SHSC’s Rehabilitation Strategy has significantly reduced the number of people in locked rehabilitation out of city and also dramatically reduced the number of new out of city referrals. A key element of the strategy has been the development of more intensive rehabilitation beds in the city to reduce the need for out of area bed use, and to provide care closer to home. We believe that sending people to locked rehabilitation units miles from their homes is neither therapeutic nor cost effective. We knew there had to be another way to intensively support our service users who need rehabilitation services. Our dedicated staff have worked hard to implement a strategy which supports service users’ recovery as close to home as possible.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
From institution to enablement – the Sheffield story The Care Quality Commission’s report, the State of Care in Mental Health Services, published last year raises concerns about service users in locked mental health rehabilitation wards, often situated a long way from their homes resulting in isolation from friends and families. This is not the reality for Sheffield mental health service users as over the past five years, Sheffield Health & Social Care NHS Foundation Trust (SHSC) has transformed mental health rehabilitation care in the city. SHSC’s Rehabilitation Strategy has significantly reduced the number of people in locked rehabilitation out of city and also dramatically reduced the number of new out of city referrals. A key element of the strategy has been the development of more intensive rehabilitation beds in the city to reduce the need for out of area bed use, and to provide care closer to home. We believe that sending people to locked rehabilitation units miles from their homes is neither therapeutic nor cost effective. We knew there had to be another way to intensively support our service users who need rehabilitation services. Our dedicated staff have worked hard to implement a strategy which supports service users’ recovery as close to home as possible. We wanted to create a model of care which supports service users’ recovery here in Sheffield. Regular contact with carers, friends and family members are key factors in service user recovery. We also wanted the model of care to be something better than increasing hospital beds. We wanted to support people to live independently in their local community and to support them to develop the skills to do so successfully.
In April 2012 the average length of stay on the rehabilitation wards was anything from 18 months to 4 years. A number of service users had been in hospital for more than 20 years, seemingly unable to be discharged to live in their local communities. There were 46 service users living ‘out of city’ in locked rehabilitation units and this was increasing at a rate of 6 more each year. Staff were concerned that for these service users ‘out of sight, out of mind’ would become the norm. We worked with staff, service users and carers to develop our vision for rehabilitation services which included a better step-down pathway out of hospital, improving the physical environment of the rehabilitation in-patient wards to them more therapeutic, active discharge planning, person and recovery orientated care, partnership working with service users, carers, families, friends and local organisations and, above all, instilling hope in our service users. The benefits for service users have been life changing with some returning home to live independently for the first time in over ten years. Over 40 service users have returned to their home city, with many now living independently in their own homes. The in-patient rehabilitation wards have been transformed from a paternalistic model to one of partnership and recovery while reducing the number of beds from 61 to 30. Out of city referrals for rehabilitation have been eliminated and by the end of this year (2018) there will be no adult working age service users placed out of city for rehabilitation. This could not have been achieved without working with service users, carers and staff to translate the vision into a realistic, achievable plan.
What makes your service stand out from others?
The Sheffield journey can be encapsulated by “Ruth’s story”. She was a relatively young service user who had been in hospital for 12 years with psychosis and anxiety so severe that she could not leave her room , prior to moving to Forest Close. When her mother knew we were planning to discharge Ruth she ended up meeting with the Service Director to raise her worries and concerns that her daughter would not be able to cope outside of a hospital environment. The service worked intensively with Ruth to co-produce a very detailed, personalised collaborative care plan and Ruth was subsequently discharged to a residential care setting where she now gets out and about by herself. Recently her mother contacted the service to say that she had been wrong to think that her daughter would not be able to cope and flourish living independently. Where there had been no hope, she now saw her daughter as being able to live independently outside of a hospital environment. The changes to clinical practice included the development of collaborative care planning, a recovery college, the implementation of SAFE wards and a positive approach to managing risk. SAFE wards is a model which is focused on keeping everyone (service users and staff) as safe as possible.
Previous research had shown that service users felt unsafe in hospital at a time when they were at their most vulnerable. Research had also identified the impact the environment has on people’s behaviour. There were also recognised concerns about safety of staff in in-patient environments. This was achieved by leadership development which included the development of a new enhanced staffing model which benefits from a Non-Medical Prescriber, a senior practitioner and a pathway coordinator role. This means that enables the staff team to work collaboratively using therapeutic relationships as the key to engagement and future recovery. However, Sheffield journey is not just about changes to process and procedure and changes to the physical environment of the in-patient rehabilitation wards – it is much more than this. It is about a major change in culture to move towards a co-production approach to recovery which is individual and person-centred, in which staff, service users and carers feel empowered to work together towards shared goals. It is the shift from a paternalistic, institutional approach to care to one which is individual, recovery focused and centred on enablement.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Working with staff included the development of effective training, team development and improved systems of supervision and appraisal. Because this was such a significant change, we had to look at training needs of the staff team. To this end we had away days, focus groups with staff to discuss anxieties and concerns about the change to help them understand why we were making the changes and what our aims and objectives were. The different approaches we required training in were working with service users with Emotionally Unstable Personality Disorder as well as adopting an approach based on Positive Behaviour Support. All staff were required to be trained in RESPECT, our no pain, no panic approach to addressing challenging behaviour which focuses on the least restrictive intervention. We don’t have a seclusion room, a decision taken by the staff team because we prefer to use de-escalation techniques and RESPECT (no pain, no panic) techniques.
Our figures for restraint are amongst the lowest in the Trust. We further developed our collaborative care planning in which care plans are co-produced with service users and focused on the goals that they identify as being important to them. Several senior staff undertook a postgraduate course in supervision and we ensure that supervision occurs every four weeks for every member of staff and the frequency and quality of supervision is audited weekly. All areas have a supervision tree highlights each individuals supervisor. Staff are aware that should difficulties arise due to shift patterns they are to seek supervision with an alternative Band 5 (for support workers) and Band 6 (for registered mental health nurses). Supervision is monitored weekly on a ward and individual basis to ensure compliance at the end of each month. We have regular team formulations, reflective practice and we are about to embark on our second away day to offer staff the opportunity to reflect on how far we’ve come, celebrate their achievements as well as the achievements of our service users and focus on our future plans for staff and service development. We have a peer support worker who is a much valued part of the team and who enriches the already considerable experience and expertise of the multi-disciplinary team. In a time when recruiting nursing staff is challenging locally, regionally and nationally, we continue to successfully recruit and retain our staff team. Most recently, a student nurse on placement with the team has been appointed to a substantive role. Compared to most teams within in-patient services in the Trust, our sickness absence rate is low.
Who is in your team?
A Clinical Nurse Manager. 3 Clinical Areas: 14 bedded male ward, 2x 8 bedded female ward. Each area has a designated Ward Manager and Deputy Ward Manager. We have a Senior Practitioner and a Non Medical Prescriber who work across the site. A senior Psychologist who works for the team 3 days. A full time assistant psychologist (who was formerly a support worker at the unit). 1.2WTE Consultant Psychiatrists. 1 Junior Doctor. Two WTE occupational therapists. Two Activities Co-ordinators. Nursing staff model was developed in conjunction with the Service Director, Clinical Nurse Manager and Finance and reflects the needs of the service users. At any one time there are a minimum of 4 RMNs across the site and seven support workers. Staffing levels increase as needed to address any additional clinical needs.
How do you work with the wider system?
The changes have been developed using a whole system approach understanding that changes to one part of the system could impact both positively and negatively on other parts of the system. This has meant city wide discussions about innovative supported accommodation projects and structures to support the delivery, for example the City Wide Care Management panel. The Panel is run by Sheffield City Council and have expertise in understanding and knowing the commissioning frameworks, level of funding required against level of need, section 117 aftercare etc. The Clinical Nurse Manager sits on the fortnightly City Wide Care Management Panel and is able to help support the panel to contribute to decisions about accommodation, care packages and funding. This has enabled better mutual understanding and eliminated delays in funding discharge packages . We work with voluntary sector organisations, private providers, our own Community Enhanced Recovery Team (CERT), our acute in-patient wards, the Clover Group GP Practices who provide physical healthcare to our service users as needed alongside our own dually trained physical healthcare needs lead nurse. The award winning Brunsmeer Awareness mental health football project began as a weekly football group at the service organised by one of the Occupational Therapists and through the development of partnerships with local community groups and charities has developed into a citywide project. It now offers a tailored and targeted intervention for men and women with moderate to severe enduring mental health conditions who play every week at a bespoke community football venue with many players choosing to play in a local football league as Brunsmeer Awareness. The project is led staff from the service in partnership with Brunsmeer Athletic, Sheffield Flourish, Sheffield and Hallamshire Football Association, Sheffield United Football Club and the Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber. The football sessions motivate service users to maintain a social network and many friendships have been forged among the members. Football offers a non-judgemental platform for service users to speak to peers in confidence, to share their experiences and to understand and develop respect for each other. The service has also developed a Recovery College which is delivered in partnership with local organisations including Sheffield Flourish, Employ, Art House Sheffield, Timebuilders and Heeley Development Trust.
Do you use co-production approaches?
The service has embraced a co-production approach to recovery which is individual and person-centred, in which staff, service users and carers feel empowered to work together towards shared goals. It is a shift from a paternalistic, institutional approach to care to one which is individual, recovery focused and centred on enablement. The Senior Practitioner and Psychologist have developed a relatives support group. Staff within the service are very keen to get the Trust signed up to the Triangle of Care and is leading on this initiative for the Trust. Peer support worker helping us develop co-production with in the service. Collaborative care planning is used throughout the service as part of commitment to co-production – the focus of the service is about empowering service users towards enablement and recovery. The service has also led on the development of a Recovery College. The Recovery College is based on the principle of Co-production between people with personal and professional experience of mental health problems. Its principles and values identify that the College must be a joint enterprise at every level and every stage, from initial planning and development, to decisions about how it runs, what is taught and quality assurance. As such, the systems and language we use (e.g. plain English) should be understandable by all involved. The Recovery College offers free courses in the following areas: Physical activity Life skills (i.e. cooking, gardening) Creative Arts (music, poetry, shared reading, art, performance art) Work, volunteering and education (GCSE maths and English, food hygiene, first aid) Health and Wellbeing (anxiety, change, self-esteem) Further courses are also being co-produced with service users in response to service user requests including photography, yoga, basic DIY and employability.
Do you share your work with others?
The service is part of the AIMS network (AIMS is the accreditation for in-patient mental health services offered by the Royal College of Psychiatrists). Staff from the service are presenting on their story at the AIMS network meeting in London on 17 May. Julie Smalley, Clinical Nurse Manager, will feature as a case study in a forthcoming publication from the Care Quality Commission celebrating the hard work of individuals to drive improvement in services as part of the NHS 70 celebrations.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
We use HONOS scores and clustering as CROMS to track the progress of our service users. The latest reports from HONOS show a significant improvement in scores over time We also are participating in a research study of the use of ReQuol a Patient reported experience measure Data is collected through out in house clinical database system Insight which allows retrieval of reports such as HONOS REQUOL and Mental Health Services Data Set Tracking the changes in service user demographic profile showing increasing proportions of younger people with personality disorders and substance misuse has informed our staff training programmes to develop the service to address this . For example we have had peer expert led training in personality disorder and basic uses of DBT, and training in motivational interviewing to tackle substance misuse Over the last 2 years we have successfully discharged 66 service users to less restrictive settings – mainly to residential accommodation (47%),or their own tenancy with community support ( 20%). This includes many people who had been in hospital in Sheffield or in out of town locked settings for decades Of these, 20% were re admitted either to Forest Close or the acute wards. Nearly all returned back to their accommodation after readmission. Of these, only 4 people remain in hospital – 2 because there is no suitable alternative, and 2 who required low secure care . The CQC inspection report noted that: Patients in the intensive rehabilitation service told us that staff always had time for patients and that staff encouraged patients to push themselves in their recovery. One patient told us that ‘being here [at Forest Close] has made me happy, when I’ve asked for things I’ve mostly heard yes rather than no and when staff say no they explain why’
Has your service been evaluated (by peer or academic review)?
The service has been peer reviewed by the Royal College of Psychiatrists. The most recent CQC inspection found that: • The intensive rehabilitation service had worked to address the issues with care planning identified in the previous inspection which meant that care planning had improved. Care plans were holistic and recovery-orientated with all plans focussed on achieving eventual discharge. • Almost all patient feedback was positive about both services. Patients in the intensive rehabilitation service told us that staff always had time for patients and that staff encouraged patients to push themselves in their recovery. In addition, the CQC found: The intensive rehabilitation service had been redesigned since the last inspection. The new service was more focussed on discharge. The service had introduced a target of eighteen months for the average length of stay. It had reduced bed numbers and had discharged 32 patients during this process, including 12 patients between November 2015 and October 2016. Three of the 12 patients discharged in this period had been admitted since the service had relaunched. And: Carers told us that they felt fully involved in the care being provided and that both services had ensured that they were given enough information about the service. Carers were invited and attended care programme approach meetings and were kept informed if any issues arose in between meetings. Carers felt able to give feedback to both services and all four carers told us that they felt the services would respond to and take action from feedback.
How will you ensure that your service continues to deliver good mental health care?
Clinical Nurse Manager has regular contact with Commissioners (City Wide Care Management Panel). Staff from the service meet regularly with colleagues within the wider Trust to look at unmet need and future direction of travel. The service is committed to continually develop staff and provide learning opportunities to future proof the service in terms of leadership. An example of the service’s innovative approach to future proofing our leadership is: a recent flexi-retirement by an experienced ward manager has been managed by his return on a 3 day week contract and a job share with a newly promoted nurse – his experience and expertise is complemented and enhanced by her energy, vigour and innovation. While her personal development is being enhanced and supported by his expertise.
What aspects of your service would you share with people who want to learn from you?
In the beginning staff wanted the service to have more of a forensic feel where they lack confidence they wanted rules. The leadership team wanted a service that embraced positive risk taking and collaboration with service users. Bringing staff with us on this journey was a significant challenge but one which was embraced wholeheartedly by the leadership team. It is testament to their skills, tenacity and emotional resilience that they succeeded and the cultural transformation has been nothing short of spectacular, having a hugely positive beneficial impact for service users as well as staff. This was achievement through a partnership working approach with staff, supporting their development, training and supervision and empowering them to embrace the new model of service provision.
How many people do you see?
We have 30 beds which are all occupied. In the past 12 months we have received 36 referrals, 20 of which have been accepted, 12 of which have been declined and 4 of which are awaiting further information. Based on referrals received, the mean wait time for assessment is 13.8 days with a maximum of 28 days. Based on admissions, the mean wait for admission to treatment from successful assessment is 9.7 weeks.
How do people access the service?
Referrals are accepted from secondary and tertiary NHS providers including acute psychiatric services, specialist secure units, community mental health teams and specialist community teams. The service is happy to consider referrals from any source. The service has a joint weekly referral meeting with the CERT Team and the outcome is communicated to service users and professionals within a week.
How long do people wait to start receiving care?
We have 30 beds which are all occupied. In the past 12 months we have received 36 referrals, 20 of which have been accepted, 12 of which have been declined and 4 of which are awaiting further information. Based on referrals received, the mean wait time for assessment is 13.8 days with a maximum of 28 days. Based on admissions, the mean wait for admission to treatment from successful assessment is 9.7 weeks.
How do you ensure you provide timely access?
We have weekly referral meetings and fortnightly City Wide Care Management Panels.
What is your service doing to identify mental health inequalities that exist in your local area?
We collect data in respect of our service users and work with individuals and communities to understand our service users’ needs. A key issue for the service is integrating our service users into their local communities so they have fair access to mainstream services, organisations and activities.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
We have service users detained under Section 47/49 who are not eligible for benefits (classed as prisoners) and therefore unable to progress their discharge – this appears to be an area of unmet need. This is a national problem to which there is no solution as yet. Our demographic has changed as the service has moved from a long-stay model to one which is focused on recovery with many more young people accessing the service.
What is your service doing to address and advance equality?
The service has developed a Recovery College which is delivered in partnership with local organisations including Sheffield Flourish, Employ, Art House Sheffield, Timebuilders and Heeley Development Trust. This offers service users the opportunity to build and develop skills that will help them live independently in the community and supports them to build links into the local community, for example, the gardening group meet at the local allotments and the football group is run in partnership with many local organisations and agencies. Service users form part of our recruitment interview panels to help us appoint staff who have the same values and belief in a recovery model of enablement and independence for our service users. We support our service users to undertake voluntary work in the local community. We also run an evening social group which supports service users to enjoy evening activities in their local community in a safe and empowering manner, giving them the life skills to enjoy meals out, cinema trips etc. The focus is on supporting service users to integrate themselves into the local community so that when they are ready for discharge they have an informal support network already in place.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
We identify service users who are in need of 24 hour rehabilitation care. We deliberately do not have an exclusion policy although we generally don’t accept people with a primary organic illness or learning disability. We assess the individual needs of each and every service user and develop a collaborative care plan in partnership with them to promote enablement and recovery. Our view is that if someone needs our service then they should get it.
How do you meet the needs of people using the service and how could you improve on this?
Our team provides a service which is therapeutic, focused on active discharge planning, person and recovery orientated care and which through partnership working with service users, carers, families, friends and local organisations instils hope in our service users. The service has adopted a co-production approach to recovery which is individual and person-centred, in which staff, service users and carers feel empowered to work together towards shared goals. It is a shift from a paternalistic, institutional approach to care to one which is individual, recovery focused and centred on enablement. The acute wards are not suitable places for people who are struggling or in the very early stages of relapse. Services users have asked to be able to come back to FC the service for respite when things are difficult and we have addressed that by the short-term care bed which is well used
What support do you offer families and carers? (where family/carers are not the service users)
The Senior Practitioner and Psychologist have developed a relatives support group. Staff within the service are very keen to get the Trust signed up to the Triangle of Care and is leading on this initiative for the Trust. The service offers individual family work where clinically indicated. The service always engages family, friends or carers in the care of service users where there is consent from the service users. The needs and views of carers are always clearly documented and any support offered to them where appropriate. The service offers information and advice to family, friends and carers on a regular basis and as and when requested. Information about Sheffield Carers Centre is also made available to families and carers.
If you have implemented any of the above, what were the benefits and challenges?
We adhere to the NCCMH schizophrenia guidelines and participate in the national schizophrenia audit. We adhere to other NCCMH guidelines for example for management of personality disorder and mood disorders and have participated as a trust in POMH UK audits of prescribing for these disorders National and local audits have driven change in our prescribing habits. We have no current service users who are over the BNF limit for antipsychotics and only 2 people receiving more than one antipsychotic, both with a recorded rationale. This has been a major achievement, as many people arriving from out of city secure settings are on complex high dose polypharmacy regimes. Reducing medications can be anxiety provoking for service users and staff, but our collaborative planning helps people contribute to how and what they will reduce, whilst multidisciplinary working with pharmacists and medical staff and experience over time has helped our staff gain confidence to support these changes Similarly national and local audits have driven change in adopting healthier lifestyles to prevent cardiac and other disease that increases mortality in our service users . We have a smoke free site and are developing in house weight watchers inspired groups and meal preparation to help people lose weight – with real success.
Population details
Brief description of population (e.g. urban, age, socioeconomic status):
City of Sheffield and the surrounding of South Yorkshire and North Derbyshire
Size of population and localities covered:
Approximately 600,000
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
NHS Sheffield Clinical Commissioning Group
Provided by (e.g. name of NHS trust) or your organisation: *
Sheffield Health & Social Care NHS Foundation Trust
