Scottish Government

Appendix II Good practice examples

Collated examples of food practice relating to accommodation and activities

Mental Health Nursing Review

In NHS Borders there has been investment in activity coordinators to ensure service users have access to a structured programme of therapeutic activities and also a project that has enabled people to access complementary therapies.

Mackinnon House, Stobhill

Award winning occupational therapy department, Lifeskills.

Meadowfield Acute Admission Mental Health Unit, Worthing

The unit is a new build, consisting of three, 16 bedded mixed sex wards. Meadowfield is situated in a residential area, some miles away from the town centre.

The unit is bright and airy with lots of natural light and designer lighting. The walls are pale with accent colours via furniture and soft furnishings and are very clean. Each ward is on the ground floor with access to garden areas, which are not overlooked by wards. All of the bedrooms are single with matching furniture and en-suite facilities with built in safety features. There are small living spaces and quiet areas. There is a galley kitchen for service users to make drinks and snacks. The garden is being landscaped with input from service users.

There is also a ward based activity programme which has a good uptake.

Acute Care Collaborative, run by the King's Fund and Care Services Improvement Partnership's London Development Centre

This programme involved 34 inpatient wards in 30 London boroughs over 15 months. Wards could choose some of 25 standards to work towards. One of the most popular was for all service users to be involved in negotiating an activity and therapy programme that includes evening and weekend activity (such as a morning group where service users cooked their own breakfast). This standard increased service user participation in activities from 13% to 40%. More activities enhanced the effectiveness of inpatient admissions.

National Patient Safety Agency Safer Acute Wards Project

Project reviewed available evidence:

Lawson & Phiri (2003) recommended a top-up culture that ensured organisational systems work to the benefit of the ward - so e.g. repairs, cleaning etc can be controlled by staff in the ward, to improve morale and sense of hope.

Project went on to pilot improvements in three areas, one of which was improving the Physical Environment through Local Management. Information on these pilots has been requested.

Newcraigs Hospital (extract from MWC unannounced inspections report 2005)

24 en-suite rooms and ample communal space. The ward is light, spacious, and attractive and appeared well maintained, and, apart from some problems with controlling cigarette smoke, was a very pleasant environment to be in.

Also - two of the wards visited had a "slow door" operating system that delays the opening of the door for a few seconds. This can remove the need to lock the door, and was popular with the patients and staff.

Department of Health Mental Health Policy Implementation Guide Adult Acute Inpatient Care Provision

Oakburn ward: "Nurses actively engage with service users in one to one sessions and groups. The environment is carefully managed to minimise noise and promote a sense of calmness and safety. The ward is highly structured, yet some of the changes made have been focused on reducing controlling interventions and replacing them with caring interventions. Nurses are more proactively engaged and spend less time "fire fighting". Strong leadership and improved teamwork have supported clinical changes. The service's own audit data shows that patients are more engaged with their named nurses, 95% of patients take part in structured one to one time daily, and consequently are better informed and more involved in their care."

Eileen Skillen ward, Brixton. "Service users are offered a range of activities to support their recovery with a range of diverse activities available. A patient community meeting is held once a week to help discuss and resolve people's concerns and as many decisions as possible are made democratically, from changes in the physical environment to asking ex-patients to participate actively in staff interviews."

Collingwood Court in Newcastle "benefits from the advantages of having created an ideal environment to meet the privacy and dignity needs of service users with a general mixed-sex area, a female-only environment and an area for patients requiring high levels of nursing observation. Service users and carers play an integral role in their own care and the ongoing development of the ward. Structured, varied therapy is available and given the much-improved physical environment of the ward, participation in activities is high from service users. The ward has been independently hailed as an area of good practice by Breakthrough."

Suggestions received on what creates good practice:

• Good, sound leadership
• Staff who have all the training and skills to do the job
• A value-based ward philosophy
• Sound appraisal and PDP framework for all staff
• Regular supervision for ALL staff
• A pleasant and safe environment
• Regular planning groups between staff and patients to plan activities and ensure a venue to air views
• Sound, robust and meaningful activities on offer to all patients including complimentary therapies
• Sharing of information to service users and carers, both verbal and written re.
• Diagnosis
• Treatments
• Assessment Process
• Services available - both ward based and locally
• Observation charts
• A culture of engagement with service users and carers
• A culture where staff can feel free to air views - be innovative and think out of the box
• Management structure and medical counterparts who fully support and embrace all of the above
• Having sound systems and policies in place i.e. Risk Management/Observation/H&S, etc.

REHAB Ward, Royal Edinburgh

Recreation nurses who take patients off the ward for all sorts of activities, both singly and in groups. Getting a commitment to an in-patient OT presence is essential to maintain a therapeutic as opposed to custodial regimen. The ward atmosphere has benefited from the refurbishment and increase in floor space that was part of the Safety Dignity and Privacy drive - which happily came with a budget.

More recently our ward staff complement has been expanded hopefully to reduce stress levels and reduce use of bank nurses but also to permit a rotation of nurses between day and night shift to keep that time therapeutic too. Our ward is thinking about introducing dedicated therapeutic time to improve key working. This would mean a block of the day when student/visitors/interruptions in general would be discouraged.

Finally, the availability of advocacy services has been a great benefit. Our ward worker is a gem who sticks to the model firmly yet encourages the patients to be as active as possible in shaping their own recovery.

Good practice relating to areas other than accommodation and activities

Royal Cornhill Hospital in Aberdeen. One of the psychotherapists offers a service to the acute unit providing urgent assessment of patients with personality disorders. She then works with staff and the patient advising on ongoing management. In addition she provides a weekly meeting for nursing staff where they can discuss so called "difficult patients". Staff and patients have valued this service.

Examples submitted to Mental Health Nursing Review

Person-centred care in practice - implementing the Tidal Model in inpatient care in NHS Greater Glasgow.

The Tidal model builds upon the nursing profession's core concepts of caring about people and is based on collaborative working that promotes people's strengths and attributes to bring about change in their own lives. The values of the model link well to the Mental Health (Care and Treatment) Act 2003. Focused individual and group work promotes recovery-centred working.

NHS Greater Glasgow has implemented the Tidal Model in several inpatient units across the city. Encouraging results have been found, including reduction in rates of physical and verbal aggression, self-harm, complaints and the use of restraint and observation. Additionally, nursing staff have consistently reported a greater sense of professional purpose and job satisfaction after the introduction of the model, and service users and carers are very positive about the recovery-focused approach and the opportunities the model presents for meaningful involvement in their care.

Putting recovery into practice - NHS Tayside

With the support of SRN, a group of mental health nurses, carers, social workers, service users and occupational therapists have taken "training for trainers" courses in recovery. The Tayside Recovery Network has now been set up to support cultural change to embrace recovery-focused practice. The network has devised a vision and strategy for supporting the dissemination of recovery into practice which includes:

• Recovery awareness-raising sessions
• Training others as recovery trainers
• An email network and intranet forum
• The development of recovery training packages

Early indications are that the principles of recovery are taking root in Tayside. The network is increasingly being asked to comment on new procedures and policies to ensure they are consistent with the principles of recovery. There is a strong believe among nurses in the network that recovery principles are the vehicle to support cultural change and to allow mental health nurses to reclaim and strengthen their art.

There is a pressing need to improve access to psychosocial therapies for people during their stay in acute inpatient units. A nurse-led initiative in NHS Argyll and Clyde enables people to access psychological assessment and therapies during their admission, helping them to increase understanding of their problems and explore psychological treatment options that will support their ongoing coping and recovery. Nurse therapists also provide training, supervision, and support to the wider nursing team to promote psychological thinking and embed psychological therapies into practice.

In NHS Highland, a transitional discharge pilot has been completed in collaboration with Stirling University, with encouraging results. The transitional discharge model is well established in parts of Canada and involves the nurse who cares for an individual during an inpatient stay maintaining involvement during the transitional period after discharge while the person establishes a relationship with community staff. The Highland pilot also included peer support for people post discharge. The outcome of the pilot produced evidence that transitional care was effective in reducing readmission rates.

Mackinnon house, Stobhill

Successful pilot of the TIDAL project on Struan, which is a nurse based form of psychological therapy.

Armdale has piloted the integrated care pathway for schizophrenia over the last year.

Glasgow Perinatal Mental Health Service

Established a staffing rota so inpatient staff nurses rotate into the community and take on community cases under the supervision of CPNs. Two E-Grade nurses are in the community at any one time. The aim has been to break down traditional barriers between in and outpatient services, enabling staff to see themselves as one service, to provide seamless follow-up for discharged inpatients, who can often be seen in the community by their inpatient key worker, and to motivate inpatient staff to develop autonomy, skills and therapeutic interventions which can enhance their care of inpatients. The feedback from staff has been very positive and the service won a nursing award for the innovative practice.

Acute Care Collaborative, run by the King's Fund and Care Services Improvement Partnership's London Development Centre

This programme involved 34 inpatient wards in 30 London boroughs over 15 months. Wards could choose some of 25 standards to work towards. Some of the most popular were:

• Naming a staff lead on dual diagnosis, who will have completed a five-day training course
• For all service users to meet with their primary or named nurse within seven days
• For all service users to have twice-weekly, documented sessions with their primary or named nurse
• For specialist substance misuse/dual diagnosis workers to provide in-reach services to an inpatient ward

There was an increase in success from 17 to 60% on the first standard, from 26 to 55% on the second and from 23 to 67% on the third. In-reach work by substance misuse workers saw the biggest rise, from 13% to 73%. Protected time - when the wards shut down to phone calls, paperwork, professionals and visitors - targeted dual diagnosis, and training were the most popular pieces of work. Three of the trusts are extending protected time to all wards because it leads to a calmer atmosphere and reduction in incidents. Staff say the dual diagnosis training was particularly useful in changing attitudes towards service users with a substance misuse problem.

Department of Health Mental Health Policy Implementation Guide Adult Acute Inpatient Care Provision

Good practice aspects of reception and service orientation include:

• a service user handbook/guide on what is available and how to access it
• clear policy on leave, access, contact with relatives and friends, visiting times, access to telephones
• code of conduct - including what to expect from staff and what is expected of all users on the ward
• explanatory information (written, video) on illness, symptoms, services, courses of treatment
• a picture board of ward staff, prominently displayed
• a floor plan/map of the ward and the unit and good signage
• a service user orientation checklist as part of care plan
• a clear reception/orientation policy

Eileen Skillen ward, Brixton

To help encourage staff recruitment and retention, the ward provides flexible working arrangements. Staff are proactive about their own learning and development. On the ward, there are two teams working to two consultants and every three months, each team will have a workshop. The second team will cover for the first team to allow them to meet, brainstorm challenges and map out solutions. The approach allows staff to engage in reflective practice with minimal disruption for patients."

"A number of innovative services have beneficially created service user support posts to enhance sensitivity to service user concerns and to assist in creating additional therapeutic capacity for staff engagement."

" Anam Cara Crisis House, Birmingham was set up in 1997, in conjunction with the local home treatment service, to provide an alternative to hospital admission for women and men (in practice working primarily with women) and a "sister" designated women-only crisis house, Celine, opened in 2001. Both houses work on a hope and recovery model with a special focus on a diverse range of complementary therapies. The ethos is very resident-led with staff regarded as "recovery guides" all of whom have had prior experience of mental distress."

" Pathways, based at Goodmayes Hospital within North East London Mental Health NHS Trust, has put in place a comprehensive practice development programme with four key components:

• service user empowerment - moving from paternalism to partnership
• multi-disciplinary working and training
• clinical and managerial systems
• research, audit and evaluation

With a team of staff from different disciplines, the unit provides therapeutic, safe care and treatments for people who cannot be safely managed on an open acute ward."

" Bolton Acute Practice Development. The "Refocusing in Bolton" project was initiated in September 2001. Two parallel groups lead on refocusing - an acute development forum which meets quarterly, made up of multidisciplinary staff, representatives of the Patients' Council, PCT and an advisor from the University of Bradford. The second group focuses on leadership, is composed of all acute F and G grades and the OT manager, meets more frequently and agrees changes for all four wards, ensuring consistency and providing a valuable opportunity for mutual support and peer learning. We have undertaken whole team training and have made sure that everyone can attend. Our values and practice changes are being phased in, the first implemented in January 2002, which has been widely supported by staff and patients."

" Northern Collaborative. The Mental Health Collaborative was set up in October 2000, jointly commissioned by Trent and Northern and Yorkshire NHS regional offices and the Northern Centre for Mental Health. The overall aim of the project has been to improve inpatient care by focusing on enhancing service users' experiences of admission, stay and discharge. The project brings together the experiences and ideas of 37 acute care teams in the Northern region of England, assessing their current comparative position and setting incremental service improvement targets."

SAMH (2004) Hospital admissions best practice

Good practice points:

• being told who your named nurse is on admission
• Being able to contact the ward for support/advice/prescription of e.g. sleeping tablets when experiencing "warning signs"
• Provision of crisis facilities - midpoint between community and hospital
• Culture in which views of service users and carers are given weight
• Staff and service users working together when they are well to plan how to handle things if they become unwell - advance statement
• A&E departments should have a "liaison nurse" trained in mental health
• Welcome/induction pack for patients when first admitted
• Freephone helpline in wards to advocacy or support organisation

Scottish Executive (2002) Don't they call it seamless care? A study of acute psychiatric discharge

Identifies good practice in components of a discharge strategy

• identification at the admission stage of elements from the wider social context, for example accommodation or finance, which need to be addressed prior to discharge
• clear identification of lead responsibility in relation to the discharge planning for each individual
• agreement and implementation of protocols for the communication of information between hospital and community and between a range of different professionals. This should include details for the notification of GPs, consideration of the timing of the initial out-patient appointment, and communication of procedures to be followed for crisis contact
• Involvement both of individual service users and, where relevant, their informal carers in the detail of decision-making, ensuring the provision of information necessary for this process
• Clarification between psychiatrist and service user of the individual's diagnosis and its implications
• Provision for each individual of the details of medication and prescription arrangements, highlighting specific implications as appropriate
• Comprehensive assessment of need and maximisation of the extent to which areas of unmet need are addressed
• Specification of the routines for clarification of individual responsibilities within the multi-disciplinary work context
• Clarification of any tie-in to existing care management or CPA procedures
• Understanding of whether an individual can expect ongoing contact from professionals and the timing and arrangements for any review