Intensive Psychiatric Care Units

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1 NHS Tayside Carseview Centre, Dundee Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009

2 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity impact assessment, please see our website ( The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer. NHS Quality Improvement Scotland 2009 First published November 2009 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. Information contained in this report has been supplied by the NHS board concerned, unless otherwise stated, and is believed to be reliable on publication.

3 Contents _~ÅâÖêçìåÇ N N lîéêîáéïçñäçå~äãéåí~äüé~äíüëéêîáåéë P O fåíéåëáîééëóåüá~íêáåå~êéìåáíéêçîáëáçå P OKN ^Çãáëëáçåíçfm`r Q OKO jççéäçñå~êééêçîáëáçå Q OKP aáëåü~êöéñêçãfm`r R P aéãçöê~éüáåë R PKN kìãäéêëçñfm`r~çãáëëáçåë R PKO k~íìêéçñ~çãáëëáçåë S PKP j~å~öéãéåíçñçíüéêéçéìä~íáçåöêçìéë S Q iáåâëïáíüçíüéêëéåìêéãéåí~äüé~äíüéêçîáëáçå T R dçîéêå~ååé~êê~åöéãéåíë T S mä~åëñçêëéêîáåéçéîéäçéãéåí T T líüéêéçáåíëíçåçíé U ^éééåçáñnódäçëë~êóçñ~ääêéîá~íáçåë V

4 Background The Scottish Government s national mental health benchmarking project (January 2008) defined intensive psychiatric care units (IPCUs) as: a multi-disciplinary team with specialised training; the ratio of nursing staff will be higher than a general psychiatric ward. The service is recovery focused; it provides intensive treatment and interventions to patients who present an increased level of clinical risk and require an increased level of observation. (Technical Appendix, January 2008). The National Mental Health Services Assessment: Towards implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003 (March 2004) Report highlighted specific challenges faced by IPCUs in light of changes in mental health legislation. In particular, the report outlines the dual function often ascribed to IPCUs where they function as both a low level secure forensic unit and as an extension of general adult inpatient psychiatric services. This is further complicated by the need for appropriate care environments for females, adolescents, older adults and those with learning disabilities. The report concludes that IPCU provision is a small but important part of services and should remain central to planning decisions when implementing the [Mental Health (Care and Treatment) (Scotland)] Act. Introduction to the IPCU project There is very little published UK data about IPCUs. The NHS Quality Improvement Scotland (NHS QIS) 3-year strategic work programme, Improving the Quality of Mental Health Services, recognised this and included a commitment to undertake an audit of IPCUs in Scotland. Before undertaking any work to assess how services are delivered within IPCUs, it is important that we have a clear picture of: how many IPCUs there are across Scotland the arrangements in place in NHS board areas that do not have local IPCU provision how the IPCUs are structured and staffed the relationships between IPCUs and other mental health services, and the referral pathways both in and out of IPCUs. In order to gather this background information it was agreed that the IPCU project would be delivered in two distinct stages. Stage 1 is a national service profiling exercise covering all of the territorial NHS boards in Scotland. In a parallel piece of work during Stage 1, the views and experiences of people who have received IPCU care and their informal carers will be sought. This work is being supported by Better Together, Scotland s national patient kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf N

5 experience programme and is being delivered in collaboration with the Mental Welfare Commission for Scotland. This report contains the service profiling information. The user and carer experience information will be included in a national overview report alongside the service profile information. The national overview will be published in spring 2010 and will give a full representation of the national picture from both the perspective of those who provide services, and those who use them. The service profiling findings along with the views and ideas of service providers and service users and carers that have been sought and captured during Stage 1 of the project will inform the detail of Stage 2. The service profiling process has two key parts: local information gathering and follow-up meetings. Using a service profiling questionnaire produced by NHS QIS, each NHS board gathered information on the IPCUs in its local area. These data were submitted, together with supporting evidence if applicable, to NHS QIS prior to the follow-up meetings. Follow-up meetings were held with local staff between May July 2009 to discuss the responses provided by the NHS board and seek clarification on any issues. This report presents the information supplied in the service profile form and the discussions at the follow-up meeting with NHS Tayside on 25 June kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf O

6 1 Overview of local mental health services Tayside is situated in the east of Scotland and has a population of around 394,134. Many of the population live in urban areas, of which Dundee and Perth are the largest in the region, although a significant proportion live in rural areas. NHS Tayside s principal organisations are Tayside NHS board, the single delivery unit (SDU) and three community health partnerships (CHPs) in Angus, Dundee and Perth & Kinross. The SDU comprises acute hospital services and provides a wide range of community-based services managed through the CHPs. Additionally the SDU provides mental health services throughout Tayside. Adult mental health services and psychiatry of old age services sit within the CHP in which they are based, eg Dundee adult mental health service sits in Dundee CHP. The adolescent mental health service is based within the women and child health directorate within the acute sector. Substance misuse is hosted in Angus CHP, while the forensic psychiatry service is hosted in Perth & Kinross CHP. There is a range of mental health inpatient provision across NHS Tayside. Adult mental health acute, rehabilitation and secure inpatient services are provided as follows: NHS Tayside Carseview Centre, Dundee Number of beds Acute mental health admissions (adult) 48 IPCU 12 Murray Royal Hospital, Perth Number of beds Low secure forensic psychiatry 28 Acute mental health admissions (adult) 43 Royal Dundee Liff Hospital Number of beds Acute mental health admissions (adult) 2 Sunnyside Royal Hospital, Montrose Number of beds Acute Mental Health Admissions 22 IPCU 6 2 Intensive psychiatric care unit provision NHS Tayside has an IPCU within the Carseview Centre, Dundee. There is also a small, locked ward at Sunnyside Royal Hospital, Montrose which performs some functions as an IPCU. For the purpose of the service profiling exercise the locked ward at Sunnyside Royal Hospital will be considered as an IPCU. This report will focus only on The IPCU at Carseview Centre; a separate report will look at the provision at Sunnyside Royal Hospital. The IPCU has 12 beds, all of which are exclusively for the use of male patients between the ages of There is no provision for female patients at the IPCU, meaning females in need of IPCU care must be accommodated elsewhere, generally at Sunnyside Royal Hospital or within the IPCU in NHS Fife. The IPCU no longer has any smoking rooms following an initiative undertaken by nursing staff. kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf P

7 NHS Tayside staff reported that the occupancy rate varies but that it can often be as high as 100%. On occasion, the detention status of patients may be suspended to allow overnight and weekend stays at home, however only a small group of patients would be able to undertake unsupervised detention. 2.1 Admission to IPCU The IPCU operational policy outlines the admissions protocol. Exclusion criteria are in place, these include females, patients under the age of 18 or over the age of 65 and those with a primary diagnosis of a learning disability. There have been very few cases of informal patients being admitted to the IPCU. The IPCU does admit forensic patients and those under (Criminal Procedures [Scotland] Act 1995 assessment orders) CPA52 but this is also not a regular occurrence. 2.2 Model of care provision Medical input on the ward comes in the form of two dedicated consultant psychiatrists who cover all responsible medical officer (RMO) and approved medical practitioner responsibilities. A junior doctor is also available on a shared basis with the rehabilitation service. Social work input is now available solely through locality teams, having previously been available through a dedicated social worker at the IPCU itself. Staff reported that social work was now more difficult to access than before. Allied health professional input is available to the IPCU through both a physiotherapy and occupational therapy service. A newly refurbished gym hosts a regular programme of activities, timetable by occupational therapy and run by physiotherapy. Hydrotherapy swimming classes are also available on a daily basis for those patients who are able to take part. Band 3 staff also take on responsibilities for the organisation of many of these activities. In addition, a physical health screening has been carried out on a group of patients, and there is a regular keep well group and subgroup in Dundee. Additional services, such as IQ assessments, cognitive behavioural therapy and further education can be accessed through in-patient services at Carseview Centre. IPCU staffing profile Medical (covers IPCU/acute admissions and CMHS) General adult psychiatrist Junior doctors Whole time equivalent (WTE) (7.5/ 3.99) kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf Q

8 IPCU staffing profile (continued) Nursing 31.4 WTE registered and unregistered Band 7 Band 6 Band 5 Band 3 (unregistered nursing assistant) Clinical Consultant clinical psychologist - psychology Social work Mental health officer - Allied health professionals Occupational therapist Occupational therapy technical instructor - - Administrative staff Administrative officer - Whole time equivalent (WTE) The IPCU has a dedicated nursing team. The minimum staffing complement for any day shift is six staff with five on the night shift. This staffing complement can accommodate one-to-one observations on up to two patients; additional staff would be required if more than two patients require this level of observation. Typically, one newly-qualified nurse on the Flying Start scheme would be taken on at any one time. All other new staff are usually required to have at least 18 months experience before being employed in the IPCU. A one-month development opportunity is being looked at to allow nursing staff to gain experience on the IPCU before the new facility opens later in An appraisal and job planning process is outlined within the job plan of all nursing staff and, as part of this, staff receive a full package of training prior to working within the IPCU. The IPCU is now looking at the focused planning approach, which is currently available across all acute wards. 2.3 Discharge from IPCU Discharge planning depends very much on the beds that are available in other wards, such as rehabilitation and acute admission. The lack of forensic beds does affect discharge planning at the IPCU. Community support and drug and alcohol services also play an important role in providing care for patients on discharge from IPCU. NHS Tayside staff reported that there are unmet needs in the area of drug and alcohol inreach services. This issue has been raised within the wider commissioning framework for NHS Tayside. The IPCU operational policy for NHS Tayside states that the last bed must be kept vacant for a Tayside patient, and would therefore not be available for an out-of-area admission. 3 Demographics The total adult population aged served by the IPCU is 391, Numbers of IPCU admissions Information supplied by NHS Tayside indicates there were 33 admissions to IPCU in There were difficulties in obtaining admission data broken down by sex and ethnicity. Although this data is gathered at the point of referral, it is kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf R

9 not readily available. On average, there maybe around four patients each month admitted to IPCU with an average length of stay of 35 days. 3.2 Nature of admissions All admissions to the IPCU are agreed by way of discussion between the admitting and referring multidisciplinary teams. The IPCU has an admission procedure for non-dundee patients. If patients are unable to be managed at Sunnyside Royal Hospital or Murray Royal Hospital, they may be required to be transferred to the IPCU at the Carseview Centre. Again, admission to IPCU and transfer arrangements would be discussed and agreed between both multidisciplinary teams. The duty co-ordinator at Carseview is ultimately responsible for the transfer arrangements of the patient into the IPCU. IPCU Admissions to Carseview Centre in 2008 Age Under Over 65 Gender Male Female Ethnicity N/A - Detention status Civil law/criminal law Informal (elective) 27* 6 Out-of-area referrals Formal agreement No formal agreement N/A N/A *The total of 27 is for Criminal/Civil Law combined as the information system is unable to break down by category. 3.3 Management of other population groups As previously reported, the IPCU operates exclusion criteria. There are however exceptions to these criteria on certain occasions. Patients who are between the ages of 12 and 16 may be admitted where there are deemed to be exceptional circumstances. An interface policy is in place in relation to child and family psychiatry admissions, and this would only take place with the approval of both the child and adolescent mental health service (CAMHS) and the IPCU consultant. Patients over the age of 65 may also, in exceptional circumstances, be admitted to the IPCU with the approval of the RMO. Similarly, patients with learning disabilities may be admitted to the IPCU where particularly challenging behaviour is deemed unmanageable elsewhere. In all the above cases, an area of the ward can be separated off to allow a separate, more private nursing environment. Communication with CAMHS, older adults and learning disability services would be ongoing in order to find an appropriate bed as soon as possible. kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf S

10 4 Links with other secure mental health provision Although there is no formal referral guidance for referral of a patient outside Tayside, admissions are discussed on a consultant to consultant basis prior to admission. NHS Tayside commented that they are undertaking a piece of work to look in more detail at the transfer and referral process. Furthermore, NHS Tayside added that they would greatly benefit from a more formalised process which outlines clear exit points from IPCU to enable a more efficient interface with low secure and forensic psychiatry. Patients stepping down from The State Hospital are not admitted to the IPCU and would instead generally be admitted to the low secure forensic psychiatry unit in Perth. There are plans for the future provision for 32 medium secure forensic psychiatry beds. 5 Governance arrangements The IPCU reports to the Dundee CHP Clinical Governance group with any outstanding governance issues. This group then reports in to the NHS Tayside board clinical governance committee. NHS Tayside reported on the extensive consultation with service users and carers, voluntary and statutory sector partners and the public with regard to the reprovision of mental health services at Carseview Centre. The method of consultation adopted by NHS Tayside on this matter has been endorsed by the Scottish Health Council. NHS Tayside s involvement manager oversees all public involvement activites. 6 Plans for service development NHS Tayside is planning the reprovision of both Carseview Centre and Sunnyside Royal Hospital IPCUs. A new facility will be based at the Carseview Centre site in Dundee and will provide between male and 4 8 female beds in two separate units, but within the same complex and served by the same nursing staff and management. The aim of the flexible bed numbers is to ensure greater flexibility of bed use without compromising the function of the IPCU. NHS Tayside reported that future priorities for staff training are to be outlined in the upcoming Training and Development Plan Summer Among the priorities will be training on suicide prevention and psychosocial interventions. Further guidance on transferring patients seamlessly will be an area for NHS Tayside to look at in the future, in order to develop new models at the new unit. NHS Tayside staff commented that they were keen to see some sort of official guidance or standards developed as a outcome from the service profile exercise. kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf T

11 7 Other points to note The reprovision of IPCU at the new unit at Carseview Centre is expected to bring significant benefits, particularly in the area of provision for female patents. NHS Tayside reported particular unmet needs in the areas of pharmacy, occupational therapy and dietetics. Despite the availability of a newly refurbished gym at Carseview Centre, staff still reported that they need more in the way of activities for patients. The make-up of the multidisciplinary teams was not seen as diverse enough at present. A new pharmacy service, including robotic dispensing will be available at Carseview Centre, next to the Carseview Centre, and is expected to feed into the new IPCU. kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf U

12 Appendix 1 Glossary of abbreviations Abbreviation CAMHS CHP IPCU NHS NHS QIS RMO SDU child and adolescent mental health services community health partnership intensive psychiatric care unit National Health Service NHS Quality Improvement Scotland responsible medical officer single delivery unit kepq~óëáçéwpéêîáåémêçñáäéoééçêíópìêîéóçñfåíéåëáîémëóåüá~íêáå`~êéråáíëekçîéãäéêommvf V

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