The service aims to support individuals who have been in hospital placements out of area to return to their local area and develop their independent living skills. Daisy is a registered hospital and is able to support service users who are and are not detained under the mental health act. Daisy is able to accommodate five individuals at anyone time. It opened in January 2017 and currently has four individuals living in the service. The aim of Daisy is to support service users to develop their coping techniques and therefore reduce the requirement for individuals to be detained.
Daisy was designed in partnership with service users, families, care coordinators and other key stakeholders. Service users and families have been actively involved in the recruitment of staff. Service users and families are encouraged to lead on their care and work towards a co-production model.
Please briefly describe your project, group, team or service
The service aims to support individuals who have been in hospital placements out of area to return to their local area and develop their independent living skills. Daisy is a registered hospital and is able to support service users who are and are not detained under the mental health act. Daisy is able to accommodate five individuals at anyone time. It opened in January 2017 and currently has four individuals living in the service. The aim of Daisy is to support service users to develop their coping techniques and therefore reduce the requirement for individuals to be detained.
Daisy was designed in partnership with service users, families, care coordinators and other key stakeholders. Service users and families have been actively involved in the recruitment of staff. Service users and families are encouraged to lead on their care and work towards a co-production model.
Daisy has made a positive difference to service users lives. One of the individuals living in Daisy were previously 100’s of miles away from home. The individual was regularly secluded and had minimal access to the community. Since moving to Daisy the same individual see’s their parents 3-4 times per week and accesses the community several times per day. In addition there has been zero incidents of seclusion and minimal use of medication to manage their behaviours.
Another individual has had a similar experience. Prior to moving to Daisy they saw their family once per month and had limited access to the community. Since moving to Daisy the same individual see’s his family at least once per week. In addition they have completed a self-management of diabetes course and is currently undertaking a diabetes facilitation course which will enable them to train staff.
What makes your service stand out from others?
Daisy is an innovative, model of care that breaks down the barriers of the traditional hospital model of care. Service users are proactively involved in the delivery of the their care. The plan for the day adapts to their needs and the service has a flexible staffing model that is able to support service users to lead fulfilling, active lives. An example of this is a service user requested to access an evening activity (they wanted to attend a social group). The times of the staff shifts were changed to facilitate this request.
In addition Daisy is able to support the service users when they are using behaviours that challenge. The service advocates the use of Positive Behaviour Support approach which uses a proactive approach to supporting service users with behaviours that challenge. This means that the use restrictive interventions such as safe holds and medication is significantly reduced compared to service users previous placements.
Daisy is able to combine an independent living model of care with a supportive, multi-professional model. Service user flats are equipped with a cooker, washing machine, fridge and bathroom. Each flat has its own front door which enables service users and visitors to access their flats without having to access the main premises. This accommodation allows flexibility of service delivery. This approach has enabled service users to develop their cooking skills in their flats with the safety of a wider team should they require additional support.
If Daisy was not a hospital, the service users would most likely still be in long stay hospitals hundreds of miles from home. Whilst the development of a hospital service would appear to contradict the current transforming care model, there is a real benefit in having a service of Daisy’s nature with a hospital registration. The hospital registration enables Daisy to support service users with complex needs in a less restrictive environment. The hospital registration enables service users to come off their sections in a safe place at their own pace. Once service users are off section they are supported to remain in the service until they are ready to access a community based setting.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Daisy is a well-resourced service. There are currently 40 wte staff assigned to Daisy. There is a mixture of registered and unregistered staff. Within the nursing team there are Registered Nurses Learning Disabilities, Registered Mental Health Nurses and an Adult nurse. The Team manager is a Registered Nurse Learning Disabilities and the service manager is a dual qualified social worker/Registered Nurse Learning Disabilities. In addition the service employs a clinical psychologist and 2 WTE psychology assistants. Currently the responsible clinician is a Consultant Psychiatrist. The long-term plan is for the service manager to be a Non-Medical Responsible Clinician once he has acquired approved clinician status. The MDT is ably supported by support worker staff.
The service is proactively supporting staff to develop their knowledge and understanding. All unregistered staff are encouraged their care certificate and several staff have completed their positive behaviour management facilitator training. Positive behaviour management training is mandatory for all staff.
All staff have monthly supervision training and clinical supervision is available.
There are shift debrief sessions at the end of every shift and psychology have sessions available for all staff.
Who is in your team?
Service Manager 8b 1 1
Consultant Psychiatrist Medical 1 0.2
Clinical Psychologist 8a 1 0.6
Team Manager 7 1 1
Music Psychotherapist 7 1 0.4
Deputy Manager 6 1 1
Registered Nurse 6 7 7
Psychology assistant 5 2 2
Senior Support Worker 4 5 5
Support worker 3 25 21.8
How do you work with the wider system?
The service works closely with the local council, CCG and community learning disabilities service. There is a monthly quality and standards meeting that care coordinators are encouraged to attend.
There is a weekly incident review meeting which the local council safeguarding team attend. In addition the CCG safeguarding lead has an open invitation to the meeting.
The service has good links with the local advocacy service and has an open door philosophy which is fully utilised by other agencies.
There is a plan to have a regional peer supervision network that will support peer review from similar services.
Do you use co-production approaches?
The service users a coproduction approach. As previously stated, the service was designed and built in partnership with service users, families and key stakeholders. This ethos has continued. Last month there were service user focus days which were led by service users and their families to review the support that they are receiving from Daisy.
Families and service users have been actively in the recruitment of staff. Prior to moving, individuals applying for posts were asked questions on film and then the clips were shown to service users. The service users then selected the staff using smiley face and unhappy face emoji’s.
Service users are supported to facilitate a service user group in the home. This has led to changes in the delivery of services including changing the location of handover.
Further work is required to ensure that service users and families are fully supported to evaluate the service.
Do you share your work with others?
The Daisy service manager has presented the Daisy model at the National NHS Benchmarking Conference for learning disabilities services in February 2018. This has been followed by the submission of a case study which will be published in July 2018.
The service manager has presented Daisy at several regional learning events.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The service is predominately measured using local reporting data. Monthly quality and standards report review incidents, use of restrictive practice and social activity for each of the service users. The data is reviewed on an individual and service level to make changes to the support that service users receive. The changes can include a reduction or increase in the amount of support that is given as appropriate.
The service has audited itself against the context of care tool. This identified areas of improvement such as developing a robust outcome based approach to service delivery.
A quality outcome measure for the service is currently embryonic and is in the process of being developed. The service is working closely with the Trust research and development service to evidence the impact of service. There are very tangible subjective indicators such as increase in access to community services, increased contact with families and increased access to educational services that evidence the effectiveness of the service. Further data detailing the effectiveness of the service will be published upon the completion of a valid, rigorous outcome measuring tool
Has your service been evaluated (by peer or academic review)?
The service has had external evaluation from CQC and NHS Improvement. The evaluations were complementary citing Daisy as a new, innovative model of hospital support for people with learning disabilities and/or autism.Daisy is on track to be a national centre of excellence for people with learning disabilities and is working hard to achieving this aim.
How will you ensure that your service continues to deliver good mental health care?
The service works closely with the CCG and NHSE to ensure that it is a sustainable service. Packages of care are reviewed regularly to ensure that they are offering value for money as well as being financially viable. The services are commissioned as individual packages of care rather than as a block. This creates flexibility within the service because there is less reliance on one defined funding stream.
The service works closely with service users and families to ensure that the service is meeting individual’s needs. The service is developing links with other organisations to ensure that service users are supported to leave Daisy in a timely manner.
What aspects of your service would you share with people who want to learn from you?
The biggest challenge of Daisy has been navigating the legislative framework. The aspiration for Daisy was to open as a nursing home using the Mental Capacity Act and Court of Protection to safeguard service users. This was not possible due to the required restrictions exceeding the court of protection safeguards. Therefore the only legislative option was to use the mental health act. Whilst this was initially seen as a negative of the service, it is now being seen as a positive solution. The use of the Mental health act has enabled the safe transition of individuals into less restrictive environment. This has allowed service users to develop their locus of control at their own pace and are now in a position to come of section.
Another key challenge has been integrating a new service into existing pathways. Engagement with community learning disabilities services, safeguarding teams and advocacy groups has been an integral part of the success of Daisy. I would recommend that engagement with key stakeholders is a key part of any new service and forms part of ongoing service strategy.
How many people do you see?
Currently there are four people living in the service
How do people access the service?
All referrals are via the local CCG.
How long do people wait to start receiving care?
Each service user has a bespoke transition plan. The length of this will vary depending on the individual needs of service users. The shortest transition was six weeks, the longest has been 12 months. Throughout the transition the needs of the service users are monitored.
How do you ensure you provide timely access?
All referrals are triaged with 72 hours of receipt. Assessment of new service users is completed within 14 days by the service manager and clinical psychologist.
What is your service doing to identify mental health inequalities that exist in your local area?
The trust is working with our partner organisations to identify the number of service users with learning disabilities who require access to secondary mental health services. The NDTi Green Light audit tool is being revisited and local CMHT and inpatient services are reviewing their local access points for people with learning disabilities services. In addition a virtual MDT consisting of a senior nurse, OT, Psychologist and behaviour nurses is being set up to provide immediate advice and guidance should a service user with learning disabilities and/or autism be admitted to an inpatient service.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
People with learning disabilities continue to struggle to access mainstream services. This is often due to a lack of understanding, inaccessible information and/or inappropriate accommodation. This inequality is exacerbated by a lack of skilled, knowledgeable residential providers that can support service users with complex needs.
What is your service doing to address and advance equality?
The service works closely with local CCG’s, local authorities and other health and social care providers to meet the needs of service users within the local population. A positive example of this was a learning disabilities celebration day that was held on 1st June 2018 in Bristol. Other 500 people with learning disabilities attended the day and it was very good way of raising the profile of people with learning disabilities.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
All service users are assessed by a senior nurse and psychologist prior to accessing Daisy.
How do you meet the needs of people using the service and how could you improve on this?
Daisy ensures compliance with NICE guidance on supporting people with learning disabilities and challenging behaviours. There is a strong focus on psychological interventions and adherence to the Stop Over Medication of People with Learning Disabilities (STOMP LD) policy.
AWP is a lead organisation in the local transforming care initiative. The organisation supports the Care and Treatment Reviews and works closely with other organisations to ensure that there are effective care pathways.
What support do you offer families and carers?
Families are actively encouraged to support the development of the service. Families are supported to access local family and groups if they would like additional support.
Further information
Avon and Wiltshire Mental Health Partnership NHS Trust is proactively involved in supporting people with learning disabilities and/or autism. The focus of this proforma has been the Daisy service but AWP supports people with learning disabilities and/or autism in variety of services including prison, substance misuse, community and inpatient mental health services. The organisation is committed to ensuring that service users with learning disabilities have equitable access to services and empowered to achieve their potential. Through this commitment, Avon and Wiltshire Mental Health Partnership NHS Trust has reduced the number of people requiring inpatient services. For those service users that do require access, there is a skilled, compassionate, dedicated workforce that strives to ensure that they are well supported. The staff working in Avon and Wiltshire Mental Health Partnership NHS Trust are a credit and deserve recognition for the job that they do.
Population details
Brief description of population (e.g. urban, age, socioeconomic status):
Adults aged 18 and over
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): CCG
Provided by (e.g. name of NHS trust): Avon and Wiltshire Mental Health Partnership NHS Trust
