.’
‘I look forward to my respite stays. The staff are so friendly and welcoming and it feels like a home away from home.’
‘I don’t know what I would do without Wainwright . . . There is no pressure when I am there. I can stay in my room and relax or I can join in with the activities. Staff are always around to talk to.’
Sharing
We would be very happy to share our experiences and have already begun to do so.
The Trust is more than happy to host a learning event.
